WhenWhen

The Beast in the ORThe Beast in the ORIsn’t Your SurgeonIsn’t Your Surgeon

Susan Clouser RN MSN CRNOSusan Clouser RN MSN CRNO

Patient HistoryPatient History

47 year old female47 year old female 300+ pounds300+ pounds Thyroid problemsThyroid problems Difficulties with activities of daily livingDifficulties with activities of daily living

Unable to find foodUnable to find food Not socializing with new neighborsNot socializing with new neighbors

Ophthalmic exam showed bilateral cataracts Ophthalmic exam showed bilateral cataracts and geographic atrophy OSand geographic atrophy OS

Cataract Surgery on Gorillas in the Cataract Surgery on Gorillas in the United StatesUnited States

Salt Lake City, UTSalt Lake City, UT 1990 Dr. Alan Crandall on Gorgeous1990 Dr. Alan Crandall on Gorgeous

Dallas, TXDallas, TX January 2009 Dr. Wayne Bowman on TimboJanuary 2009 Dr. Wayne Bowman on Timbo

Miami, FLMiami, FL October 2009 Dr. Frank Spektor on JosephineOctober 2009 Dr. Frank Spektor on Josephine

Why a “people” ophthalmologist instead of a Why a “people” ophthalmologist instead of a veterinary ophthalmologist?veterinary ophthalmologist?

Medical School/Zoo CollaborationMedical School/Zoo Collaboration

Ophthalmic Examination of the Captive Ophthalmic Examination of the Captive Western Lowland Gorilla Western Lowland Gorilla Journal of Zoo and Wildlife Medicine 2005Journal of Zoo and Wildlife Medicine 2005

All gorillas at the Dallas Zoo examined to All gorillas at the Dallas Zoo examined to determine the norms for gorilla eyes.determine the norms for gorilla eyes.

Gorilla vs. Human EyesGorilla vs. Human Eyes

Human GorillaHuman Gorilla

Axial length 23.5Axial length 23.5 22.75mm 22.75mm

Keratometry 42-44D 44.38DKeratometry 42-44D 44.38D

Corneal diameter 12.0mm 13.4mmCorneal diameter 12.0mm 13.4mm

IOP 21.0mmHg 12.0mmHgIOP 21.0mmHg 12.0mmHg

Central cornea .56mm .49mmCentral cornea .56mm .49mm

Medical School/Zoo CollaborationMedical School/Zoo Collaboration

Ophthalmic Examination of the Captive Ophthalmic Examination of the Captive Western Lowland Gorilla Western Lowland Gorilla Journal of Zoo and Wildlife Medicine 2005Journal of Zoo and Wildlife Medicine 2005

“ “ These similarities may allow diagnostics, These similarities may allow diagnostics, techniques and equipment for human eye techniques and equipment for human eye surgery, such as those used for cataract surgery, such as those used for cataract extraction and IOL implantation to be extraction and IOL implantation to be successfully utilized for gorillas.”successfully utilized for gorillas.”

Critical FactorsCritical Factors

Surgery locationSurgery location Hospital vs. ZooHospital vs. Zoo

Surgery TeamSurgery Team Surgery DateSurgery Date Equipment/SuppliesEquipment/Supplies Which eye first or both eyes at the same time?Which eye first or both eyes at the same time? Postoperative CarePostoperative Care

LocationLocation

Hospital vs. ZooHospital vs. Zoo

TransportTransport Equipment/SuppliesEquipment/Supplies MedicationsMedications

Assembling the TeamAssembling the Team

SurgeonSurgeon AssistantAssistant CirculatorCirculator Scrub personScrub person

Assembling the TeamAssembling the Team

Geographic atrophy = Retina specialistGeographic atrophy = Retina specialist New retina camera = camera rep + assistantNew retina camera = camera rep + assistant

IOL measurements = UltrasonographerIOL measurements = Ultrasonographer Phaco machine = Alcon repPhaco machine = Alcon rep Microscope = Zeiss repMicroscope = Zeiss rep Interested resident + additional cornea fellowInterested resident + additional cornea fellow

Surgery DateSurgery Date

How about a Tuesday?How about a Tuesday?

How about a Sunday?How about a Sunday?

Critical FactorsCritical Factors

Equipment (shipped in)Equipment (shipped in) Microscope: ZeissMicroscope: Zeiss Phaco machine: AlconPhaco machine: Alcon

Equipment (transported from hospital)Equipment (transported from hospital) A scan, Retinal camera, Indirect ophthalmoscope, A scan, Retinal camera, Indirect ophthalmoscope,

hand held keratometerhand held keratometer

Critical FactorsCritical Factors

SuppliesSupplies Custom packCustom pack MedicationsMedications SutureSuture GlovesGloves

Which IOL?Which IOL?

Larger optic for a larger eyeLarger optic for a larger eye FoldableFoldable Lower incidence of posterior capsule Lower incidence of posterior capsule

opacificationopacification

MC50BMMC50BM

Which eye first?Which eye first?

