INSTRUMENTS, DYES & DRUGS in ophthalmology.pptx

Instrument in ophthalmology - surgical instruments in ophthalmic surgery or eye surgery
Dyes in ophthalmology - various dyes
Drugs in ophthalmology - ocular drugs

1. INSTRUMENTS, DYES AND DRUGS INDEX INSTRUMENTS Cataract :3-12 Sac surgeries :14-17 Cornea :19-21 Squint :23-26 Glaucoma :28,29 Eyelid :31-34 Trauma :36 Destructive procedures :38,39 Dry eye :41-45 Dyes :47-50 DRUGS Immunosuppressants :52,53 Antibiotic :54 Antifungal :57,58 Mydriatic &cycloplegic :60-63 Anti glaucoma :65-76 NSAID’s & steroids :78-80 Others :81 1

2. CATARACT (3-12) 2

3. Barraquer’s self retaining eye speculum Most common eye speculum Fenestrated blades Light weight Minimal pressure on the globe Available in pediatric(14 mm) and adult sizes( 16- 18 mm) 3

4. Superior rectus holding forceps It is a toothed forceps (1 × 2 teeth) with S-shaped double curve near the tip. Used to hold the superior rectus tendon while passing bridle suture beneath it Traction suture in various surgeries , e.g., extra capsular cataract extraction, glaucoma filtration surgery 4

5. Castroviejo Corneal Scissors Used to enlarge corneal or corneoscleral incision for conventional intra capsular and extra capsular cataract extraction techniques of cataract surgery. To enlarge corneal incision in keratoplasty operation. To cut the scleral and trabecular tissue in trabeculectomy . It can also be used for cutting and undermining conjunctiva in various operations. 5

6. Lim’s forceps Corneoscleral forceps used to hold cornea/sclera edge while suturing in Open globe injury repair Keratoplasty Glaucoma filtration surgery 6

7. Keratomes Sharp angled/straight/curved/ pointed/arrow shaped blades Available in various sizes and shapes , e.g., 150 blades, 2.8 mm, 2.2 mm Used to make valvular corneal incisions of various dimension and depths 7

8. Hydrodissection cannula It is a single bore 25G, 27G or 30G cannula with a 45° angulation at about 10 to 12 mm from the free end. The tip at the free end can be flattened or bevelled . Use : It is used to perform hydro dissection and hydrodelineation in phacoemulsification and manual SICS . This cannula is attached to the syringe carrying irrigating fluid .. 8

9. Cystitome or capsulotome It is a small needle knife with a bent tip which is sharp on both the edges. Presently, disposable cystitome is prepared by bending the disposable 26 gauge or 30 gauge hypodermic needle. Use: It is used for doing anterior capsulotomy or capsulorhexis during extracapsular cataract extraction. 9

10. Wire vectis It is a wire loop attached to a metallic handle. Use : It is used to remove subluxated lens and anteriorly dislocated lens in ICCE technique and the nucleus in ECCE technique. 10

11. Kelman -McPherson forceps These are fine forceps with bent limbs. Uses : To hold the superior haptic of IOL during its placement. To tear-off the anterior capsular flap in ECCE. Can be used for suture tying. 11

12. Bimanual automated irrigation aspiration cannula Can be bimanual or coaxial Aspiration is usually 0.75 to 1.5 mm away from tip Opening can be 0.2,0.3,0.4, or 0.5 mm in diameter 19G , 21G, 23G, or 25G Used to remove cortical matter to facilitate implantation of IOL Remove excess viscoelastic before end of surgery to decrease inflammation To polish the posterior capsule 12

13. SAC SURGERIES (14-17) 13

14. Citelle’s bone punch It consists of a stout spring handle and two blades attached at right angle. The upper blade has a small hole with a sharp cutting edge . The lower blade has a cup-like depression. Use: It is used to enlarge the bony opening during DCR operation by punching the bone from margins of the opening. Carelessness during this step can cause accidental damage to the nasal mucosa and the nasal septum. 14

