Deck 17: Ophthalmic Surgery

Question 1

When preparing for pars plana vitrectomy in the posterior segment,the perioperative nurse must be aware that a combined scleral buckling procedure may be necessary.Other important information the perioperative nurse should know before preparing the OR for the procedure includes the location of the ocular problem,the surgeon's plan to address the problem,and the instrumentation and biomedical equipment and devices to be used.Technologic advances in ophthalmic surgery require that perioperative nurses be familiar with complex biomedical equipment.A best practice,stated below,relevant to the safe use of complex equipment would be:

A) determine the presence and appropriate date (not expired) of the biomedical monitoring label.
B) demonstrate competence with equipment and check each piece carefully before the patient arrives in the OR.
C) schedule the manufacturer's representative to be present to provide technical support.
D) schedule the biomedical clinical engineer to check all equipment before each procedure.

Answer 1

B
Technologic advances in ophthalmic surgery require that perioperative nurses be competent to prepare and check each piece carefully before the patient arrives in the OR.

Question 2

Patients presenting for ophthalmic surgery may have endured chronic progressive impairment,or recent decrease,in visual acuity.Most patients are admitted through an ambulatory admission area adjacent to the surgical suite.Select an appropriate nursing action(s)when admitting the ophthalmic surgery patient.

A) Fully orient the patient to the physical surroundings.
B) Use detailed descriptions and reinforce them.
C) Approach the patient from the unaffected side to avoid startling the patient.
D) All of these interventions are appropriate for the ophthalmic surgery patient.

Answer 2

D
On admission,a staff member should fully orient the patient to the physical surroundings.Constant description and reinforcement are important to visually impaired patients.Approaching the patient from the unaffected side increases the patient's independence and decreases the possibility of startling the patient.

Question 3

To accommodate near and distant focus,the lens changes shape and focus by relaxation and tightening of the zonular fibers.What physiologic change of the normal aging process is typically corrected with bifocals?

A) Cataracts
B) Presbyopia
C) Glaucoma
D) Astigmatism

Answer 3

B
The lens changes shape and focus (accommodation)by relaxation and tightening of the zonular fibers.Over time (particularly after age 40),the lens and lens zonules become progressively less elastic,resulting in presbyopia.This loss of accommodative power is typically corrected with reading glasses or bifocals.

Question 4

Cycloplegic drugs produce a similar effect on the pupil as mydriatic drugs,with one difference.From the options below,select the most appropriate statement about the effects of cycloplegics.

A) Anticholinergics dilate the pupil and inhibit focusing.
B) Epinephrine is added to balanced salt solution (BSS) to constrict sclera vessels and the pupil.
C) Homatropine hydrobromide (Isopto Homatropine) sustains the longest and most potent duration of dilation.
D) Cycloplegics and mydriatics have similar effects on the pupil;however,cycloplegics preserve the patient's ability to refract light and focus.

Question 5

Miotics and mydriatics produce opposite effects on the pupil of the eye.Select the most appropriate statement about miotic and mydriatic drugs.

A) Miotic drugs are anticholinergic drugs useful in lowering intraocular pressure.
B) Mydriatic drugs,such as phenylephrine,dilate the pupil.
C) Miotic drugs dilate the pupil for posterior chamber access after lens removal.
D) Mydriatic drugs are often referred to as cycloplegics.

Question 6

Select the true statement about dacryocystorhinostomy (DCR).

A) A DCR is performed for chronic or recurrent dacryocystitis,which is also called epiphora.
B) A dacrolithotripsy is attempted if the DCR is unsuccessful.
C) DCR establishes a new passageway for tear drainage into the nasal cavity.
D) The passageway is usually restored with the use of ultrasonic lacrimal probes.

Question 7

Patients scheduled for enucleation,evisceration,or exenteration may present with other injuries or conditions that will impact their care and recovery.During nursing assessment,the perioperative nurse should review the patient's record for the presence of conditions or injuries related to the surgical diagnosis that may impact a successful surgical outcome and recovery.Select the patient statement from the list below that is an example of a related secondary condition that may impact the patient's care.

A) "I think I must be coming down with a chest cold or the flu."
B) "I'm still feeling a little weak since I had my last chemo treatment."
C) "Yes,I took my blood pressure and cholesterol pills this morning with a sip of water."
D) "Will they give me some sedation soon? I think I might have a panic attack."

Question 8

Sutures used in ophthalmic surgery are very fine and range in size from 4-0 to 10-0.Handling and arming these sutures can be a challenge for the perioperative nurse with uncorrected presbyopia.Eye sutures should be handled as little as possible to avoid:

A) weakening and fraying.
B) causing the formation of needle burrs.
C) losing sutures among the drapes or on the floor.
D) reaction and discomfort for the patient.

