Injectable Medications in Primary Eyecare

Transcription

1 Injectable Medications in Primary Eyecare Andrew Rixon OD, FAAO Mike Dorkowski OD,FAAO Scott Ensor OD John Neal OD Jennifer Sanderson OD, FAAO Please silence all mobile devices and remove items from chairs so others can sit. Unauthorized recording of this session is prohibited. Disclosure Statement: Nothing(to(disclose 1

2 Standard'of'Care The(courts(have( ruled(that( Optometry(and( Ophthalmology( are(held(to(the(same( Standard(of(Care. The(Optometrist( must(adhere(to( the(rules(governing the(practice(of( Optometry(for( his/her(state. SB'220 2

3 SB'220 Universal'Precautions Universal*Precautions is(an(approach( to(infection(control.(according(to(the( concept(of(universal(precautions,(all( human(blood(and(certain(human( body(fluids(are(treated(as(if(known(to( be(infectious(for(hiv,(hbv,(and(other( bloodborne pathogens.( 3

4 Standard'Precautions 1)(bloodQ( ( 2)(all(body(fluids,(secretions,(and( excretions,((except*sweat,(regardless( of(whether(or(not(they(contain( visible bloodq 3)(nonTintact( skin(4)(mucous(membranes.( Includes(Hand(Washing(and(appropriate use(of(ppe =(((((((((X(2(((((((( Personal'Protective' Equipment'' Determination( of(ppe(based(on( anticipated( exposure(to(blood(or( other(potentially( infectious( body(fluids( during(any(given(procedure Use(gloves(or(masks(if(warranted( Lab(coats/surgical(gown(to(protect( clothing 4

5 Gloves' Latex?(Nitrile?( Neoprene?( Avoid(vinylQ(reduced( barrier(protection. Use(correct(size Powdered(vs Non NonTsterile(vs.(sterile? >15%'of'healthcare'workers'exhibit'latex' allergy Amarasekera M,(et(al.**Int J*Occup Med*Environ*Health.(2010( 23(4):( 391T396 Glove'Selection 5

6 Proper'Glove'Removal Universal'Precautions Biohazardous Definitions: Any(material(other(than(sharps(that( is(contaminated(with(blood,(bodily( fluid,(or(tissue(is(biomedical(waste. Needles(and(other(sharps(must(be( disposed(of(in(proper(containers. 6

7 Sharps'and'Biohazard'Bags Biohazards Waste(should(be(placed( in(a(red bag(which(has( been(labeled( according(to(federal,( state(and(local( regulations(with(the( biohazard(symbol(&( word( BIOHAZARD. 7

8 Handling'Needles/Sharps Do(not(bend,(recap,(or(remove( contaminated( needles(and(other( sharps(unless(such(an(act(is(required( by(a(specific(procedure( or(has(no( feasible(alternative( Do(not(shear(or(break(contaminated( sharps.((osha(defines(contaminated as(the(presence(or(reasonably( anticipated( presence(of(blood( or(other( potentially( infectious(materials( on(an(item( or(surface) Sharps Any(item(with(corners( edges,(etc.(capable(of( piercing(skin Must(be(placed(in(red,( OSHA(compliant( sharps(container 8

9 OSHA'Compliant'Sharps Closable,(punctureTresistant,(leakTproof( on(sides(and(bottom.( Accessible,(maintained(upright,( and(not(allowed(to((overfill. Labeled(or(color(coded( Colored(red/labeled(with(the(biohazard( Labeled(in(fluorescent(orange/orangeT red((with(lettering(and(symbols(in( contrasting(color( Red(bags(may(be(substituted(for(labels(( Disposal Care(and(disposal(of(waste(can(be( arranged(and(coordinated(through( various(pathogen(control( companies(in(your(area They ll(supply(bags,(boxes,(etc.(and( can(arrange(for(pickup(on(virtually( any(schedule: Weekly,(monthly,(quarterly,(etc Sharps(containers,(bags,(etc.(are(also( available(through(retailers(of(most( surgical(equipment 9