15. Lacrimal probes ( Bowmam’s ) Available in sizes ranging from 0000 to 4 Size 0=1mm diameter, with 0.1mm gradation To perform probing of nasolacrimal duct (NLD) in CNLDO To identify and localize the distance of canalicular obstruction To diagnose and treat lacrimal canalicular stenosis To “tent-up” the medial lacrimal sac mucosa for fashioning lacrimal sac flaps in external and endoscopic dacryocystorhinostomy (DCR) surgery To do a lacrimal canalicular assessment in cases of canalicular lacerations To prevent and identify an inadvertent injury to canaliculus while operating in its vicinity (e.g., medial diamond conjunctivoplasty for punctum ectropion ) 15

16. Lacrimal sac dissector and curette It is a cylindrical instrument, one end of which is a blunt tipped dissector and the other end is curetted. Use : In lacrimal sac surgery 16

17. Punctum dilator ( Nettleship’s ) It has a cylindrical corrugated metal handle with a conical pointed tip. Use : To dilate the punctum and canaliculus during syringing, probing, dacryocystography , DCT and DCR procedures 17

18. CORNEA (19-21) 18

19. Tudor Thomas Stand Cup at the top for positioning and fixing whole eye globe (donor) Trephination for both lamellar and full thickness grafts can be done with epithelial side up 19

20. Corneal trephine Available in sizes from 3 to 17 mm diameter Can be attached to a handle for greater stability and control Donor trephination done with endothelial side up Disposable trephines are used with Teflon blocks for retrieval of donor button Trephines help in retrieval of a predetermined circular corneal button for keratoplasty 20

21. Trephine blade 21

22. SQUINT (23-26) 22

23. Prism bar Alternate prism bar cover test – measurement of angle of deviation.(primary and secondary) Krimsky prism bar cover test 4 Δ prism test Used in measurement of fusional reserve 23

24. Maddox rod Used in Maddox rod test for To subjectively detect & measure latent, manifest, horizontal or vertical deviation for near & distance Small to moderate vertical deviations where there is simultaneous perception & normal retinal correspondence Decompensated phorias Acquired strabismus Double Maddox rod test for cyclophorias Macular function test 24

25. Red green goggles Uses In worth four dot test Lancaster for measurement of strabismus To assess the diplopia 25

26. Jameson Muscle Hook Straight shaft 6 mm hook with a bulbous tip Uses Retrieving the rectus muscles at their insertion sites with minimal distortion 26

27. GLAUCOMA 28,29 27

28. Kelly descemets punch Produces round punches without tissue tags Has serrated squeeze action handles Two sizes: 0.75 mm, 1 mm punch Uses : Creation of dural window in optic nerve fenestration surgery Trabecular meshwork block excision in trabeculectomy 28

29. Ahmed glaucoma valve It was developed by Mateen Ahmed and was approved by FDA in 1993. It consists of 3 parts 1 ) a plate, 2 ) a drainage tube and 3 ) a valve mechanism Valve mechanism of AGV consists of thin silicone elastomer membranes, which are 8 mm long and 7 mm wide and create a Venturi -shaped chamber. The membranes are pretensioned to open and close in response to variations in IOP. As the pressure reaches the preset threshold value( IOP variations, in the range of 8–12 mmHg), the valve opens, thus decreasing the IOP. 29

30. EYELID (31-34) 30

31. Berke’s ptosis clamp Forceps with J shaped ends having internal serrations. The clamp has a locking mechanism Uses : To hold levator palpebrae superioris muscle during ptosis surgery. 31

32. Ptosis sling Used in frontalis sling surgery for ptosis repair It contains 2 ultra sharp stainless steel needles of 58 mm long joined with silicone tube It is sterile and disposable 32

33. Lid clamp/ Snellen entropion clamp It is a self retaining It has two limbs, one looks like a D-shaped plate and other is a U-shaped rim that can be closed with a screw The handle is kept toward the temporal side, plate toward conjunctiva , and rim on the skin side Used for entropion / ectropion surgery It protects the eyeball, supports the lid tissue and provides haemostasis during surgery 33

34. Lambert chlazion clamp Used in incision and curettage of the chalazion Can be used to perform canaliculotomy and curettage Can be used to excise small or localized eyelid masses Can be used to ensure hemostasis while performing an incisional or excisional biopsy of an inflamed or vascular eyelid mass 34