Question 9

The extraocular muscles work in yoked pairs,with ocular movements generated by an increase in the tone of one set of muscles and a decrease in the tone of the antagonistic muscles.Of the two muscle types,how many are represented in each eye?

A) Two recti muscles and four oblique muscles
B) Two superior muscles and one lateral muscle
C) Four recti muscles and two oblique muscles
D) Two inferior muscles and two medial muscles

Question 10

The perioperative nurse prepares a sterile treatment set-up for the surgeon to use before the DCR operative procedure is started.Select the statement that describes the justification for this sterile treatment set-up.

A) The surgeon will cut and mold the nasal splint to size before the nose becomes edematous.
B) The silastic tubing needs to be cut to size and soaked during the procedure.
C) The skin markings,with methylene blue,are done on clean skin before the skin prep.
D) The nasal cavity is anesthetized with cocaine and a local anesthetic is administered.

Question 11

Local anesthesia,or monitored anesthesia care (MAC),is used for most ophthalmic surgery.The local anesthetic regimen,administered by the operative surgeon,is typically a combination of anesthesia delivery methods,or routes.Select the anesthetic plan that is administered by the surgeon before the start of surgery.

A) Subconjunctival block and topical anesthetic eye ointment
B) Topical anesthetic eye drops,subconjunctival infiltration,and retrobulbar block
C) Ganglionic infiltration and periorbital block of the anterior chamber
D) Peribulbar infusion into Tenon's capsule and periorbital skin infiltration

Question 12

The nurse must ensure that the microscope used in ophthalmic surgery is specifically intended for safe use in eye surgery.The perioperative nurse must also be familiar with adjusting the pupillary distance (distance between pupils of the user's eyes)and diopter settings on the oculars (eyepieces)for operator vision correction to work without eyeglasses.How should the oculars be set for a user with astigmatism?

A) Set the oculars to the same diopters as the user's corrective lenses.
B) Set the oculars to the half setting of the diopters of the user's corrective lenses.
C) Set the oculars at zero;users should wear their eyeglasses.
D) None of these options are appropriate for a user with astigmatism.

Question 13

Anesthetic management impacts the success of ophthalmic surgery.Safe ambulatory surgery,especially in certain populations,depends on patient selection,preoperative evaluation,preparation,monitoring,and local anesthesia techniques.Select the patient below that would be an appropriate candidate for general anesthesia,instead of local anesthesia alone.

A) A 78-year-old patient with dementia and claustrophobia
B) A 48-year-old healthy male with mild head tremors
C) A 22-year-old healthy female for a tear duct probing
D) All of the patients are general anesthesia candidates.

Question 14

How does the lacrimal gland differ from the lacrimal sac?

A) The lacrimal gland produces hormones that stimulate the lacrimal sac to secrete tears.
B) The lacrimal sac stores and concentrates the tears secreted by the lacrimal gland.
C) The lacrimal gland and lacrimal sac are the same structure.
D) The lacrimal gland secretes tears that are drained by the lacrimal sac and duct system.

Question 15

Oculocardiac reflex (OCR)is an intraoperative emergency that can occur during eye surgery.It is characterized by bradycardia that can lead to asystole,hypotension,and a wide range of other dysrhythmias attributable to negative inotropic and conduction effects.Select the definition of the response and contributing factor(s).

A) Trigeminal-vagal response caused by pressure on the globe or retrobulbar block
B) Increased intracranial pressure response to traction on extraocular muscles
C) Adrenergic response to effect of retrobulbar block on the pituitary
D) Lidocaine toxicity caused by intravascular uptake of retrobulbar anesthetic

Question 16

Select the appropriate procedure performed for a patient with Fuchs' dystrophy,edema after cataract surgery,or keratoconus (abnormal steepening)of the cornea.

A) Keratoplasty
B) Keratorefraction
C) Laser epithelial keratomileusis
D) Laser-assisted in-situ keratomileusis

Question 17

The refractive apparatus of the eye directs (refracts)the light rays to strike the:

A) retina.
B) optic nerve.
C) vitreous body.
D) lateral geniculate body.

Question 18

A cataract is defined as any opacification of the lens.Cataracts may be congenital,posttraumatic,or induced by medications,but are most commonly the result of age-related changes.Which of the following statements about cataracts best describes its presentation or etiology (cause)?

A) A cataract can be compared to a window that is frosted or yellowed.
B) Cataracts can be classified as brittle or pliable,based on collagen matrix fibers in the capsule.
C) Cataracts are an early sign of type 1 diabetes.
D) The cloudiness is caused by clumping of lipoproteins in the lens capsule.

Question 19

Select the true statement about antimetabolite drugs and their indications for use.

A) These cytotoxic/antineoplastic drugs are also useful as thrombolytic agents.
B) Antimetabolites are regulated by TPA and facility policies.
C) 5-Fluorouracil and mitomycin can both be administered topically to dissolve scars and pterygia.
D) Denuded corneal epithelium responds positively to topical applications of mitomycin.

