Surgical Assisting Procedures Flashcards

During a phacoemulsification procedure, the surgeon requests a second instrument to manage a posterior capsule tear that occurred during cortex removal. Which of the following maneuvers would be MOST appropriate for the surgical assistant to anticipate immediately after this complication?

Answer: Passing a vitrectomy handpiece and preparing anterior vitrectomy settings on the phaco machine

A posterior capsule tear during cortex removal risks vitreous prolapse into the anterior chamber. The priority is anterior vitrectomy to remove any prolapsed vitreous before it becomes incarcerated or causes traction. The surgical assistant must anticipate the vitrectomy handpiece and verify the machine is switched to vitrectomy mode with appropriate cut rate and low vacuum. Increasing bottle height could worsen the tear by elevating pressure; a Sinskey hook is inappropriate at this stage; and continued irrigation without vitrectomy risks extending the tear.

When preparing a surgical field for a trabeculectomy with mitomycin-C (MMC), which sequence of steps correctly reflects the role of the ophthalmic surgical assistant regarding MMC application?

Answer: Soak MMC-saturated sponges for the surgeon, then immediately discard gloves and instruments exposed to MMC into a designated chemotherapy waste container after removal

The surgical assistant's critical responsibilities with MMC include preparing the sponges at the surgeon's specified concentration, timing the exposure, and ensuring all MMC-contaminated materials (sponges, instruments, gloves) are disposed of as chemotherapy waste immediately upon removal—not regular biohazard waste. The surgeon (not the assistant) applies the sponges under the flap. MMC is typically reconstituted with sterile water (not BSS, which can affect stability), but preparation is pre-operative pharmacy work. Documentation must occur contemporaneously per OR protocol, not post-procedure.

A patient undergoing strabismus surgery under general anesthesia develops bradycardia to 42 bpm during manipulation of the medial rectus muscle. The anesthesiologist asks the surgical assistant to relay information to the surgeon. What is this reflex called, and what is the FIRST recommended intervention?

Answer: Oculocardiac reflex; the surgeon should immediately cease traction on the muscle and allow heart rate to recover before proceeding

The oculocardiac reflex (OCR) is triggered by traction on extraocular muscles (medial rectus most commonly), compression of the globe, or retrobulbar block injection, causing bradycardia via the trigeminal-vagal arc. The FIRST step is to have the surgeon immediately release traction—this typically resolves the bradycardia within seconds. Atropine is reserved for refractory or recurrent OCR, or if the rate drops dangerously low. Deepening anesthesia does not treat OCR and may worsen hemodynamic compromise. Trendelenburg is inappropriate.

In a vitreoretinal surgical suite, the assistant is setting up for a pars plana vitrectomy (PPV) with planned silicone oil tamponade. The surgeon specifies 5000 centistoke (cs) silicone oil. Compared to 1000 cs silicone oil, which statement about 5000 cs oil is TRUE and directly affects assistant preparation?

Answer: 5000 cs oil requires a dedicated, higher-pressure injector system because of its greater viscosity, and the assistant must confirm the correct injector is loaded before the tamponade step

Silicone oil viscosity directly affects injection mechanics. 5000 cs oil is significantly more viscous than 1000 cs and cannot be injected through standard tubing at typical pressures—it requires a dedicated high-pressure/high-torque injector (e.g., a viscous fluid injector). If the assistant loads the wrong injector, the oil cannot be delivered or the system may fail catastrophically. Both 1000 cs and 5000 cs oils have similar buoyancy (both are lighter than vitreous); 5000 cs actually emulsifies less rapidly; and routine warming is not a standard protocol step.

During preparation for a Descemet's Membrane Endothelial Keratoplasty (DMEK) procedure, the surgical assistant is asked to 'stain the donor tissue.' Which agent is used and what is its precise purpose in this context?

Answer: Trypan blue 0.06% is used to stain the Descemet's membrane/endothelium complex, allowing the surgeon to visualize orientation and confirm the scroll is placed endothelial-side down

In DMEK, the donor DMEK scroll must be oriented correctly (endothelial side down against the recipient stroma) inside the anterior chamber, which is extremely difficult with an unstained, transparent scroll. Trypan blue (0.06%) is applied briefly to the donor tissue to stain the endothelium/DM complex, providing visual contrast that allows the surgeon to determine scroll orientation and confirm the 'S-stamp' or edge markings are reading correctly. BBG is used in retinal surgery for ILM peeling; ICG has been used historically in DSEK but not for orientation purposes; fluorescein measures leak patterns, not donor quality.

During a glaucoma drainage device (tube shunt) implantation, the surgeon ligates the tube with a 7-0 polyglactin (Vicryl) suture to prevent early hypotony. The assistant is asked to create a 'ripcord.' What material is used and what is its function?

Answer: A 3-0 or 4-0 nylon suture is passed through the tube lumen alongside the ligature; when pulled post-operatively at the slit lamp, it breaks the Vicryl and opens the tube to aqueous flow

A ripcord technique involves threading a 3-0 or 4-0 nylon suture through the lumen of the tube before or after placing the Vicryl ligature. The suture's free end is left accessible (typically tucked under conjunctiva with the end accessible at the limbus). Once the Vicryl has served its purpose (preventing early hypotony in the first few weeks), the clinician can pull the nylon suture at the slit lamp, mechanically tearing the Vicryl and allowing aqueous to flow through the device. This is preferred over waiting for Vicryl absorption. Options B, C, and D misidentify the mechanism—laser suture lysis and external sutures do not pass through the tube lumen.