10 Medical'Supplies Syringes Image'courtesy'of' David'K.'Talley'OD,'FAAO 6(cc/ml( 5(cc/ml 1(cc/ml Tip,(Barrel,(Plunger Medical'Supplies Hypodermic'Needles 20(gauge 27(gauge 1 ½ 30(gauge Image'courtesy'of' David'K.'Talley'OD,'FAAO Bevel,(Shaft,(Hub ½ 10

11 Needle'Anatomy Syringe'Anatomy 11

12 Safety'Device'Designs Self'ReXsheathing' Needles Winged' Steel'Needles Syringe'with'Retractable'Needles e Syringe'Selection' 12

13 Bevel'Position Visualization(easier( with(bevel(up? Bevel(away(from( globe(on(true( peribulbars? Chamber(Tap(bevel( down? More(comfortable(for( SubQ. Bevel'Up Avoiding'the'Vacuum' Ready'medication' Air'In' 13

14 Aspirating'Suspension' Draw'out.1'X 1cc'of' medication' Periocular'Basics 14

15 Instrumentation Chalazion'Clamps Spring(Loaded Mechanical O.D. Image'courtesy'of' David'K.'Talley'OD,'FAAO Instrumentation Jaeger'Plate Metal(or(plastic Used(to(protect( globe(when( giving(injection Image'courtesy'of' David'K.'Talley'OD,'FAAO 15

16 Informed'Consent Elements*of: 1)(the(nature( of(the(decision/procedure( 2)(reasonable( alternatives(to(the(proposed( intervention( 3)(the(relevant(risks,(benefits,(and((( uncertainties(related( to(each( alternative including(risks(of(denying( procedure( 4)(assessment(of(patient(understanding( 5)(the(acceptance(of(the(intervention(by(the( patient( EHR? What(about(obtaining(eTsignature? Physical(signature(is(always(preferable Wikipedia.com 16

17 Sample'Informed'Consents Intralesional Indications (Chalazion/Chalazia (Capillary(Hemangioma 17

18 Intralesional Injection TechniqueXTranslesional 1(to(2(gtt Proparacaine Xylocaine to(conj optional Apply(hemostatic(chalazion clamp Use(27(gauge,(½ (needle Aspirate(vs(non(aspirate Insert(needle( and(push(through(entire lesion Slowly(remove( needle( while(injecting( contents(of(syringe Remove(chalazion clamp Atlas'of'1 Eyecare'Procedures 18

19 Intralesional' Video Intralesional Complications Pain Depigmentation PtosisTTemporary Delayed(Wound(Healing Eyelid(Necrosis Globe(Perforation Microembolization Always(R/O(SCC(if(recalcitrant! 19

20 11900'and' TInjection,(Intralesional,(up(to( and(including(7(lesions *$52.81(PAR(non(Facility 11901TInjection,(Intralesional,( >7(lesions *66.56(PAR(non(Facility *2018 Palmetto GBA Medicare Allowable TN Intramuscular'Injection Typically(reserved(for(irritating(medications Also(used(for(administering(larger(volumes((( of(medication T Typically(3T5mL. Optometric'Use: T Anaphylactic(reaction(to(IVFA T IM(benadryl or(im(epinephrine(1:1000 T IM(phenergan for(patients(with(known( nausea(response(to(ivfa 20

21 Intramuscular Recommended'SitesXIM 21

22 Obesity'Influence? Johnstone(J,(et(al.(Allergy 2015Q(70:( Med(J(Armed(Forces(India.(2014(OctQ70(4):338T43. Intramuscular'Equipment 1T3(cc(syringe 22T25(gauge(needle Depends(on(viscosity(of(med 5/8(to(1(½(inches Under(130lbs(5/8T1 130T152lbs((1 152(T260lbs((1T1.5 Over(260((1.5 Alcohol(pad,(gauze,(bandTaid Sharps(container,(biohazard(bag 22

