Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Ophthalmology
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thalmic set prepared. All instruments should be sterilized in an autoclave before
reuse but, for emergency sterilization, instruments may be immersed in 70% ethanol
for 1 hour. Good illumination is invaluable; a bright focused beam is required
and should be backed up with head-light. Fine sutures are required. It is advisable to
practice using them before you are required to do so in an emergency situation. 8/0
is the smallest suture that can be practically used without a microscope. Before surgery,
the patient should be treated 24 hours with antibiotic eye drops. On the day of
surgery, irrigate the eye with sterile saline and mark on the patient the eye to be
operated on. The lashes should be cut to minimize the risk of infection.
General anaesthesia is recommended for major intraocular surgery and for children.
Otherwise regional anaesthesia, such as facial (7 th cranial nerve) and retrobulbar
blocks, may be used.
Postoperative care for extraocular surgery consists of changing the dressing on
the first day after surgery and using 1-2% tetracycline ointment for 7-14 days. Sutures
should be removed after about 5-14 days. Intraocular surgery requires greater
postoperative care, and patients should remain in hospital for 5 days more. Clean
dressing and appropiate medication should be applied daily. Conjunctival sutures
should be removed after one week, corneoscleral suture after 3 weeks.
Entropion Repair
Temporary relief from trichiasis can be gained through removal of the lashes
using forceps under local anaesthesia. If the condition has progressed to entropion
(where the lid margin is also inverted), surgery is required.
Procedure
The lids should be cleaned with sterile saline and the area draped. Topical anaesthetic
should be applied to the eye. Local anaesthetic (lidocaine) should be injected
into the lid at two points along a horizontal line midway between the lid margin and
the eyebrow.
Evert the lid and grasp the tarsal surface with forceps. Incise the palpebral conjunctiva
2 mm from the lid margin. Undercut the tarsal plate on both sides of this
incision, including the entire lash-baring area. Insert two 4/0 mattress sutures through
the lid and the larger tarsal flap. This will pull the flap inferiorly, everting both the
lashes and the lid margin. The distal tarsal flap should remain unstitched.
Cataract Extraction
Cataract extraction is primarily an operation to improve sight but may also be
performed to relieve secondary glaucoma. Patients with bilateral cataracts should be
operated on when their vision is less than 6/60. If the patient is blind in one eye and
has a cataract in the other, surgery should be delayed until the patient has difficulty
coping on his or her own. If surgery is performed before this time, there is the risk of
complications leading to complete blindness.
Cataract extraction may be perfomed in small hospitals but should only be done
by doctors who have received the appropriate surgical training. The following guide
is designed only to help you remember the stages in such an operation. On admission
the patient should receive standard preoperative care in addition to acetazolamide
250 mg orally, 8 hours and 2 hours before surgery. Intracapsular extraction is
less technical and less prone to complications, and is therefore recommended.
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