ADVANCED PROCEDURES IN OPTOMETRIC PRIMARY CARE JOHN NEAL, OD SCOTT ENSOR, OD, MS.

ADVANCED PROCEDURES IN OPTOMETRIC PRIMARY CARE

JOHN NEAL, ODSCOTT ENSOR, OD, MS

About the Lecturers

John Neal OD Southern College of Optometry 2007 Memphis VAMC Residency 2008 Assistant Professor at Southern College of Optometry 2008-2013 CAVHS 2013-Present Adjunct Faculty at Southern College of Optometry

Scott Ensor OD MS Southern College of Optometry 2001 Memphis VAMC Residency 2003 Eye Health Partners Assistant Director 2003-2007 Assistant Professor at Southern College of Optometry MS in Pharmacology/Toxicology, Michigan St University, 2013

No Disclosures

Standard of Care

The courts have ruled that

Optometry and Ophthalmology

are held to the same Standard

of Care.

The Optometrist must adhere to

the rules governing the practice of Optometry for his/her State/Province.

1045-02-.12 PRIMARY EYE CARE PROCEDURES. For the purpose of 1993 Public Acts Chapter 295

The performance of primary eye care procedures rational to the treatment of conditions or diseases of the eye or eyelid is determined by the board to be those procedures that could be performed in the optometrist’s office or other health care facilities that would require no more than a topical anesthetic. Laser surgery and radial keratotomy are excluded.

Authority: T.C.A. §§4-5-202, 4-5-204, 63-8-12, and Public Chapter 295, Acts of 1993. Administrative

History: Original rule filed February 14, 1993; effective April 30, 1994.

TN Senate Bill 220

Inclusions of Amendment

Needle drainage of eyelid abscess, hematoma, bulla and seroma

Excision of single epidermal lesion without characteristics of malignancy

Incision and curettage on non-recurrent chalazion

Simple repair of eyelid laceration no larger than 2.5cm, no deeper than orbicularis, not involving lid margin or lacrimal drainage

Removal of foreign bodies similar restrictions as above

Prohibitions of Amendment

Reconstruction of the eyelid Procedures not approved by

board of optometry prior to this bill becoming law

No larger than 5 mm No deeper than dermal layer of

skin

TN SB 220 cont

Informed Consent

Pt or representative have right to make informed decision re: care

Description of diagnosis Description of procedure including anesthesia Risk & benefits with likelihood of occurrence Alternative therapies Likely consequences of refusal of therapy Who will perform, will resident or extern be

involved All communicated in language that pt or PR can

understandhttp://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/scletter07-17.pdf

EHR?

What about obtaining e-signature? Physical signature is always your best bet

Informed Consent

Informed Consent

Safety

Occupational Safety and Health Organization-U.S. (OSHA)

-Developed under the Occupational Safety and Health Act (1970) -Standards for safety in most work environments

Infectious Control

Bloodborne Pathogens means pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, HBV and HIV.

Exposure control plan-Reviewed annually Sharps injury log Standard for safer medical devices

Self sheathing needles, engineered sharps container, etc.http://www.cdc.gov/HAI/settings/outpatient/checklist/outpatient-care-checklist.html

Universal Precautions-OSHA

Universal Precautions is an approach to infection control. According to the concept of Universal Precautions, all human blood and certain human body fluids are treated as if known to be infectious for HIV, HBV, and other bloodborne pathogens.

Body secretions such as urine, vomitus, feces, or sputum are not controlled under universal precautions, and are instead usually covered under a set of guidelines called body substance isolation.

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051 Bloodborne Pathogens standards

Standard Precautions-OSHA

Set of infection control strategies and standards designed to protect workers from exposure to potential sources of infectious diseases.

Based on the premise that all blood, body fluids, secretions, excretions, mucous membranes, non-intact skin or soiled items are potentially infectious. –Excludes sweat

Mainly adopted by healthcare providers Apply to all professions in which workers may

become exposed to infectious microorganisms through contact with blood and body fluids.

Risk Assessment

What task am I going to perform? What is the risk of exposure to: -Blood and body fluids including respiratory secretions? -Non-intact skin? Mucous membranes? -Body tissues? -Contaminated equipment? How competent/experienced am I in performing

this task? Will the patient be cooperative while I perform

the task?

Hand Hygiene

http://www.ccohs.ca/oshanswers/diseases/washing_hands.html

X 2

http://www.cdc.gov/handwashing/

Personal Protective Equipment

Determination of PPE based on anticipated exposure to blood or other potentially infectious body fluids during any given procedure

Use gloves or masks in warranted situations

Lab coats/surgical gown to protect clothing

Gloves

Latex? Nitrile? Neoprene? Avoid vinyl; reduced barrier protection.Use correct sizePowdered vs NonNon-sterile vs. sterile?