23 PER'CDC For(all(intramuscular(injections,( the(needle(should(be(long(enough(to( reach(the(muscle(mass(and(prevent( vaccine(from(seeping(into(subq tissue,(but(not(so(long(as(to(involve underlying(nerves,(blood(vessels,( or(bone Aspiration(NOT necessary Procedure 1.(Cleanse(area(with(alcohol(swab(in(circular(motion. 2.(Apply(pressure(to(the(skin(in(a(spreading(motion( in(order(to(make(the(entry(point(taut. 3.(This(ensures(the(muscle(is(isolated(and(prevents( injection(into(the(subcutaneous(space. 4.(Insert(the(needle(fully(into(the(tissue(at(a(90 angle(and(inject(the(bolus. 5.(Retract(the(needle(and(apply(direct(pressure(to(the( injection(site(with(a(cotton(ball(or(gauze(pad. 6.(Dispose(of(needle(in(sharps(container. 23

24 Intramuscular'Injection Botox'administered' Subcutaneously Injection(directly( in(the(affected( muscle(relieves( the(muscle( spasm. The(duration(of( effect(lasts( about(3(months. O.D. Botox'Coding 64612T Chemodenervation of(muscle(s):( muscle(s)(innervated(by(facial(nerve *$124.69(PAR(Non(Facility J0585(Injection,(onabotulinumtoxinA per( unit( Will(be(100(Units(regardless(of(waste *Palmetto GBA Medicare Allowable TN

25 Subcutaneous' Injection Subcutaneous Shallow(injection(into(loose( connective(tissue Absorption(time(about(30(minutes. Used(for(epinephrine,(insulin,( tetanus(toxoid,(vaccine,(narcotics,( vitamin(b12. 25T27(gauge(needle SubQ Indications Focal(SubQ infiltration(of(the(lid Use(of(local(anesthetic(to(block(the( nerves(traversing(the(injected(area 25

26 What'to'Inject Lidocaine Logistics Anesthetic Equivalent/ concentration Onset/// (minutes) Duration/ (hours) Maximal/ dose/ (mg/per/kg) Maximal/ dose/ (ml/per/70/kg) Lidocaine4 (Xylocaine) 14or42% <2 1.54to42 4/mg/per/kg,4 not4to4exceed4 2804mg 284mL4(1%);4 144mL4(2%) Lidocaine44 with4 epinephrine 14or42%44444 lidocaine, 1:100,0004or 1:200,0004 epinephrine <2 24to46 7mg/per/kg,4 not4to4exceed4 500mg Based4on4 lidocaine 50mL4(1%); 25mL4(2%) Based(on(Table(from(Achar S(and(Kundu S.(Priniciple of(office(anesthesia:(part(i.(infiltrative(anesthesia.(am* Fam Physician.(2002(Jul(1Q66(1):91T4.( 26

27 Adverse/Contraindications Less(common(than(with(regional( blocks(or(general(anesthesia. Severe(Hepatic(Disease Impaired(cardiovascular(function Lidocaine' Liability LIDOCAINE(HYDROCHLORIDE(INJECTION,(FOR( INFILTRATION(AND(NERVE(BLOCK,(SHOULD(BE( EMPLOYED(ONLY(BY(CLINICIANS(WHO(ARE(WELL( VERSED(IN(DIAGNOSIS(AND(MANAGEMENT(OF(DOSET RELATED(TOXICITY(AND(OTHER(ACUTE( EMERGENCIES(THAT(MIGHT(ARISE(FROM(THE(BLOCK( TO(BE(EMPLOYED(AND(THEN(ONLY(AFTER(ENSURING( THE(IMMEDIATE(AVAILABILITY(OF(OXYGEN,(OTHER( RESUSCITATIVE(DRUGS,(CARDIOPULMONARY( EQUIPMENT(AND(THE(PERSONNEL(NEEDED(FOR( PROPER(MANAGEMENT(OF(TOXIC(REACTIONS(AND( RELATED(EMERGENCIES.((See(also(ADVERSE( REACTIONS(and(PRECAUTIONS.)(DELAY(IN(PROPER( MANAGEMENT(OF(DOSETRELATED(TOXICITY,( Drs.RixonDorkowskiEnsorNealSa UNDERVENTILATION(FROM(ANY(CAUSE(AND/OR( nderson 27

