Office-Based Surgery! for the Optometric Physician! ADVANCED PRACTICE OPTOMETRY! DISCLOSURE

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Stanley Rich
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1 Office-Based Surgery! for the Optometric Physician! ADVANCED PRACTICE OPTOMETRY! Richard E. Castillo, OD, DO! Medical & Surgical Ophthalmology! Tahlequah, OK! DISCLOSURE I have no financial interest in any of the actual products or devices mentioned in this talk. I do have a financial interest in Take10Vision Educational Video Productions. I have no financial interest in Ellman or Oasis Medical products or services which may be mentioned in this talk. Office-Based Surgery! Biopsy! Punch Biopsy! Incisional Biopsy! Excisional Biopsy! Shave Biopsy! 1

Biopsy: A most underutilized optometric procedure!

! Punch Biopsy in Optometric Practice! Punch Biopsy vs Incisional Biopsy!

Usuing a skin punch is generally more practical around the eye.

2 Biopsy: A most underutilized optometric procedure! Biopsy removes all or part of a lesion for histopathologic analysis.! Incisional: samples an area.! Excisional: removes the lesion with clear margins and deep to the subcutaneous plane.! Shave: removes entire lesion but does not penetrate the dermis.! Punch Biopsy in Optometric Practice! Punch Biopsy vs Incisional Biopsy! Essentially the same thing! Usuing a skin punch is generally more practical around the eye.! Why should ODs Biopsy?! Because you never know for sure without the path report.! Because you can t always tell were the actual borders are by gross examination.! Because it s the standard of care for suspicious lesions.! Because it s in the patients best interest.! Because medico-legally, it s in your best interest.! 2

3 Punch Biopsy in Optometric Practice! Useful to categorize as benign or malignant prior to definitive excision.! Helpful in planning procedure to minimize uneccessary tissue loss which can impact function and appearance.! Punch Biopsy in Optometri Practice! 1 mm, 1.5 mm, and 2 mm -sized skin punches are most useful.! Lesion margins may be inked prior to injecting anesthetic (optional).! Specimen should be taken along lesion border when possible.! Here s how you do one! 3

Punch Biopsy in Optometric Practice! Specimen is placed in formalin cup provided to you by the lab.

! Patient is billed directly by the lab.

fat stains.! Punch Biopsy in Optometric Practice!

4 Punch Biopsy in Optometric Practice! Specimen is placed in formalin cup provided to you by the lab.! Lab is notified and courier picks up sample and requisition slip.! Patient is billed directly by the lab.! NOTE: suspected sebaceous cell carcinoma is never placed in formalin as this precludes necessary fat stains.! Punch Biopsy in Optometric Practice! Mild cautery may be applied BUT SIMPLE PRESSURE to control bleeding is best!! Patient sent home with antibiotic ointment applied bid x 1 week.! Wound is left to heal by secondary intent, NO SUTURING!! Definitive management follows pathology report.! 4

Office-Based Surgery! Minimally Invasive Entropion Repair (Everting Lid Sutures)! The Minimally Invasive Entropion Repair! AKA: Everting Sutures! Indications:!

! As a permanent fix in cases of early to moderate involutional entropion with little horizontal lid laxity or dehiscence of lower lid retractors.! The Minimally Invasive Entropion Repair!

5 Office-Based Surgery! Minimally Invasive Entropion Repair (Everting Lid Sutures)! The Minimally Invasive Entropion Repair! AKA: Everting Sutures! Indications:! As a temporizing measure for cases of spastic or involutional entropion.! When patient refuses or is unable to undergo a more definitive procedure.! As a permanent fix in cases of early to moderate involutional entropion with little horizontal lid laxity or dehiscence of lower lid retractors.! The Minimally Invasive Entropion Repair! A mechanical explanation of the problem:! Shortening/Contraction of the posterior lamellae of the lid.! Lengthening/Laxity of the anterior lamellae of the lid.! Horizontal lid laxity +/- dehiscence of lower lid retractors.! Results in overiding of the lid margin by the pre-septal orbicular.! Lid margin rolls inward.! 5

contact with the pre-septal orbicularis.

dissolves helps maintain the lid position.

What it looks like at the conclusion of the

6 Everting Sutures! 1 to 3 absorbable sutures placed as shown.! Tightening the suture placates the retractors of the lower lid, bring them into contact with the pre-septal orbicularis.! Fibrosis along suture tract as suture dissolves helps maintain the lid position.! The Minimally Invasive Entropion Repair! What it looks like at the conclusion of the procedure.! Suture begins to dissolve in 7-10 days.! The Minimally Invasive Entropion Repair! Here s what you use! 6

7 Here s how you do it! Office-Based Surgery! Three-snip Punctoplasty! 7

For the Correction of Punctual Stenosis!

