The Operation Day - More

The Operation Day

This section provides more information about the events on the operation day and what to expect. It expands on the brief explanation given on the previous page. It includes information about:

• The preparations before going to the operating theatre
• Getting to the operating theatre
• What happens in the anaesthetic room
• What happens in the operating theatre
• What happens after returning from the operating theatre

To Recap

Each hospital or cataract surgery centre will have their own specific arrangements and procedures for patients on the day of the operation. Hopefully the patient will have been made aware of these in advance. The information given here should be considered as a guide only.

Preparations Before Going to the Operating Theatre

Certain preparations will need to be gone through in order to get the patient ready for their visit to the operating theatre. These are listed below although they may not happen in the order stated.

• The patient's identity must be confirmed. The nursing staff will run through and confirm personal details with the patient. An identity bracelet may be attached around the patient's wrist.
• The discharge arrangements will be confirmed with the patient. These include such things as how the patient will be getting home and who will be escorting them.
• The medical notes and paperwork will be checked. The operation to be performed is confirmed with the patient. If the consent form has not previously been completed this will be done.
• The patient's blood pressure and temperature may be taken. The patient may be asked if they have suffered any health problems since they were last seen and especially since the pre-operative assessment was performed. In specific cases last minute tests may need to be performed, e.g. a blood sugar measurement in patients with diabetes. One of the aims of the pre-operative assessments is to minimise the number of 'on the day' tests.
• The patient may be asked when they last had anything to eat or drink. If the operation is to be under a general anaesthetic most anaesthetists require the patient to have had "nil by mouth" for 6 hours. However most cataract operation are performed under some form of local anaesthetic. If no sedation is used it is then often not necessary for the patient to have been formally 'starved'. Indeed some food intact in the hours leading up to the operation may be wise particularly for patients with diabetes. Opinions on limiting food and drink prior to eye surgery do differ amongst anaesthetists and eye surgeons.
• Dilating drops are placed into the eye to dilate the pupil. A large pupil makes it easier for the surgeon to see and remove the cataract safely and efficiently.

Getting to the Operating Theatre

Within eye units in the UK there is a wide variation in the manner in which the patient is taken to the operating theatre. This may depend on the distance form the eye ward or day case unit to the operating theatre, and on the health and mobility of the patient. When the surgery is to be performed under a local anaesthetic there are advantages in keeping the arrangements simple. Progressive units permit the patients to remain in their own (clean and tidy) clothes, or to have a simple gown worn around these. A theatre hat and over shoes may be required. Special wheeled recline-able chairs may be used. The patient is seated in this on the ward and pushed to the operating theatre on it. Once in theatre the chair may be reclined into a lying position for the surgery. Once this has been completed the seated position is resumed and the patient returned to the ward without ever having had to get on and of any trolley or operating table. This arrangement is safe and ergonomically efficient. In some units fit mobile patients may be permitted to walk to and from theatre with assistance. In more conventional units hospital trolleys and tables are still used and these are certainly necessary if the surgery is to be performed under a general anaesthetic.

In the Anaesthetic Room

The anaesthetic room is usually immediately adjacent to the operating theatre. As the name suggests it is where the anaesthetic is administered and the final preparations are completed. All staff within the theatre complex, which includes the anaesthetic room, will be dressed in theatre clothes and hats. These are pyjama like shirts, trousers and dresses.

The steps taken just before the operation, and often performed in the anaesthetic room, will depend upon the form of anaesthetic to be used and may vary a little from one eye unit to another.

• A cannula (very fine tube) may be placed into a vein, usually on the back of the hand, wrist area or forearm. This will feel like an injection as a needle is used to introduce the cannula into the vein. The needle is then removed leaving the cannula in place. For a local anaesthetic this is done for safety reasons. It will allow life saving drugs to be given rapidly in the unlikely event of a medical emergency. For a general anaesthetic the drugs that induce (bring on) unconsciousness will be injected via this intravenous cannula.
• A clip like device will be placed over one finger tip. This is called a pulse-oximeter. It measures the patient's pulse during the operation and the amount of oxygen in the blood stream.
• Heart monitor (ECG or electrocardiogram) tabs, usually three, may be placed on the upper chest or forearms. These are about twice the size of a 10p coin and stick to the skin. Wires are then clipped to them to monitor the heart. These are always used for a general anaesthetic but may be omitted if the operation is under a local anaesthetic.
• For a general anaesthetic a blood pressure cuff may be placed around one upper arm.

If the patient is to have a general anaesthetic it is usual practice in the UK for the patient to be "put to sleep" in the anaesthetic room and then moved through to the operating theatre already unconscious.

If a local anaesthetic is to be used this is sometimes administered in the operating theatre itself. However it often helps with patient through put for the local anaesthetic to be given in the anaesthetic room. In this way one patient can be receiving their local anaesthetic whilst another is undergoing surgery in the adjacent theatre. This allows time for the anaesthetic to take effect and the patient can be transferred to the operating theatre as soon as it is vacated.

What Happens in the Operating Theatre

In the operating theatre the patient is positioned reasonably flat on their back. The critical factor is to have the face level, i.e. to have the brow and chin at about the same height. This will give the surgeon the best access to the eye and therefore the best conditions for successful surgery. Under a local anaesthetic some patients may find it difficult or impossible to lie perfectly flat. With a little imagination and adjustment it is usually possible to obtain an acceptable position. For example the chest may propped up slightly but if the chin is elevated the face will still be level. The head needs to be stable and unmoving during the operation and special head rests facilitate this.

