The technician is usually the patient’s first contact in the clinic. He or she frequently will perform the initial history to include both medical and ocular conditions and may perform the initial stages of the exam, including dilating the patient. As the first contact, the technician has an important role in obtaining a good medical history and a detailed medication and allergy list. In addition, the technician needs to understand the significance of this information in preparing the patient for surgery.
See the next page for answers.The technician is usually the patient’s first contact in the clinic. He or she frequently will perform the initial history to include both medical and ocular conditions and may perform the initial stages of the exam, including dilating the patient. As the first contact, the technician has an important role in obtaining a good medical history and a detailed medication and allergy list. In addition, the technician needs to understand the significance of this information in preparing the patient for surgery.
Anesthesia in eye care
Anesthesia is defined as a temporary state involving a lack of pain, loss of memory, muscle relaxation, and/or unconsciousness. In ophthalmology, anesthesia is very broad, ranging from the anesthetic eye drops used in clinic to the sedation and analgesia of cataract surgery and finally to the general anesthesia that may be used for strabismus or retinal surgery. Achieving this wide range of goals may require multiple classes of medications for anxiolytic (anti-anxiety), muscle relaxation, analgesia, and loss of awareness.
Except for a few minor office procedures which may require only eye drops, most patients for cataract, retinal, and many plastic procedures will undergo conscious sedation anesthesia either in the hospital or ambulatory surgery center (ASC) setting. Moderate sedation/analgesia (conscious sedation) is defined as the use of medication which allows patients to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function, protective reflexes, and the ability to respond purposefully to verbal and/or tactile stimulation.1
This is usually achieved through a combination of medications, first to relieve anxiety followed by an anesthetic agent which may be topical, locally injected, or systemic. The goal is to provide a safe and controlled environment for the surgeon while at the same time allow the patient to have a relaxed, pain-free experience with rapid return to normal activity.
Preparing for surgery
In preparation for surgery, all patients undergoing procedures in Medicare-approved facilities are required to have a comprehensive history and physical prior to the surgery. In 2010, CMS provided guidelines to clarify when this needs to be done and what it should include.2
The history and physical needs to be:
• Performed by qualified personnel
• Placed in the record prior to surgery
• May be combined with the pre-surgical assessment
• May not be more than 30 days in advance of the procedure
The purpose of the history and physical is to establish the patient’s chief complaint, record pertinent findings, and, when appropriate, record laboratory testing. The surgeon ultimately determines the need for the procedure, but much of the initial assessment starts with the technician. It is valuable to the surgeon not only to know the patient’s ocular complaint but also the patient’s perception of his problem as well as the patient’s ability to understand and communicate. Is the patient extremely anxious? Is the patient hard of hearing? What other ongoing medical problems and what medications, both prescribed and over the counter, are present? In addition, baseline vital signs, including height and weight, are essential to calculate dosages for anesthesia.
When the patient is scheduled to undergo a procedure requiring more than local anesthesia, he is usually given a medication first to relieve anxiety, followed by a medication to prevent pain. The medications that are given intravenously must have dosages adjusted for both age and physical condition. This is particularly true for our geriatric patients. Geriatrics is arbitrarily defined as age 65 or older, but aging is associated with a one percent to 1.5 percent decrease in major organ function after age 30.
The anesthesia provider will review the information in the history and physical to make a decision for what medications can be used. Many times with geriatrics, the anesthesia provider may need to reduce the doses by 30 percent to 50 percent and wait longer before being able to fully assess the full pharmacologic effect. This can be particularly true in the patient with multiple medical problems involving the heart, lungs, and kidneys in which the functional age may be much more than the chronological age. These observations of how a patient looks and acts when recorded in clinic will help the anesthesia provider develop a plan for the procedure.3
Anesthesia and medication
Medication history is important not only for allergies but also the increased risk of bleeding. Over-the-counter medications and herbals such as ginkgo biloba, ginseng, garlic, and ginger as well as high levels of Vitamin E have been associated with increased risk of bleeding. Again, it gets back to that initial assessment, making sure that all medications, including over-the-counter products, are recorded.