8 Causes of punctual stenosis:! Infection! Inlammation! Trauma! Chemotherapy! Irradiation! Topical antivirals! The Three Snip Punctoplasty! For the Correction of Punctual Stenosis! Easily performed in the office under local anesthesia.! Removes posterior ampullae of the punctual.! Here s how you do one! 8

Office-Based Surgery! Radiosurgical Telangiectasia Destruction!

9 One Punch Punctoplasty! Using a Christensen Punctal Punch you can do the same thing with one snip! Office-Based Surgery! Radiosurgical Telangiectasia Destruction! Radiosurgical Telangiectasia Destruction! Uses an insulated fine gauge needle electrode.! Transdermal anesthetic cream may be applied.! Low power setting in coagulationmode on radio surgical device.! 9

Office-Based Surgery! Radiosurgical Follicular Ablation! The Permanent Trichiasis Solution! Radiosurgical Follicular Ablation! The definitive correction of trichiasis is surgical.

! Cryosurgery, electrolysis, lasers have all been used and are painful and traumatic.! The Permanent Trichiasis Solution! Radiosurgical Follicular Ablation!

10 Office-Based Surgery! Radiosurgical Follicular Ablation! The Permanent Trichiasis Solution! Radiosurgical Follicular Ablation! The definitive correction of trichiasis is surgical.! Epilating with forceps DOES NOT SOLVE THE PROBLEM.! The lash grows back shorter, stiffer, and more irritating!! Cryosurgery, electrolysis, lasers have all been used and are painful and traumatic.! The Permanent Trichiasis Solution! Radiosurgical Follicular Ablation! Performed quickly, easily, and painlessly under local anesthesia.! A small-gauge insulated wire electrode is introduced alongside lash into the follicle.! The RFS unit is set to lowest setting and activated for a brief instant permanently destroying the lash follicle.! The shaft heals with minimal discomfort or scarring.! 10

11 The Permanent Trichiasis Solution! Radiosurgical Follicular Ablation! Here s what you use! The Permanent Trichiasis Solution! Radiosurgical Follicular Ablation! Insulated needle electrode! Here s what it looks like:! Low Power setting! Hemo (Coag) mode! Insert needle parallel to lash into follicle! Apply brief (1 sec) burst of energy! Here s how you do it! 11

Numerous spot burns are placed with RFS bipolar forceps on the palpebral conj at the bottom of the

12 Office-Based Surgery! Thermal Punctoplasty! Indications! Punctal eversion! Medial ectropion! Procedure! Thermal Punctoplasty! For Everted Punctum/Medial Ectropion! Numerous spot burns are placed with RFS bipolar forceps on the palpebral conj at the bottom of the tarsus directly below the punctum.! Resultant shortening of the posterior lamellae of the lid forces inversion of the everted punctual.! 12

Office-Based Surgery! Radiosurgical Punctal Occlusion! Radiosurgical Punctal Occlusion! Indications! Dry eye syndrome/ocular surface disease!

13 Office-Based Surgery! Radiosurgical Punctal Occlusion! Radiosurgical Punctal Occlusion! Indications! Dry eye syndrome/ocular surface disease! Where medical management and reversible punctual occlusive therapy have failed.! Radiosurgical Punctal Occlusion! Topical or local anesthetic applied.! RFS broad-based needle electrode is inserted into anesthetized punctum and activated briefly to achieve mucosal scarring and closure.! 13

14 Here s how you do one! Local anesthetic injection with 0.5% Lidocaine! Punctal Dilation and Treatment Begins! 14

15 Look for the blanching around punctal opening..! Office-Based Surgery! Chalazion Insicion & Currettage! An interesting video! 15

Office-Based Surgery! Radiosurgical Surface Ablation! Neoplasia Risk Assessment! ABCDE Rule! Dermoscopy! Consent Form! Infiltrative anesthesia! Skin prep!

16 Office-Based Surgery! Radiosurgical Surface Ablation! Neoplasia Risk Assessment! ABCDE Rule! Dermoscopy! Consent Form! Infiltrative anesthesia! Skin prep! Radiosurgical Surface Ablation! of Periorbital Lesions! Surface ablation utilizing radiosurgical unit! Antibiotic ointment bid x 1 week! Here s how you would remove benign SK s in your practice! 16

17 Here is how you would manage a benign-appearing nevus! 17

18 Thank You! Sponsored by:! 18

Benign vs. Cancer. Oculofacial Biopsy. Evolution of skin cancer. Richard E. Castillo, OD, DO

Benign vs. Cancer. Oculofacial Biopsy. Evolution of skin cancer. Richard E. Castillo, OD, DO Oculofacial Biopsy Richard E. Castillo, OD, DO Benign vs. Cancer Evolution of skin cancer Metaplasia Dysplasia Carcinoma-in-situ Invasive carcinoma Intravasation Overview Preoperative Planning Choosing