• >15% of healthcare workers exhibit latex allergyAmarasekera M, et al. prevalence of latex allergy among healthcare workers. Int J Occup Med Environ Health. 2010 23(4): 391-396

Proper Glove Removal

KEEP A CONSTA

NT

BARRIER!

Environmental Controls

Consistent and stringent equipment and work area cleaning

Proper disposal of waste such as sharps, biomedical, and pathological waste.

Appropriate ventilation and other engineering controls.

Installation of easily accessible and clearly identified waste containers, hand hygiene product dispensers, and dedicated hand wash sinks.

Effective placement and segregation of sources of contamination.

Sharps

Any item with corners edges, etc. capable of piercing skin Must be placed in red, OSHA compliant sharps container Containers should be easily accessible in the immediate area

where sharps are used

Handling Needles/Sharps

• Do not bend, recap, or remove contaminated needles and other sharps unless such an act is required by a specific procedure or has no feasible alternative

• Do not shear or break contaminated sharps. (OSHA defines contaminated as the presence or the reasonably anticipated presence of blood or other potentially infectious materials on an item or surface)

OSHA Compliant Sharps

Closable, puncture-resistant, leak-proof on sides and bottom. Accessible, maintained upright, and not allowed to overfill. Labeled or color coded Colored red/labeled with the biohazard Labeled in fluorescent orange/orange-red with lettering and

symbols in contrasting color Red bags may be substituted for labels

Biohazard/Biomedical Waste

Wastes other than sharps that contain blood, fluid or tissue which may transmit disease must be disposed of in red biohazard bags

Stored in a designated and secured area until pickup by waste management company

Regular scheduled pickups should be maintainedthroughout year

Storage of Medical Waste

Disposal

Care and disposal of such wastes can easily be arranged and coordinated through various pathogen control companies in your area They’ll supply bags, boxes, etc. and can arrange for pickup on

virtually any schedule: Weekly, monthly, quarterly, etc

Sharps containers, bags, etc. are also available through retailers of most surgical equipment

www.stericycle.com

Exposure Control Plan

According to the OSHA Bloodborne Pathogens Standard, an Exposure Control Plan must meet certain criteria:

It must be written specifically for each facility It must be reviewed and updated at least yearly (to reflect

changes such as new workers positions or technology used to reduce exposures to blood or body fluids)

It must be readily available to all workers You must regularly educate your workers on the uses of the

Exposure Control Plan and where it's kept, so it is available when needed

Systems Autoclave - (heat/steam)

Required for invasive surgery Cost $1200 - $6000

Ethyl Oxide - can also be used to sterilize instruments for intraocular surgery

Chemical - (germicide) is an inexpensive way to sterilize hand instruments

Sterilization

Autoclave

Autoclave Sterilization

Germicide is an inexpensive and effective way to sterilize instruments for minor surgery

Most require 10 minutes for disinfection and 10 hours for sterilization

Metricide

Chemical Sterilization

Surgical Tray

Image courtesy of David K Talley OD, FAAO

Surgical Instruments

Scissors Preferred over

scalpels for making sharp cuts, particularly with loose skin

Surgical Instruments

Blades/Scalpels The smaller the field,

the smaller the blade Blades dull quickly,

after 2-3 cuts

Equipment Pictures

Chalazion Clamp

Toothed Forceps

Surgical Scissors

Equipment Pictures

#11 Scalpel

Flat Forceps

Collection Materials

Specimen vials May be provided free of

charge by lab

Collection services Available in most areas. Can

schedule pickup as needed

Biopsy

Obtain histologic exam for all excised tissue

Set up account at local lab Lab will provide forms and vials for tissue

sample Complete pathology report and arrange for

pickup Review report at post-op 1 week

Biopsy

Path report courtesy Jennifer Snyder OD

Anesthesia

Appropriate anesthesia is required to ensure patient comfort and cooperation

The procedure will be much more difficult with insufficient anesthetia

Anesthesia Options

Conjunctival-Tetracaine-Lidocaine 4% sol-mucous membranes-Cetacaine-mucous membranes, toxic to cornea

Liquid, ung, sprayDermal Anesthesia -Lidocaine by liposomes -Iontophoresis -Injectable

Topical Anesthesia-Proparacaine

Onset within 30 sec Persists 15min or longer Indicated for tonometry,

foreign body removal, suture removal, conjunctival scraping, gonioscopic exam and prior to surgical operations such as cataract surgery

1-2 drops pre procedure Every 5 to 10 for deep

anesthesia ~$7.50/15mL

Topical Anesthesia-Tetracaine

Higher Viscosity Increase corneal contact time, deeper penetration, greater anesthetic effect

BAK preserved Indicated for procedures of short duration i.e. Tonometry, foreign body removal, suture removal

Better than Lidocaine Jelly?~$20/5mL

Topical Anesthetics-Lidocaine

• Onset of action between 20 to 60 seconds • persists 5 to 30 min or more• Viscous gel formulation for extended localized contact• Only FDA-approved lidocaine available for ocular

procedures• Preservative free• Recommended 2 drops prior to procedure• ~$45.00/5mL

Topical Anesthesia-Lidocaine Solution

Indicated for the production of topical anesthesia of accessible mucous membranes of the oral and nasal cavities and proximal portions of the digestive tract.