During a cataract operation there are a number of personnel in the theatre who collectively make up the theatre team. They are the surgeon, the anaesthetist and/or anaesthetic assistant, the scrub nurse, other nurses and theatre assistants. Many eye theatres carry out teaching and training of staff and any one of the above personnel may have a colleague or student with them undergoing training.

The expression "scrub nurse" is traditionally used to indicate the nurse that is responsible for the sterile instruments during the operation. Both she/he and the surgeon wash their hands and forearms with antibacterial soaps in preparation for the operation. This may involve the use of a nail scrubbing brush hence the term "scrub nurse". During the operation both the surgeon and the scrub nurse will be dressed in sterile theatre gowns and gloves and will be positioned close to the patient.

The other nurses are present for the general care of the patient and to support the surgeon and scrub nurse. For example they may need to fetch additional items during surgery. These members of staff will be positioned a little more in the background.

The theatre assistants cover the general duties, e.g. moving patients in and out of theatre etc. In a well run harmonious theatre there will be a degree of interchange of tasks between staff.

If the operation is being performed under a local anaesthetic it is usual practice for one member of staff to hold the patient's hand during the operation. This gives human contact and reassurance and provides a means of non-verbal communication. This person is sometimes called the patient's "buddy". If the patient needs to get the attention of the staff during the operation they should firmly squeeze the buddy's hand. This person will then speak to the surgeon who can stop the operation at the next convenient moment. The patient should not speak unless they are told they may do so. This is because with talking the head and therefore the eye may move. This can cause problems if it happens at a critical point during the surgery. The patient should squeeze the buddy's hand if they experience pain or distress. Other reasons for doing so include a desire to move or cough or sneeze. The patient should refrain from these until the surgeon gives the all clear.

Once the patient has been positioned appropriately the eye is cleaned with antiseptic solution. This contains Iodine and is usually brown in colour. After the operation the patient may notice a slight brown colour to the skin around the eye. This will wash off easily. A drape is then placed over the eye and a clip, called a speculum, is slipped under the margins of the lids to keep the eye open during the operation. An operating microscope is then swung into position over the eye. This provides the surgeon with good illumination and magnification of the eye during the surgery. This microscope sits about 25cms above the eye.

The surgeon may sit in line with the patient's head, resting his/her fingers on the patient's forehead and brow, or to the side of the eye undergoing surgery. The chosen position will depend on the individual surgeon's personal preference and operating technique and on which approach provides the best access to the eye.

Most surgeons sit to perform the operation. This is because ideally both hands and both feet should be free. The surgeon's hands are obviously used in holding and manipulating the surgical instruments. One foot is used to control the phacoemulsification (cataract removing) machine and the other foot controls the focus and zoom of the operating microscope.

During the operation the patient may be aware of the gentle touch of the surgeons fingers around the eye and certain noises. These noises are made by the phacoemulsification (cataract removing) machine and tell the surgeon precisely what the machine is doing at any given moment. For most machines there is a "shshshshsh" type sound as the cataract is disintegrated and a whirl or whine type sound as the machine sucks. This is though a rather crude description and the sounds will vary somewhat from theatre to theatre. A special saline fluid is flushed through and across the eye during surgery. A thin plastic pouch is stuck to the side of the patient's face to collect this but sometimes the fluid may trickle beneath this towards the patient's ear.

During the operation the patient sees little or nothing of what is being done to the eye. The fellow eye will be covered. If a local anaesthetic injection has been used this often puts the vision "to sleep" as well as all feeling and any ability to move the eye. The bright light of the operating microscope, which shines down onto the eye during surgery, will also tend to bleach vision. Even if only anaesthetic eye drops are used (topical anaesthesia) the most that patients will be aware of is brightness and shadow. This is because the surgery is occurring within the eye and everything is very out of focus. Sometimes patients report a kaleidoscopic or sparkling phenomena. This may be due to the effect of local anaesthetic on the optic nerve, the nerve that carries vision from the eye to the brain.

Typically the operation last about 15 - 20 minutes, although it can be quicker or longer than this. At the end of the operation a plastic eye shield, with or without a pad, will be placed over the eye. This shield is to prevent anything accidentally rubbing or bumping the eye in the hours following the operation.

After Returning from the Operating Theatre

After the operation the patient is taken back to the ward or discharge lounge. If a cannula had been placed into a vein in the hand or forearm this will be removed. The nursing staff will run through the post-operative instructions and what eye drops should be used and when. Ideally this information should also be available in written form for the patient to take home with them. An appointment for a post-operative check will be made. The patient may also be given a contact phone number to call in case of unanticipated problems or in the event of an emergency with the eye.

It is wise to keep the eye shield over the eye for the rest of the day and through the first night following surgery. Some surgeons recommend use of the shield during sleep for a further period of time beyond this, especially if the incision was large enough to require sutures.

Most cataract surgery nowadays is performed on a day case basis and the patient may leave the eye unit within an hour or two of surgery in the company of an escort, usually a relative or friend. The patient should not drive themselves home even if they have driving standard vision in the fellow eye. The remainder of the day following surgery should be spent restfully. The eye should not be rubbed although a gentle dabbing over the closed lids in order to dry watering is permitted. With modern small incision cataract surgery the eye is very robust soon after surgery and gentle activity at home can be under taken almost immediately. Specific advice on when the patient may return to driving, work and more vigorous activity should be sought from the patient's own surgical team.

Some patients experience no more than grittyness and watering following cataract surgery. However it is quite common for there to be some temporary mild discomfort or throbbing in and around the eye, particularly if a local anaesthetic injection was used. This discomfort may be due to bruising at the injection site rather than from the surgery to the eye itself. If the discomfort is bothersome I recommend that the patient take whatever they normally use for relief of a simple headache. The eye should not be unduly painful in the hours following surgery.