In the past, many doctors would have standing orders to discontinue blood thinners prior to surgery. “The issue of the medical-legal aspects is a very critical one… The older literature indicates that anticoagulation should be modified or discontinued prior to embarking on ocular surgery. But a more recent appraisal of the literature shows that certainly cataract surgery can be done safely despite anticoagulation.”4
The trend now is not to stop most anticoagulants prior to surgery, recognizing that the risk of discontinuing the medication may outweigh the risk associated with the procedure. It is acceptable to continue anticoagulants such as aspirin, clopidogrel (Plavix, Bristol-Myers Squibb), and warfarin (Coumadin, Bristol-Myers Squibb) for both cataract and retinal surgery, although many plastic and strabismus cases will still require some adjustment in blood thinners. If the ophthalmologist feels that blood thinners need to be limited or discontinued prior to the procedure, he may wish to seek evaluation from the patient’s internist prior to the procedure. This is especially true if the patient has a drug-eluting heart stent in which there is a risk of occlusion during the first year after placement of the stent.
Anesthesia, as discussed earlier, uses a wide range of topical, local, and systemic medications. For most cases within the ASC setting, this would involve an IV medication for analgesia or pain relief, amnesia, and relaxation. This is usually followed with a local anesthetic. Local anesthesia is the mainstay for ophthalmology, both in the office and ASC setting. This would include eye drops for topical anesthesia and local injection into the skin or around the globe with retrobulbar or peribulbar block not only to provide pain relief but limit motion of the globe.
There are two general classes of local anesthetics: esters and amides. Esters which include procaine (Novocain, Hospira) are no longer used routinely systemically; but most of our commercially available eye drops such as benoxinate (Fluress, Akorn), proparacaine, and tetracaine are esters. The amides are the injectable class of anesthetics. They include lidocaine, mepivacaine, and bupivacaine and may have additives such as epinephrine to prolong the effect. The ester class of anesthetics has been associated with an increased risk of allergic reaction which may include rash, redness, hives, and asthma; but the amides rarely have been reported to have significant allergic reaction. Because most topical anesthetics such as Fluress are esters, in the presence of a well-documented history of Novocain allergy or in the patient who has a documented reaction to the commercially available anesthetic drops, the use of preservative-free lidocaine can be substituted in the presence of a Novocain allergy.5
The amide anesthetics such as lidocaine have traditionally been used for injection into the skin or for peribulbar and retrobulbar anesthesia, both to numb the tissue and limit the movement. In recent years, lidocaine, either as a drop or gel form, has been used commonly in cataract surgery topically on the conjunctiva and in the preservative-free form of lidocaine within the eye. The addition of epinephrine to the intraocular lidocaine may reduce the risk of a tamsulosin-related complication called intraoperative floppy iris syndrome (IFIS).6
The success of the patient’s clinical and surgical experience depends greatly on the success of the anesthesia. The technician’s role as the first contact with the patient is critical in collecting key data to ensure a safe experience for the patient.
Every member of the ophthalmic team has an important role in the ultimate success of the clinical and surgical experience. It starts with the technician’s initial contact with the patient. The technician must gain the confidence of the patient, spend the time necessary to identify medications and potential risks, record these findings, and convey key information to the doctor and nurses or ASC staff.
1. AORN. (2013) Perioperative Standards and Recommended Practices. Denver, AORN, Inc.
2. Centers for Medicaid, CHIP, and Survey & Certification/Survey & Certification Group December 17, 2010. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter11_06.pdf. Accessed 8/25/14
3. Kost, M. (2004) Moderate Sedation/Analgesia Core Competencies for Practice (2nd ed.). St. Louis, Saunders.
4. Dayani, PN, Grand GM. Maintenance of warfarin anticoagulation for patients undergoing vitreoretinal surgery. Trans Am Ophthalmologic Soc. Dec 2006;104:149-160.
5. Dance D, Basti S, Koch D. Use of preservative-free lidocaine for cataract surgery in a patient allergic to “caines.” J Cataract Refract Surg. 2005 Apr;31(4):848-50.
6. Chang DF. ASCRS issues clinical alert on intracameral alpha agonists. EyeWorld. http://eyeworld.org/article.php?sid=6762. Accessed 8/25/14.