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Surgical Procedures and Enucleation
Orbital surgeries may be performed to repair fractures, remove a foreign body, or remove benign or malignant growths. Surgical procedures involving the orbit and lids affect facial appearance (ie, cosmesis). The goals are to recover and preserve visual func-tion and to maintain the anatomic relationship of the ocular structures to achieve cosmesis. During the repair of orbital frac-tures, the orbital bones are realigned to follow the anatomic positions of facial structures.
Orbital surgical procedures involve working around delicate structures of the eye, such as the optic nerve, retinal blood vessels, and ocular muscles. Complications of orbital surgical procedures may include blindness as a result of damage to the optic nerve and its blood supply. Sudden pain and loss of vision may indicate in-traorbital hemorrhage or compression of the optic nerve. Ptosis and diplopia may result from trauma to the extraocular muscles during the surgical procedure, but these conditions typically re-solve after a few weeks.
Prophylaxis with intravenous antibiotics is the usual postopera-tive regimen after orbital surgery, especially with repair of orbital fractures and intraorbital foreign body removal. Intravenous cor-ticosteroids are used if there is a concern about optic nerve swelling. Topical ocular antibiotics are typically instilled, and an-tibiotic ointments are applied externally to the skin suture sites.
For the first 24 to 48 hours postoperatively, ice compresses are applied over the periocular area to decrease periorbital swelling, facial swelling, and hematoma. The head of the patient’s bed should be elevated to a comfortable position (30 to 45 degrees).
Discharge teaching should include medication instructions for oral antibiotics, instillation of ophthalmic medications, and ap-plication of ocular compresses.
Enucleation is the removal of the entire eye and part of the optic nerve. It may be performed for the following conditions:
· Severe injury resulting in prolapse of uveal tissue or loss of light projection or perception
· An irritated, blind, painful, deformed, or disfigured eye, usually caused by glaucoma, retinal detachment, or chronic inflammation
· An eye without useful vision that is producing or has pro-duced sympathetic ophthalmia in the other eye
· Intraocular tumors that are untreatable by other means
The procedure for enucleation involves the separation and cutting of each of the ocular muscles, dissection of the Tenon’s capsule (ie, fibrous membrane covering the sclera), and the cut-ting of the optic nerve from the eyeball. The insertion of an or-bital implant typically follows, and the conjunctiva is closed. A large pressure dressing is applied over the area.
Evisceration involves the surgical removal of the intraocularcontents through an incision or opening in the cornea or sclera. The optic nerve, sclera, extraocular muscles, and sometimes, thecornea are left intact. The main advantage of evisceration over enucleation is that the final cosmetic result and motility after fit-ting the ocular prosthesis are enhanced. This procedure would be more acceptable to a patient whose concept of the alteration of body image is severely threatened. The main disadvantage is the high risk of sympathetic ophthalmia.
Exenteration is the removal of the eyelids, the eye, and vari-ous amounts of orbital contents. It is indicated in malignancies in the orbit that are life threatening or when more conservative modalities of treatment have failed or are inappropriate. An ex-ample is squamous cell carcinoma of the paranasal sinuses, skin, and conjunctiva with deep orbital involvement. In its most ex-tensive form, exenteration may include the removal of all orbital tissues and resection of the orbital bones.
Orbital implants and conformers (ie, ocular prostheses usually made of silicone rubber) maintain the shape of the eye after enu-cleation or evisceration to prevent a contracted sunken appear-ance. The temporary conformer is placed over the conjunctival closure after the implantation of an orbital implant. A conformer is placed after the enucleation or evisceration procedure to pro-tect the suture line, maintain the fornices, prevent contracture of the socket in preparation for the ocular prosthesis, and promote the integrity of the eyelids.
All ocular prosthetics have limitations in their motility. There are two designs of eye prostheses. The anophthalmic ocular pros-theses are used in the absence of the globe. Scleral shells look just like the anophthalmic prosthesis (Fig. 58-19) but are thinner and fit over a globe with intact corneal sensation. An eye prosthesis usually lasts about 6 years, depending on the quality of fit, com-fort, and cosmetic appearance. When the anophthalmic socket is completely healed, conformers are replaced with prosthetic eyes.
