Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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346 Surgery and Healing in the Developing World
Procedure
The patient should be sedated and anaesthetized using facial and retrobulbar
blocks. Local anaesthetic drops should be applied to the eye, which should then be
massaged, with the lid closed for one minute. The patient should be prepared with
providone-iodine from hairline to chin and draped accordingly. The eye should
then be irrigated with copious amounts of sterile saline.
Retract the lids using an eyelid speculum. If one is not available, insert two 3/0
silk suture into the upper lid, just above the lash line, and one suture in the lower lid,
just below the lash line. These sutures can then be held with haemostats to provide
adequate lid retraction.
Locate the conjunctiva at the edge of the cornea that is nearest the patient’s
supraorbital margin. Grasp with toothed forceps. Locate the superior rectus tendon
and anchor with 3/0 thread. This causes the eye to rotate downwards. Incise a
semi-circle in the conjunctiva at its junction with the cornea. Separate the conjunctiva,
dissecting using conjunctival scissors. Make a further incision, within the margin
of the first, cutting through approximately half the corneoscleral tissue. Insert
an 8/0 suture crossing this incision at its midpoint.
Open the anterior chamber with a No. 11 blade and continue to extend the
corneoscleral incision using corneal scissors. Have an assistant gently lift the 8/0
suture. Grasp the iris, withdraw carefully and remove a small piece with iris scissors
to perform a peripheral iridectomy.
Grasp the anterior lens capsule with capsule forceps and gently extract. If the
capsule ruptures, remove the nucleus and wash out with sterile saline.
Tie the prepared 8/0 suture and place at least four others at the corneoscleral
incision. Reform the anterior chamber by injecting a small amount of air. The
conjuctiva should be drawn to form a flap, covering the suture line. Secure the
conjunctiva in place with two 8/0 sutures, one at either side of the incision margin.
Remove the rectus suture. Inject gentamicin 20 mg subconjunctivally and apply
tetracycline 1% eye ointment. Dress with a sterile pad. Tetracycline 1% eye ointment
should be used daily for 5 days, with hydrocortisone 1% eye ointment being
used in addition from day two. If treatment can be supervised, hydrocortisone ointment
may be continued for 2-3 weeks. Sutures should be removed after 2-3 weeks
and glasses provided.
Enucleation
Surgical removal of the eye should only be considered in patients who have a
malignant intraocular tumor or a painful, completely blind eye. Eye trauma is not
an indication; the damage should be repaired as best possible, and the patient referred.
In the case of the blind painful eye, an alternative to enucleating the eye is to
destroy its sensory nerves. This can be achieved by giving a retrobulbar block using
1 ml of 2% lidocaine and leaving the needle in place. When the block is effective, 2
ml of >50% alcohol should be injected. The orbit will become severely edematous
for 7-14 days. Chloramphenicol drops should be used 4x daily, for 7 days. This
treatment is not definite, and the condition may relapse and require further injections.