28 Epinephrine'Effects Promotes(hemostasis( (<1:100,000( no(sig( ) Decreases(rate(of(systemic( absorption( by(1/3( Reduces(likelihood( of( systemic(side(effects Increases(analgesia( duration( by(up(to(50% Wait(at(least(7min(for( vasconstriction to(occur Infiltrative'Technique 27T30G( ½(inch( needle,( 1.5cc( anesthetic( in( syringe 1T2( gtts topical( anesthetic,( 1T2gtts( optional( phenyl/brimonidine (palpebral( side) Alcohol( prep( pad( with( percutaneous( approach Pull( skin(laterally( until( slightly( taut Introduce( needle( in(subq tissue( approximately( 15 to(eyelid( surface Inject( 0.5cc( of(solution,( distribute( using( a(gentle( turning( motion Drs.RixonDorkowskiEnsorNealSa nderson Apply( pressure( to(increase( diffusion 28

29 Atlas'of'1 Eyecare'Procedures Video 29

30 Post'Injection'Blanching SUBCONJ'INDICATIONS (Refractory(Uveitis( (Cystoid(Macular(Edema (Noncompliant( patient (Failing( trabeculectomy (Bleb(needling) (Recalcitrant( pterygium p(sx (Alternative( route( of(anesthesia( in( trabeculectomy or(cataract(surgery (Anterior( Scleritis 30

31 Corticosteroids Anterior'Seg Posterior'Seg Injectable Info Name Trade'Name Potency' (cortisol equivalents) Duration' of' Action Triamcinolone Acetonide (10, 20, 40 mg/ml) Kenalog 1 2T4 mos IO, >3mos perioc. Methylprednisone Acetate (40, 80, 160 mg/ml) DepoTmedrol 1 >3 mos Table(based( on(cunningham( ET,(et(al.(Canadian* Journal*of*Ophthalmology 2010Q45,4:( 352T357 31

32 SubConj Technique 25T30G,(½ (needle(with(1cc(syringe Instill(topical(anesthetic Direct(patient s(gaze(away(from(site Position(needle((technique(dependent) Insert(needle Inject(the(desired(amount(of(medication( forming(a( bleb (within(the(subconj space Withdraw(the(needle May(apply(pressure Which'one? 32

33 Brimonidine??? Nice(job(as( vasoconstrictor Reduction(in( SCH? Growing'Pains? Video(Courtesy(of(David(Talley(O.D.,(FAAO 33

34 Tent???? Inferior'Fornix 34

35 Deep 'Subconj SubConj Complications Subconjunctival Hemorrhage Pain/irritation(during/post(injection Increased(IOP Secondary(ocular(infections Chemosis Ecchymosis Perforation(of(the(globe Retained(drug(deposits 35

36 SubConj Ca$h 68200TSubConjunctival(Injection *$39.48(PAR(Non(Facility *Palmetto GBA Medicare TN Allowable 2018 Retinal'Realities #1T healthy(retinal(vessels(are(not fenestrated(and( therefore(should(not leak(dye.( #2T vessels(comprising(a(nontcompromised( choriocapillaris are fenestrated(and(should( leak creates(the(choroidal(flush(seen(in(the(early( phase #3 An(intact(RPETBruch s(membrane(complex(forms( a(barrier(between(fluid(within(the(choriocapillaris and( sensory(retina #4 RPETBruch s(provides(a(filter(which(prevents( complete(visualization(of(fluorescence(within(the( underlying(choroid. Andrew(J.(Rixon,(O.D,(F.A.A.O 77 36