35. TRAUMA 36 35

36. Pig tail probe It is used in canalicular laceration repair This instrument is used to intubate both canaliculi and would be inserted first into the uninvolved canaliculus and rotated until the end of the probe was visualized in the nasal end of the torn canaliculus . A silicone stent was then inserted which connects the two canaliculi. When the severed deep ends of the laceration are difficult to identify, pigtail probe may still be a useful instrument. 36

37. DESTRUCTIVE PROCEDURES 38,39 37

38. Wells Enucleation Spoon It has a spoonlike , shallow, concave, hemispherical end attached to a long shaft . It features an optic nerve guide or groove (10 × 5 mm) for the engagement of the optic nerve . Uses To perform enucleation in advanced malignant intraocular To perform enucleation while harvesting an eyeball during an “eye donation” To enucleate an eye with phthisis bulbi for cosmetic rehabilitation To perform therapeutic enucleation for painful blind eyes 38

39. Evisceration spatula Rectangular blade with slightly convex surface and blunt edges Used to separate uveal tissue from sclera during evisceration 39

40. DRY EYE (41-45) 40

41. Punctal plug It is used in dry eye Mechanism of action: Mechanical occlusion of lacrimal puncta to block the tear drainage and there by prolonging the action of natural tears along with artificial tears 41

42. Schirmer strips Whatmann 41 filter paper is used Dimensions – 5mm *35 mm Uses Rate of tear formation is estimated (aqueous tear production) 42

43. Fluorescein strips Fluorescein strip consists of 0.6mg to 1mg (fluorescein sodium) USES : Diagnosis of Dry eye disease Corneal ulcer Corneal abrasions,laceration To perform Seidel’s test Jone’s dye disappearance test Applanation tonometry Contact lens fitting 43

44. Rose Bengal strips 44 Concentration : 1.3mg impregnated strips Stains dead and devitalized cells including mucuos strands on ocular surface Uses : Conjunctival staining in diagnosis of dry eye disease,conjunctival squamous neoplasms Corneal staining for herpetic dendrites, SPK Diagnosis of MGD.

45. LISSAMINE GREEN STRIPS Concentration:1.5mg dye impregnated strips. Stains dead and degenerated cells, including mucous strands Uses Diagnosis of dry eye disease Kerato conjunctivitis sicca Lid wiper epitheliopathy Contact lens used conjunctival staining 45

46. DYES (47-50) 46

47. Trypan blue Concentration 0.6% in anterior capsular staining Uses To stain anterior capsule of lens in cataract surgeries To stain descemets membrane in DSEK Stripping corneal endothelium from donor button in DALK 47

48. Methylene blue Its an aniline dye. Uses To stain the lacrimal sac before DCR To stain anterior capsule of lens in capsulotomy in cataract surgery 48

49. Fluorescein dye IV injection preparations for FFA ( Flourescein Fundus Angiography) 10% dye in a 5ml vial 20% dye in a 2ml vial Fundus fluorescein angiography  - 5ml of 10% or 20% flourescien is given as an IV bolus injection. To assess various pathologies such as diabetic retinopathy, retinal vein occlusions, age related macular degeneration (wet), and macular ischemia . Iris angiography for evaluation of vasculature Vitreous fluorophotometry . 49

50. Indocyanine green 40mg in 2ml for IV injections The dye comes in a 25-mg vial of ICG, which is mixed with 5 mL of the aqueous solvent that comes with it to yield the 5 mg/mL (0.5%) concentration dye Uses For staining the anterior capsule during cataract surgery. In chromovitrectomy to  visualise the ILM. In ICGA, to visualise choroidal circulation 50

51. IMMUNOSUPPRESSANT 51

52. Cyclosporine eye drops It is calcineurin inhibitor and is fungal metabolite derived from cultures of Tolypocladium inflatum Uses Various forms of posterior uveitis like VKH Behcet’s 0.05% emulsion used in treatment of dry eye disease Atopic keratoconjunctivitis Side effects Lid erythema conjunctivitis 52

53. Mitomycin It is an anti mitotic agent isolated from Streptococcus calspitosus Concentration 0.02-0.04% Indications Recurrent pterygium surgery Glaucoma filtering surgery Conjunctival and corneal squamous cell neo plasia After PRK Complications Scleral thinning,corneal thinning/ulceration Conjunctival irritation Secondary glaucoma 53