Good for off label, deeper anesthesia of the conjunctiva

Topical Anesthetics

Cetacaine Topical Anesthetic Spray

• Indicated for all mucous membranes except the eye

• Superior for anesthesia of the conjunctiva and procedures involving the nasolacrimal duct.

Cetacaine FACTOID

Cetacaine Topical Anesthetics are also available in liquid and gel forms.

Rapid onset within 30 seconds and effective for up to 60 minutes.

Slide courtesy of David K.Talley O.D.,FAAO

The Xylocaine Difference

Xylocaine 4% and 2%

Xylocaine 2% is for injection only and is available w/ or w/o epinephrine

Xylocaine 4% is for topical application only

Caution!

Xylocaine 2% with epinephrine can cause significant side effects

Hypertension in patients taking MOIs or TCAs

Phenothiazines and butyrophenones may reduce or reverse the beneficial effect of epinephrine

Types of Incisions

Stab – cuts and separates

Lineate – linear stab incisions

Excision – removes tissue

Snip – removes tissue

Marsupialization

Cruciate – cross pattern

Shave excision – biopsy

Radiosurgical – cut and cauterize

Lesion Removal

Incisional procedure Central piece of lesion removed Usually done for biopsy

Excisional procedure Removal of entire lesion

Lesion Removal

Excisional procedure Dissection with scissors Shave excision Punch excision

Identification of Lesions

Asymmetry

• Distinct vs Indistinct

Borders

• Consistent vs Mixed• Light, medium, or dark

Color

• Larger than 6mm

Diameter

Identification of Lesions

Other considerations

New vs chronic

Associated discoloration/loss of lashes

Associated pain

Associated redness

Evolving or changing lesion

Basal Cell Carcinoma

Examples of Common Lesions

Molluscum Chalazion Dermatosis Papulosis Nigra Subcutaneous Sebaceous Cyst Hidrocystoma Seborrheic Keratosis Papilloma

Sessile vs Pedunculated

Molluscum

Molluscum

Chalazion

Chalazion

Chronic Lipogranulomatous inflammation of the eyelid caused by obstructed sebaceous glands Deep or Superficial Typically painlessNoninfectious Most resolve spontaneously

Courtesy of Jason Duncan O.D, FAAO

Sebaceous Carcinoma

Rare, highly malignant, and potentially lethal tumor of the skin

Most commonly occurs in the eyelid

Lesions occur in meibomian glands, glands of zeis

Predominantly upper lidMust out in cases of recalcitrant chalazia

Image courtesy of Evan Silverstein, MD and Louise Mawn, MD http://eyewiki.aao.org/Sebaceous_carcinoma

Chalazion Histology

Chalazion Cures

Watch it/Warm Compress it Cut it Inject It

Images from Simon B, et al. Am J Ophthalmol 2011 Apr;151(4):714-718

TA>>I&C?

Simon B, Rosen N, Rosner M, Spierer A Am J Ophthalmol 2011 Apr;151(4):714-718

(TOP) LUL chalazion with only partial resolution 1 week p I&C

(Bottom) complete resolution after an injection of TA

I&C>>TA?

LUL chalazion (Top left) before, (Top right) 1 week p TA, and (Bottom left) 5 weeks after TA injection. Note that the lesion remained unchanged, as did small precipitates of TA. (Bottom right) The lesion underwent I&C with complete resolution.

Chalazion Surgical Set

Chalazion I&C

Asepsis

Antiseptic Agent

Mechanism of Action

Gram - Gram + Viruses Rapidity of Action

Precautions

Iodine/Betadine

Oxidation/substitution with free iodine

Excellent

Good Good Moderate Prolonged skin contact may cause irritation; Inactivated by blood and debris

Alcohol (Isopropyl or Ethyl Alcohol)

Denatures protein

Excellent

Excellent

Good Excellent Flammable

Table courtesy of Jennifer Snyder OD

Methods – Incision and Curettage

Chalazion – Technique Discussion

Apply anesthetic

Apply chalazion clamp

Perform cruciate incision

Vigorous curettage of area

Apply topical antibiotic

Chalazion I & C

Surgical Images Courtesy of Jason Duncan OD, FAAO

Chalazion I&C

Chalazion I & C

Chalazion I and C

General Surgical Approach

4 minute video on chalazion removal

Dermatosis Nigrans

Papilloma - sessile

Papilloma

Methods – Snip Excision

Pedunculated lesion Apply anesthetic Lift the lesion with

toothed forceps to access the base

Use a snip incision to excise the lesion

Apply pressure w/ gauze

Topical antibiotic ung

Snip Incision

Papilloma - pedunculated

Seborrheic Keratosis

Seborrheic Keratosis

Hidrocystoma

Hidrocystoma Histology

Subcutaneous sebaceous cyst

Zeiss Cyst Dissection

PRE POST

Equipment

Toothed forceps Chalazion Clamp Westcott scissors Flat forceps #11 scalpel Chemical Cautery