37 Indocyanine Green'(ICG):'Properties Water(soluble Tricarbocyanine dye Peak(absorption(at(800(nm Fluoresces(in(IR(spectrum Transmission(through( pigment,fluid,(lipid(and( hemorrhage(more(efficient(than( fluorescein Contains(5%(sodium(iodide ~98%(bound(to(blood(protein Indications:(CNV,(RAP,(PCV,( CSCR,(intraocular(tumors,( choroidal(inflammation 78 Fluorescein Sodium:' Properties Biological( Dye WaterTSoluble( Disodium( salt Adjusted( to(ph( 8+ Low( Molecular( weight Up(to(80%(binds(to(plasma( proteins Max(absorption( peak( 465(to( 495nm Emission( at(525( to( 530nm λ of(emitted(light(blocked(by(the(overlying( RPE DrsRixonDorkowskiEnsorNealSanderson 79 37

38 Hypofluorescence 40(seconds DrsRixonDorkowskiEnsorNealSanderson 80 Hypofluorescence DrsRixonDorkowskiEnsorNealSanderson 81 38

39 Hyperfluorescence DrsRixonDorkowskiEnsorNealSanderson 82 Hyperfluorescence 1'min' 8'min 83 39

40 IVFAXEquipment 25% Fluorescein Dye Infusion set-23 or 25g Tourniquet Syringe-3 or 5cc Alcohol prep pads Bandaids Emesis basin ** Angio-Pro-Pak Justiceop.com $30.95/pk IVFA'Equipment 40

41 Stat'Kits or'crash'carts StatKit 1000HD StatKit ZX Treatment'with'a STAT'Kit Acute(Coronary(Syndrome Allergy Anesthesia(Related( Oversedation Asthma Cardiac(Arrest Congestive(Heart(Failure Dysrhythmias GI(Distress(with(Hypotension Hypertension(Emergencies Hypoglycemia Pain(Management Poison(Emergencies Seizures Vasovagal(Syncope Statkit

42 CPR'Updated??? A(Tennessee(optometrist(using(local(anesthetic(in(the( manner(allowed(by(sb(220(shall(provide(to(the(board(proof( that(the(he/she(has(current(cpr(certification(by(an( organization( approved( by(the(board Or(providing( that(another( person(who( has(current(cpr( certification(will(be(present(in(the(office(at(all(times(that(a( local(anesthetic(is(used(by(the(o.d.(in(conjunction(with(the( treatment(of(an(eyelid(lesion Check(that( card! Drs.RixonDorkowskiEnsorNealSanderso n Emergency'University Scenarios Acute(Coronary(Syndrome Allergy Anesthesia(Related(OverT sedation Asthma Cardiac(Arrest Congestive(Heart(Failure Dysrhythmias GI(Distress((c(Hypotension Hypertensive(Emergencies Hypoglycemia Pain(Management Poison(Emergencies Seizures Vasovagal(Syncope 42

43 IVFAXPractical'Considerations Flashback( equal(stable(venous(access Open(the(cap(at(end(of(infusion(set(to(confirm(in(lumen(of(vein( (Open(System) May(need(to(keep(cap(off(initially(if( concern(over(quality(of(veins( to(avoid(infiltration Tape(site(down(to(stabilize Can(reattach(cap(prior(to(attaching(syringe(if(hydrostatic(pressure( too(much Remove(tourniquet(once(site(is(stable/Do(NOT(inject(against( tourniquet Extravasation Damage(caused(by(the(efflux(of(solutions(from(a(vessel( into(surrounding(tissue(spaces(during(iv(infusion Incidence(of(upwards(of(39%(in(adults Incidence(of(extravasation(injuries(0.1T6%(in(chemo(pts Due(to(high(pH(can(result(in(severe(local(tissue(damage Complications(includeQ Tsloughing(of(the(skin Tsuperficial(phlebitis( Ttoxic(neuritis(along(the(curve(of(the(antecubital(area 1) AlTBenna S,(et(al(ISRN(Dermatology(2013 2) extravasationtinjurytcausedtbytthetleakagetoft intravenoust html 43