54. ANTIBIOTIC 54

55. Ciprofloxacin is first generation fluoroquinolone . Dose -Topical - 0.3% 1 to 4 hrly Fluoroquinolones are potent synthetic agents having broad spectrum of activity against Gram-positive and Gram-negative organisms. Mechanism of action. Fluoroquinolones are bactericidal drugs . They inhibit the bacterial DNA synthesis. 55

56. ANTI FUNGAL 56

57. Voriconazole Voriconazole is a triazole anti fungal agent. MOA : Inhibition of 14-sterol demethylase, & impair the biosynthesis of ergosterol for the cytoplasmic membrane and impairing the functions of certain membrane-bound enzyme systems, thus inhibiting the growth of the fungi . USES : Fungal Keratitis Acantahamoeba keratitis Fungal endophthalmitis Aspergillus chorioretinitis Orbital aspergillosis Fungal Subretinal abscess,Scleritis and epibulbar abscess 57

58. Natamycin Derived from Streptomyces natalensis Topical administration produces effective conc. of natamycin in corneal stroma but not in the intra ocular fluid. Indication Fungal blepheritis Conjunctivitis Keratitis Contraindication Hypersensitivity Adverse reaction Conjunctival chemosis Hyperemia Allergic Dosage Conc -5% 1 drop hourly or 2 hourly intervals for 14 – 21 days 58

59. MYDRIATIC & CYCLOPLEGIC 59

60. Cyclopentolate eye drops Cyclopentolate is a short acting cycloplegic . Its effect lasts for 6 to 18 hours. P eak effect – 80-90min It is used as 1% eyedrops in patients between 8 and 20 years of age. Contraindication Narrow angle glaucoma Hypersensitive Children with emosional problems Adverse effects Increased IOP, blurring of vision, photophobia Psychotic reaction Dryness of mouth, headache or allergic reactions Dosage One drop followed by second drop in 5 minutes of arc 60

61. Homatropine eye drops Homatropine is anticholinergic drug used as 2% drops. Its effect lasts for 48 to 72 hours . Peak effect – 60-90min Directly blocks muscarinic action of acetylcholine Indication Cycloplegic refraction Treatment of inflammatory uveal tract condition Contraindication Tendency with occludable angles Patient who have allergic to atropine Adverse reaction Follicular conjunctivitis Vascular congestion 61

62. Tropicamide eye drops Most common anticholinergic medriatric drug Stronger – 1%, paralysis accomodation 0.5% produce mydriasis with slight cycloplegia Indication Diagnosis of refractive errors Pre and post operative stages Infants – combination with phenylephrine Contraindication Narrow angle glaucoma Hypersensitive Adverse effect Stinging sensation Confusion or hyperactivity Dosage 2 drops of 1% in each eye 2 to 3 times at 5 min intervals 62

63. Atropine eye drops Atropine sulfate is anticholinergic – 0.5%, 1%,3% Strongest drug in cycloplegics .peak effect - 2-4th day duration of action - 10–20 days Inhibitor of muscarinic action of acetylcholine Indication Mydriasis & cycloplegia Pupil dilation in inflammatory condition of iris Amblyopia therapy Contraindication Angle closure glaucoma Hypersensitive Adverse effects Allergic responses Blurred vision Photophobia Dryness of skin & mouth Skin rash Dosage 1 or 2 drops 0.5% to each eye, twice daily for 1 to 3 days prior to examination 63

64. ANTI GLAUCOMA 64

65. Timolol eye drops It is a nonselective beta-1 and beta-2 blocker . It is available as 0.25% and 0.5% eyedrops . The salt used is timolol maleate. Its action starts within 30 minutes, peak reaches in 2 hours and effects last up to 24 hours. Therefore , it is used once or twice daily. The drug is very effective, however, the phenomenon of ‘short-term escape’ and ‘ long-term drift ’ are well known . C ontraindications Bronchial asthma, Emphysema , COPD, heart blocks, congestive heart failure or cardiomyopathy. 65

66. Betaxolol It is a cardioselective beta-blocker and thus can be used safely in patients prone to attack of bronchial asthma Available as 0.5% suspension, and 0.25% suspension, and is used twice daily. Its action starts within 30 minutes , reaches peak in 2 hours and lasts for 12 hours . 66