Question 20

A wide range of equipment is used in ophthalmic surgery.The perioperative team's knowledge of proper operation should be confirmed through inservice education and training specific to new equipment,plus demonstrated competency.To ensure patient safety and appropriate function and application of surgical devices,which statement best reflects recommended practice when using complex biomedical equipment?

A) Use the device according to the manufacturer's directions and test for proper performance before the patient enters the OR.
B) Follow the policy and procedure of the facility and/or unit,and request biomedical support.
C) Request assistance and technical support from the appropriate vendor representative;encourage the vendor to operate the device or equipment,or request biomedical support.
D) Follow the explanation and demonstration as originally provided by the preceptor during orientation.

Question 21

Vitrectomy is narrowly defined as removal of all or part of the vitreous gel (body).Vitrectomy can also vacuum any pooled blood to enhance visual clarity.Select all indications and complications that apply to vitrectomy.

A)Excision of fibrotic membranes
B)Electrocoagulation of bleeding vessels
C)Extraction of floaters
D)Removal of retained foreign bodies
E)Infection
F)Retinal tears and detachment
G)Total vision loss.
H)Cataract

Question 22

The procedure for cataract extraction with implantation of an intraocular lens (IOL)exposes the patient to risks of infection of the anterior chamber and corruption of the implanted device.Appropriate measures for the circulating nurse and scrub person include managing patient safety needs.Efforts are directed at preventing foreign substances from being introduced intraocularly.Select all of the nursing actions that may ensure this outcome.

A)The sterile field should be created with lint-free drapes.
B)Powder-free gloves should be worn.
C)Instruments should be cleaned with gauze sponges.
D)Gloved hands should not touch the intraocular tip of the instrument.
E)Instruments should be soaked in sterile water when not in use.f.The procedure room should be warm,quiet,and peaceful.

Question 23

Toxic anterior segment syndrome (TASS),also known as sterile endophthalmitis,is a sterile noninfectious form of acute inflammation that occurs after eye surgery (typically cataract surgery).It frequently begins within 24 hours after surgery and is characterized by decreased vision,significant corneal edema,and moderate to severe inflammation in the anterior chamber of the eye.Select all of the possible causes and risk reduction strategy statements.

A)Introduction of an infectious,toxic substance into the anterior chamber during surgery
B)Introduction of a noninfectious,toxic substance into the anterior chamber during surgery
C)Introduction of sterile lint or debris into the anterior chamber during surgery
D)Introduction of sterile mineral deposits into the anterior chamber during surgery
E)Educate patient/family about signs and symptoms of TASS before discharge.f.Practice vigilant compliance with cleaning,disinfection,and sterilization of equipment and instrumentation.

Question 24

Anna Lindeman,a 59-year-old woman with a significant retinal tear close to the macula,emerges from anesthesia in the PACU after a 4-hour pneumatic retinopexy with scleral buckling,posterior vitrectomy,and injection of a gas bubble to close and support the retinal tear.She will have to maintain a face-down head position for 7 to 10 days,followed by laser surgery or cryotherapy to seal the tear.As she prepares for discharge from the PACU,she informs the perioperative nurse that she has reserved a flight to Denver,Colorado in 3 weeks to visit friends and celebrate the end of her ophthalmic surgeries and survival of sustained face-down positioning during recovery.The nurse firmly informs Anna that she should cancel and delay her trip until the surgeon approves that type of travel.What statement below justifies the nurse's response to Anna's vacation plans?

A) Facial edema from sustained face-down position will not have resolved within the time frame before her vacation.
B) Airplane cabin pressure and recirculated air are significant risk factors for infection after complex vitreous surgery.
C) The dry air and high elevation of Denver will dehydrate the cornea and sclera,causing the sclera to buckle and the tear to loosen.
D) Airplane cabin pressure and high elevations will cause severe enlargement of the gas bubble and increase intraocular pressure.

Question 25

MATCHING
Match the three descriptive statements with their appropriate globe and orbital surgical procedures.
a.Removal of the eye contents with sclera and muscles left intact
b.Removal of the entire orbital contents,including the periosteum
c.Removal of the entire globe,severing muscular attachments and optic nerve
Enucleation

Question 26

MATCHING
Match the three descriptive statements with their appropriate globe and orbital surgical procedures.
a.Removal of the eye contents with sclera and muscles left intact
b.Removal of the entire orbital contents,including the periosteum
c.Removal of the entire globe,severing muscular attachments and optic nerve
Exenteration

Question 27

MATCHING
Match the three descriptive statements with their appropriate globe and orbital surgical procedures.
a.Removal of the eye contents with sclera and muscles left intact
b.Removal of the entire orbital contents,including the periosteum
c.Removal of the entire globe,severing muscular attachments and optic nerve
Evisceration