Left eyeLeft eye Geographic atrophy/less visual potentialGeographic atrophy/less visual potential PracticePractice Observe postoperative behaviorsObserve postoperative behaviors

Postoperative considerationsPostoperative considerations

Unable to instill eye dropsUnable to instill eye drops RubbingRubbing

Veterinarian ConcernsVeterinarian Concerns

Safety of the animalSafety of the animal Safety of the surgical teamSafety of the surgical team PrivacyPrivacy

No photos except those taken by the official Dallas No photos except those taken by the official Dallas Zoo photographer, Cathy BurkeyZoo photographer, Cathy Burkey

Rules for the ZooRules for the Zoo

Respectful of the inhabitants of that settingRespectful of the inhabitants of that setting Wear required personal protective equipmentWear required personal protective equipment Don’t touch the gorilla without permissionDon’t touch the gorilla without permission Limit conversation to that pertinent to the surgeryLimit conversation to that pertinent to the surgery

Rules for the ZooRules for the Zoo

FlexibilityFlexibility Ability to innovateAbility to innovate

Back tableBack table ChairsChairs Wrist restWrist rest

PreopPreop

Tranquilizing dartTranquilizing dart Placed on “OR table”Placed on “OR table” Dilating dropsDilating drops

TropicamideTropicamide CyclopentolateCyclopentolate 2.5% Phenylephrine2.5% Phenylephrine

Moved to the ORMoved to the OR

In the ORIn the OR

Positioned at the top edge of the tablePositioned at the top edge of the table Endotracheal tube and tubing positioned and Endotracheal tube and tubing positioned and

secured out of the surgical fieldsecured out of the surgical field Bair-hugger warming unitBair-hugger warming unit MonitorsMonitors Head positioned and secured with tapeHead positioned and secured with tape

Preop exam and testPreop exam and test

Retinal examRetinal exam IndirectIndirect PhotosPhotos

AscanAscan KeratometryKeratometry

IOL CalculationsIOL Calculations

Axial length = 27.5mmAxial length = 27.5mm K readings = ?????K readings = ?????

Getting in positionGetting in position

OR table configurationOR table configuration DimensionsDimensions

3 feet wide 3 feet wide 6 feet long6 feet long

Solid sidesSolid sides Surgeon normally operates temporally but chose to Surgeon normally operates temporally but chose to

position himself superiorly because he could not position himself superiorly because he could not reach the eye if he was at the side. reach the eye if he was at the side.

Getting in positionGetting in position

Can he sit?Can he sit? OR table doesn’t go very lowOR table doesn’t go very low Available chairs don’t go very highAvailable chairs don’t go very high Must be able to reach foot pedalsMust be able to reach foot pedals

Uh-ohUh-oh Where can we put the foot pedals?Where can we put the foot pedals?

Getting in positionGetting in position

OR table configurationOR table configuration Thick mattress and baseThick mattress and base Straight down, no head restStraight down, no head rest Surgeon’s legs cannot be under patient’s headSurgeon’s legs cannot be under patient’s head No room for foot pedalsNo room for foot pedals

Sat on edge of chair with legs at wide anglesSat on edge of chair with legs at wide angles

Surgical PrepSurgical Prep

Betadine 10% Betadine 10% In the cul de sacIn the cul de sac Periocular with 4x4 gauze spongesPeriocular with 4x4 gauze sponges Lid margins with cotton tip applicatorsLid margins with cotton tip applicators 5 minutes 5 minutes BSS rinseBSS rinse

Learn and TeachLearn and Teach

Learn from the veterinarians and zoo staff Learn from the veterinarians and zoo staff about what is required to care for these about what is required to care for these animalsanimals

Teach them about cataract surgery, intraocular Teach them about cataract surgery, intraocular lenseslenses Narrate surgery as it was shown on the monitorNarrate surgery as it was shown on the monitor Answer questions about procedure and different Answer questions about procedure and different

types of IOLstypes of IOLs

Variations in the Surgical Variations in the Surgical ProcedureProcedure

Anterior capsule tougher and thickerAnterior capsule tougher and thicker Larger eye changed the angles some and made Larger eye changed the angles some and made

some things slightly more difficult to reachsome things slightly more difficult to reach Posterior pressurePosterior pressure 10-0 vicryl stitch in both incision and 10-0 vicryl stitch in both incision and

paracentesisparacentesis

End of Procedure MedicationsEnd of Procedure Medications

Subconjunctival injectionsSubconjunctival injections CefazolinCefazolin GentamicinGentamicin KenalogKenalog

Polysporin ointmentPolysporin ointment Both eyes to prevent exposure keratitis during the Both eyes to prevent exposure keratitis during the

wake up periodwake up period

Post op first eyePost op first eye

Moved to her gorilla “condo”Moved to her gorilla “condo” Woke up about 1 hour laterWoke up about 1 hour later No analgesicsNo analgesics Snack and juice in the afternoonSnack and juice in the afternoon Did not rub eyeDid not rub eye

Post op day #1Post op day #1

Area kept dim to allow acclimation to new Area kept dim to allow acclimation to new visionvision

Some problems with depth perceptionSome problems with depth perception Bumped into mesh that is the wall of her habitatBumped into mesh that is the wall of her habitat Difficulty passing items through the meshDifficulty passing items through the mesh

One week post opOne week post op

Surgeon did face to face examSurgeon did face to face exam Appeared clearAppeared clear No redness or discharge notedNo redness or discharge noted

Second eye scheduled for one week laterSecond eye scheduled for one week later

Second eye surgerySecond eye surgery

Two weeks after firstTwo weeks after first First eye looked quiet, vicryl stitches still in First eye looked quiet, vicryl stitches still in

placeplace Uneventful post opUneventful post op

One month post second surgeryOne month post second surgery

Face to face exam in gorilla houseFace to face exam in gorilla house Came to mesh and took peanuts Came to mesh and took peanuts Vision testVision test Ate other food: carrots, lettuceAte other food: carrots, lettuce PurredPurred More active, looking into research stationMore active, looking into research station