67. Latanoprost (0.005 %) It is a synthetic drug which is an ester analogue of prostaglandin F2-a. It acts by increasing uveoscleral outflow and by causing reduction in episcleral venous pressure . Latanoprost is a prodrug and is inactive in vitro, requiring hydrolysis to release the active form Its duration of action is 24 hours and is, thus, administered once daily. Its side effects include conjunctival hyperaemia , foreign body sensation and increased pigmentation of the iris . 67

68. Travoprost (0.004 %) It is a synthetic prostaglandin F2 analogue and decreases IOP by increasing uveoscleral outflow of aqueous . Unlike Latanoprost,it is stable at room temperature and does not require refrigeration. In a randomized, controlled trial in which the efficiency of travoprost , latanoprost and timolol were compared, travoprost produced the greatest reduction in intraocular pressure 68

69. Bimatoprost (0.03 %) It is a prostamide which decreases IOP by decreasing ocular outflow resistance . It mimics the effects of prostaglandin alpha-2 (PGα2) without acting on any known PG receptor . The onset of the effect is about 4 hours after administration, reaching a maximum at 8–12 hours. This effect is maintained for at least 24 hours, permitting once daily treatment . Bimatoprost is well absorbed by the cornea 69

70. Brinzolamide (1 %) It is a topical CAI. It inhibits the enzyme carbonic anhydrase and therby lower the IOP by reducing the aqueous humour formation It is administered twice daily (BD). 70

71. Brimonidine (0.2%). Mechanism of action. It is a selective alpha-2 adrenergic agonist and lowers IOP by decreasing aqueous production and enhancing uveoscleral outflow. It has an additive effect to betablockers . Dosage: It has a peak effect of 2 hours and action lasts for 12 hours; so it is administered twice daily. Side-effects Systemic side-effects include hypertension, tachycardia , headache, palpitation, tremors, nervousness and anxiety. Local side-effects are burning sensation, reactive hyperaemia of conjunctiva, conjunctival pigmentation , allergic blepharoconjunctivitis , mydriasis and cystoid macular oedema ( in aphakics ). 71

72. Pilocarpine eye drops Pilocarpine. It is a direct-acting parasympathomimetic drug. Indications : ( i ) Primary open-angle glaucoma; ( ii) Acute angle closure glaucoma ; ( iii) Chronic synechial angleclosure glaucoma . Contraindications: inflammatory glaucoma, malignant glaucoma and known allergy. Available preparations and dosage are: ( a) Eye drops - 1%, 2% and 4% strengths. The onset of action occurs in 20 minutes, peak in 2 hours and duration of effect is 4–6 hours. Therefore, the eye drops are usually prescribed every 6 or 8 hourly. (b) Ocuserts are available as pilo-20 and pilo-40 (c) Pilocarpine gel (4%) is a bedtime adjunct to the daytime medication . Adverse effects Systemic : bradycardia, increased sweating, diarrhoea , excessive salivation and anxiety . Local : Myopia and frontal headache, retinal detachment, lenticular opacities , iris cyst formation, mild iritis , lacrimation and follicular conjunctivitis 72

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74. 74

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76. 76

77. NSAID’S & STEROIDS 77

78. It is a NSAID group of drug MOA : Irriversible blocking of cyclo oxygenase enzyme thus inhibiting prostaglandin synthesis Conc 0.1% eye drops Uses Episcleritis Scleritis Uveitis CME 78

79. Flubiprofen eye drops Inhibit the cyclo-oxygenase enzyme Indication Inhibition of intraoperative miosis Postlaser & postoperative ant. segment inflammation Contraindication Dendritic keratitis Hypersensitive Patient with bleeding tendency Adverse effect Transient burning Stinging Dosage Total 4 drops instilling 1drop in every 30 min, 2hrs before surgery 79

80. Prednisolone eye drops Synthetic corticosteroid Inhibits edema, fibrin deposition, capillary dilatation & deposition of collagen and scar formation Contraindication Acute untreated purulent ocular infection Dendritic keratitis Viral disease of cornea & conjunctiva Fungal diseases of eye Adverse effects Increased IOP with optic nerve damage Visual field defect PSC formation Dosage 1-2drops for 2-4 times daily 80

81. OTHERS 81