Kit

Sharps Container Gauze Gloves Tissues Anesthetic

Iris Scissors

Video Courtesy of David Talley OD, FAAO

Video on cyst removal

Wound closure

Prevent bacterial contamination Maintain apposition of wound edges until

scar tissue forms Distribute uniform tension along the entire

incision

Wound Closure Options

Wound Closure

Tissue adhesive/Dermabond Advanced™ Used on wounds with clean edges, do not

require deep sutures and are not under tension

Provides microbial barrier Wears off naturally 7-10 days Apply one thin layer in light

stroke while holding the wound together

Strong flexible bond in 2 ½ minutes Waterproofhttp://www.dermabond.com/product/how-it-works

Wound Closure

Tissue adhesive/Dermabond Advanced™ Do not get adhesive in the wound Do not apply liquid or ointment medications Cannot be used too close to the eye 2 year shelf life

http://www.dermabond.com/product/how-it-works

Dermabond Video

2:30 video on dermabond

Sutures

Indicated by the use of “0” -The more 0s the smaller i.e. 5-0< 3-0 Absorbable vs Nonabsorbable Synthetic polymer vs

Mammalian derived collagen Rate of absorption and tensile

strength duration will vary by material

http://www.dolphinsutures.com/types-of-sutures

Suture Characteristics

Configuration-single or multi stranded Size- in 0s Tensile Strength-ability to resist

breakage Knot Strength-force necessary to cause

slippage Elasticity and plasticity-ability to regain

form, retain form Handling-ease on bending, slipperiness Tissue Reaction-inflammation created

http://emedicine.medscape.com/article/1127693-overview

Some Suture Options

5-0 to 7-0 size Catgut -Absorbable within 7 days -Natural -Used for skin alignment, not for closing wounds under tension Prolene(Polypropylene) -nonabsorbable -synthetic -Good for lesions along the eyelid

Surgeon’s Knot

• The surgeon’s knot is an adaptation of the square knot

• Two helical twists in the first throw

• Additional twist increases the friction within the first throw

• Helps to hold it tight while the second throw is made

• Each twisting layer of the knot is called a throw

Pfenninger&Fowler’s Procedures for Primary Care 3rd Edition

Instrument Tie of Surgeon’s Knot

Video Courtesy Jennifer Snyder O.D.

1:40 video on knot tie

Wound Closure

Thermocautery High temp cauterization is effective at

closing small wounds and providing hemostasis

Wound Closure by Cautery

Close wound using direct pressure if lesion < 2 mm

Close wound using high temp cautery unit if > 2 mm

15 sec video

Newer Options

Chemical Cautery

Chemical Cautery Apply petroleum

jelly to the surrounding area

Apply cauterant to the lesion

Lesion will turn white

Scab will form

Chemical Cautery

RadioFrequency Concept

Ellman Radiofrequency Unit

http://www.ellman.com/

Ellman Electrodes

Pfenninger&Fowler’s Procedures for Primary Care 3rd Edition

Ellman Radiofrequency Unit

Radiofrequency System Advantages

Less tissue damage Faster healing Less scar formation

Radiofrequency Chalazion Sx

http://www.youtube.com/watch?v=PmX2w6EOZ0M

2:30 part 1

Radiofrequency Chalazion Cont….

http://www.youtube.com/watch?v=PmX2w6EOZ0M

1min part 2

Questions?

References http://classconnection.s3.amazonaws.com/980/flashcards/565980/png/chalazion1328138524523.p

ng

http://www.skinsight.com/images/dx/webAdult/dermatosisPapulosaNigra_42219_lg.jpg

http://flylib.com/books/3/283/1/html/2/10%20-%20Oculoplastics_files/C10FF43.png

http://eyecancerinfo.com/photogallery/2_5.JPG

http://www.dermaamin.com/site/images/clinical-pic/a/apocrine_hidrocystoma/apocrine_hidrocystoma1.jpg

http://www.moondragon.org/health/graphics/sebaceouscysteye.jpg

Melore G. “Lessons to Remove Lid Lesions and Anomalies” Review of Optometry April, 2005 pp 66-77

Ellman Radiosurgical Unit operational manual

http://www.aboutcancer.com/basal_cell_eye_1007.jpg

http://www.images.missionforvisionusa.org/