Cornea

Assisting with minor procedures

Part four of a seven-part corneal/anterior segment survival guide.

BY STEPHANIE D. MCMILLAN, MHA, COT

For technicians, there may come a time when your physician wants you to assist with performing a minor surgical procedure. Minor procedures, performed in the examination room or the minor operating room, can range from a simple swab to more complex biopsies. After the corneal specialist determines the appropriate treatment for a patient, it is up to the technician to prepare materials, instruments, and the patient for the upcoming procedure.

While technique may vary among the physicians, the ophthalmic assistant’s job remains constant, with more involvement in pre-operative care, ophthalmic instruments, aseptic technique, local and topical anesthesia, and pharmacology.

Pre-operative care

Timely organization of patients and materials is an essential part of the job of the ophthalmic assistant who assists in minor procedures. Patient education and obtaining consent may also be involved. Patient education can be provided via handouts, electronic media, or verbal discussion. Assistants inform the patients of steps they need to take before the procedure, such as not wearing make-up or bringing a companion to drive them home. Also, they discuss any ocular or systemic medications, whether the patient should start or stop those medications before surgery and what the patient should expect during the procedure.

Informed consent contains risks and benefits of the procedure, possible complications, explanation of alternative treatments, and detailed explanation of the procedure. While the ophthalmic assistant may explain and answer questions, the physician should obtain the actual consent.

Aseptic technique or clean technique

In 2013, the Joint Commission defined aseptic technique as a method used to prevent contamination with microorganisms and requires the use of various barriers, such as sterile gloves, gowns, drapes, and masks, to prevent the transfer of microorganisms from health-care personnel and the environment to the patient during a procedure. Conversely, clean technique requires reducing the risk of contamination with the use of hand hygiene and clean gloves. In essence, many procedures performed in the exam room can be classified as clean, while procedures in a minor operating room are aseptic.

Pharmacology

Basic knowledge of ophthalmic medications is essential for ophthalmic technical personnel who assist in surgical cases. An informed technician will be less likely to make mistakes and be able to anticipate what and when the physician needs a medication (For a list of common ophthalmic medications, their uses and possible adverse reactions, see the online version of this article).

Ocular treatments

While assisting the corneal specialist, we are constantly learning the best treatment options utilized on corneal pathologies. With any procedure, it is helpful for the technician to become familiar with the ophthalmic instruments and materials needed. Creating a preference list, composed of medications, materials, and instruments saves time and projects a sense of confidence to the physician and patient.

Ophthalmic technicians should be aware of the following corneal treatments if working in a cornea clinic.

• Superficial keratectomy. This procedure is performed for a number of reasons with the intention of a healthy reforming epithelium without pathology. Reasons for a superficial keratectomy include:

1. ◦ Anterior basement membrane dystrophy

   ◦ Salzmann’s nodular degeneration

   ◦ Neurotrophic epithelial defects

   ◦ Map dot fingerprint corneal dystrophy

   ◦ Recurrent corneal erosion

   ◦ Band keratopathy in conjunction with EDTA chelation

   ◦ Epithelial ingrowth after LASIK

The physician may perform this removal of epithelial cells with a combination manual and mechanical methods. The manual method involves smoothing the corneal surface with a blunt instrument. Mechanical methods of removing the epithelial involve the use of a burr instrument.

Ophthalmic assistants should prepare for the procedure by organizing instruments and materials ahead of time based on the physician’s preference list. Pre-packaged kits are an alternative to ordering each supply individually.

• Sutureless amniotic membrane (AM). The innermost layer of the placenta can be used to treat ocular inflammation. The graft is placed on the cornea to prevent scarring and treat severe dry eyes, neurotrophic ulcers, and other epithelial defects. The AM is usually removed after seven to 10 days in most cases, however in some cases the AM may persist for a month. AM can be acquired in dehydrated or cryopreserved form. Again, keep in mind the physician preference for the assistant to prepare accordingly. Ophthalmic personnel can also help with pre-operative testing and patient education, which helps guide the physician in the type of AM to use.

• Corneal collagen cross-linking. Corneal collagen cross-linking is performed to treat keratoconus and ectasia after LASIK. Liquid riboflavin is applied to the cornea and reacts with ultraviolet (UV) light to stabilize and sometimes strengthen the cornea. Recently approved by the FDA, corneal cross-linking is now performed on a routine basis for sufferers of degenerative cornea disease with the aim to stop the progression of irregular cornea shape. The technician prepares the patient for the procedure and performs pre-operative testing, such as refraction and topography, and administers anesthetic drops. Once the physician debrides the epithelium, the technician administers the riboflavin drops until absorbed into the anterior chamber. UV light is then administered for up to 30 minutes, followed by a bandage contact lens for comfort as the epithelium regrows. OP

Basic ophthalmic medications:

Minor procedure instrument kit with speculum, scissors, and forceps.

	Kendall E. Donaldson, MD, MS, is associate professor of ophthalmology and medical director of Bascom Palmer Eye Institute in Plantation, Fla.
	Stephanie D. McMillan, MHA, COT, is the lead ophthalmic technician and a clinical and informatics trainer at Bascom Palmer Eye Institute in Plantation, Fla.