44 IVFAXLogistics Watch(for(extravasation( during(push Speed(of(injecting( bolus(has(been( disproven(to( increase(risk(of(nausea/vomiting,( is(anecdotal Suggested( rates(vary(from(1t6sec(for(entire(2cc(bolus Leave(the(line(in(until( confirm(patient( is(stable??tno Flushing( line???tdepends Where?'Netter'knows

45 OR... Intravenous' Injection' Order'Recap' Informed(consent/Vitals Prepare(IV(tray. Wash(hands(and(don(Gloves. Advance(infusion(line(into(vein((bevel(up)(watching(for( blood(return. Remove(tourniquet. Attach(syringe(and(inject(while(observing(site Remove/Retract(needle(and(apply(gauze. Inspect(injection(site(and(apply(bandage. Discard(gloves/Waste Check(vitals 45

46 IVFAXProcedure Site(Selection((((((((((((((((((((((((((((((((( Alcohol(Prep IVFAXProcedure Tourniquet VenipunctureTShallow 46

47 IVFAXProcedure Remove(infusion(set( Apply(pressure Venous'Air'Embolism Severity(depends(on(volume,(rate(of(accumulation( and(body(position Small(amounts(of(air(are(generally(broken(up(in( the(capillary(bed(and(absorbed(from(the( circulation(without(complications Ingress(of(300T500mL(of(air(at(a(rate(of( 100mL/sec(can(be(lethal 1 TThis(involves(a(14G(needle(with(pressure(gradient(of(5cmH2O TInvolves(central(venous(catheterization((Large(veins(i.e Jugular) Symptoms(may(arise(in(as(little(as(20mL/sec 2 1)(Respiratory( Medicine( Case(Reports( 18((2016)( 58T61 2)(Indian( Journal( of(anaesth 2010( JanTFebQ(54(1):(49T51 DrsRixonSandersonDorkowskiEnsorNeal

48 Closed 'System Open 'System 48

49 FANGXComplications Nausea Vomiting Pruritis Urticaria Anaphylaxis Syncope Tachycardia Extravasation( DeathTMI Incidence' of'complications Yannuzzi(et(al,(Fluorescein(Angiography( Complication(Survey((FACS),( Ophthalmology 1986Q(93:(611T responding( retinal(specialists N=221,781( IVFAs(performed(in(1984 Moderate(adverse(reaction((1:63 (transient(effect,(possible(medical(intervention)( Severe(reaction(was(1:1900 (prolonged( requiring( intense(tx)( Rate(of(death(1:222,000.( 49

50 Jennings' and'mathews 1st(optometric(exploration(into(the( adverse(reactions(of(ivfat1994 N=1, %(of(patients(had(adverse(effects Nausea(0.8%,(Urticaria(0.6%,( Emesis(0.2%,(Extravasation(0.2% Not(one(factor(existed(which(served(to( adequately(predict(which(patients(will( have(an(adverse(rxn(to(the(nafl(dye J(Amer(Optom(Assoc(1994(JulQ65(7):465T71 Financial' Facts 92235( R/L(Fluorescein(Angiography( $81.55( TC($ ( R/L((Indocyanine T Green(Angiography $ (((((((((Special(Anterior(Segment( Photography(with((Angiography $ (((((((((Fundus(Photography( $53.70((( Palmetto'GBA'Medicare'Allowable'TN'2018'PAR'NonFacility 50

51 SubTenon s Techniques Smith(and(Nozik Orbital(Floor Cannula(Method Intravitreal'Utilization Based(on(publically(available( medicare claims(in(2012( 583,593(patients(treated 1 2,869(physicians 1 4,749,026(injections 1 $1,474,501,217(Total(Payments 1 Projected(over(6(million(in( )Baisiwala S,(et(al.(Ophthalmic* Surg Lasers* Imaging*Retina.( 2016Q47:555T62 2)(Avery(RL,(et(al(Retina.(2014( 34:S1TS18 51