An ocularist is a specially trained and skilled professional who makes prosthetic eyes. After the ophthalmologist is satisfied that the anophthalmic socket is completely healed and is ready for prosthetic fitting, the patient is referred to an ocularist. The heal-ing period is usually 6 to 8 weeks. It is advisable for the patient to have a consultation with the ocularist before the fitting. Obtain-ing accurate information and verbalizing concerns can lessen anx-iety about wearing an ocular prosthesis.
Removal of an eye has physical, social, and psychological rami-fications for any person. The significance of loss of the eye and vision must be addressed in the plan of care. The patient’s prep-aration should include information about the surgical procedure and placement of orbital implants and conformers and the avail-ability of ocular prosthetics to enhance cosmetic appearance. In some cases, patients may choose to see an ocularist before the surgery to discuss ocular prosthetics.
Patients who undergo eye removal need to know that they will usually have a large ocular pressure dressing, which is typically removed after a week, and that an ophthalmic topical antibiotic ointment is applied in the socket three times daily.
After the removal of an eye, there is a loss of depth perception. Patients must be advised to take extra caution in their ambula-tion and movement to avoid miscalculations that may result in injury. It may take some time to adjust to monocular vision.
The patient must be advised that conformers may accidentally fall out of the socket. If this happens, the conformer must be washed, wiped dry, and placed back in the socket. When surgical eye removal is unexpected, such as in severe ocular trauma, leav-ing no time for the patient and family to prepare for the loss, the nurse’s role in providing reassurance and emotional support is crucial.
Teaching Patients Self-Care.Patients need to be taught how toinsert, remove, and care for the prosthetic eye. Proper hand wash-ing must be observed before inserting and removing an ocular prosthesis. A suction cup may be used if there are problems with manual dexterity. Precautions, such as draping a towel over the sink and closing the sink drain, must be taken to avoid loss of the prosthesis. When instructing patients or family members, a re-turn demonstration is important to assess the level of under-standing and ability to perform the procedure.
Before insertion, the inner punctal or outer lateral aspects and the superior and inferior aspects of the prosthesis must be identi-fied by locating the identifying marks, such as a reddish color in the inner punctal area. For people with low vision, other forms of identifying markers, such as dots or notches, are used. The upper lid is raised high enough to create a space; then the patient learns to slide the prosthesis up, underneath, and behind the upper eyelid. Meanwhile, the patient pulls the lower eyelid down to help put the prosthesis in place and to have its inferior edge fall back gradually to the lower eyelid. The lower eyelid is checked for correct positioning.
To remove the prosthesis, the patient cups one hand on the cheek to catch the prosthesis, places the forefinger of the free hand against the midportion of the lower eyelid, and gazes upward. Gazing upward brings the inferior edge of the prosthesis nearer the inferior eyelid margin. With the finger pushing inward, downward, and laterally against the lower eyelid, the prosthesis slides out, and the cupped hand acts as the receptacle.
Continuing Care.An eye prosthesis can be worn and left in placefor several months. Hygiene and comfort are usually maintained with daily irrigation of the prosthesis in place with the use of abalanced salt solution, hard contact lens solution, or artificial tears. In the case of dry eye symptoms, the use of ophthalmic ointment lubricants or oil-based drops, such as vitamin E and mineral oil, can be helpful. Removing crusting and mucous discharge that accumulates overnight is performed with the prosthesis in place. Malpositions may occur when wiping or rubbing the prosthesis in the socket. The prosthesis can be turned back in place with the use of clean fingers. Proper wiping of the prosthesis should be a gentle temporal-to-nasal motion to avoid malpositions.
The prosthesis needs to be removed and cleaned when it be-comes uncomfortable and when there is increased mucous dis-charge. The socket should also be rendered free of mucus and inspected for any signs of infection. Any unusual discomfort, irritation, or redness of the globe or eyelids may indicate exces-sive wear, debris under the shell, or lack of proper hygiene. Any infection or irritation that does not subside needs medical attention.
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