52 Intravitreal Indications Neovascularization Inflammation Infection Intravitreal Guidelines No(contraindications(exist Use(of(Antibiotics(unsupported(( Bilateral(injections(should(be(treated( as(separate(procedures Gloves/Draping(has(not(been(shown( to(reduce(endophthalmitis Minimize(speaking/surgical(mask PovidoneTIodine(5T10%(last(agent(to( be(applied(pretinjection Avery(RL,(et(al.(Retina 2014(DecQ(34(Suppl 12:(S1TS18 52

53 Intravitreal Guidelines Speculum(or(manual(lid(retraction(ok If(gel(anesthetic(is(used(apply( povidonetiodine(pre(and(post Deliver(injection(between(horizontal( and(vertical(rectus(muscles(3.5t 4.0mm(posterior(to(limbus Use(30G(or(smaller,(18mm(or(shorter Post(injection(need(to(confirm(formed( vision(prior(to(pt departure Avery(RL,(et(al.(Retina 2014( DecQ(34(Suppl 12:(S1TS18 Intravitreal'Technique 53

54 InVitria Intravitreal Complications Endophthalmitis Retinal(Detachment Conjunctival Hemorrhage Vitreous(Reflux Eye(pain Cataract(Development Increased(IOP RPE(tears Hypotony 54

55 Endophthalmitis Rates Reported(ranges(from(0.0%T0.36%(c(and( s(antibiotic(prophylaxis 1,2 MetaTanalysis(of(16(studies/105,536( injections(average(0.049% 3 0(per(15,144(with(mask(c(povidone( irrigation 4 Rates(comparable(amongst(bevacizumab,( ranibizumab,(and(aflibercept (0.039%,( 0.035%,0.035%) 5 1)(Hasler PW,(et(al(Acta Ophthalmol.(2015Q93:122T125( 2)(Cheung( CS,(et(al.(Ophthalmology.( 2012Q119:1609T1614 3)(McCannel CA.*Retina.(2011Q31:654T661( 4)(Shimada( H,(et(al.((Graefes Arch*Clin Exp Ophthalmol.( 2013Q251:1885T1890 5)(Rayess N,(et(al.(Am*J*Ophthalmol 2016Q(165:88T93 Nurses'and'Orthoptists? 55

56 Retrobulbar Indications Globe'anesthesia Orbital'pain'relief Retrobulbar Technique 25(g(1(½ (needle(c(blunt(point Have(pt(stare(superior(nasally Insert(needle(through(lower(eyelid(.5mm(medial(to(lateral(canthus Redirect(needle(into(muscle(cone Aspirate(syringe Inject((2T5mL) Remove(needle Apply(Pressure(to(globe 56

57 Retrobulbar Technique Lange* Anesthesiology* Fig*38R1 Retrobulbar Complications Retrobulbar(hemorrhage Globe(perforation((>26mm) Optic(nerve(atrophy Frank(convulsions Oculocardiac(reflex Acute(neurogenic(pulmonary edema Respiratory(arrest Postretrobulbar(apnea(syndrome( Death 57

58 Current(Injectable(Authority D.C. Limited'to'Treatment'of'Anaphylaxis Use'of'Injectables [Including'Tx of'anaphylaxis] Sept/2018 Slide4Courtesy4of4Catherine4Hendricks4The4AOA Acknowledgements Owen(Bell Erin(Jaffe Erin(Nosel O.D.,(FAAO Phil(Ridings David(K.Talley O.D.,(FAAO Corrie Wicklund O.D. 58

59 Thank'You! Additional(QuestionQ Please(remember(to(complete(your( session(evaluations(on(the(academy.18(meeting(app Tweet(about(this(session(using( the(official(meeting(hashtag( #Academy18' 59