Ophthalmology is a shining example of daycare surgery which has increased its application by leaps and bounds. Not only have the techniques of surgery changed over the last 25 years but so has the anaesthesia accompanying it. The success of daycare surgery is dependent upon patient’s satisfaction, patient’s safety, ophthalmologist’s comfort and the success of the surgery. The minimum requirements of nursing, literally, a completely mobile patient, has made ophthalmology and an ideal daycare surgery procedure.

Advances in cataract surgery
Since virtually 95% of all surgery done by the ophthalmologist is cataract surgery, it therefore behooves us to first examine this surgery and see what changes have led to its application for day care. Cataract surgery also has the advantage that its success rate, in good hands, is almost 98 to 99%. It is also the surgery which enables instant visual gratification; a surgery which enables recovery within a four-day period, adequate to have normal mobility, normal moment, house activities and normal cleaning procedures like bathing, washing ones face, etc

Examining the changes in cataract surgery through the ages is interesting. It was initially intracapsular cataract surgery wherein a 180 degree cut was made in the clear cornea, the cataractous nucleus along with its enclosing capsular bag was removed by vacuum or a forceps or cryo. This left the patient with virtually no safety bar to the contents coming out on the slightest pressure or injury. The eye was closed with three to five sutures. Invariably the patient had sandbags at the side of the head and had to lay flat on his back of a minimum period of 15 days. This led to the common concept, unfortunately still prevalent, that cataract surgery should only be done in the cooler months and never in the hot months. On analysis, this wide sweeping statement was fairly obvious: if one is unable to change one’s position it was only in the winter month’s one could lie comfortably without sweating and itching.

Intracapsular cataract surgery was replaced by extracapsular surgery where the cataractous nucleus was removed but the posterior part of the capsular bag was left behind. It provided a modicum of protection, afforded by the residue of the capsule, usually, enabled healing to proceed adequately by permitting a modicum of movement to be restored in three weeks or less.

Advances in suturing techniques of the corneal 180 ° incision, and the availability of finer 10/0 monofilament nylon sutures enabled the incision to be closed more appropriately and more securely. Still the 10 to 15 day barrier remained as the slightest injury, or even severe bout of coughing, would precipitate a ‘sutures break’ leading to partial expulsion of intraocular contents, usually with irreversible, affection of vision

The advent of intraocular implants gave a further level of protection in the form of a barrier and enabled the 10-day safety margin to be established. But still the slightest injury to the incisional wound would lead to consequences which may, well nigh, be irreversible

In 1989, phacoemulsification was first introduced in India by the author in regular practice. In the earlier days limited to a few centres the inherent safety of this procedure wherein, an entire cataract can be performed by a small 3.2 mm incision, later to diminish further. This opening, which is inherently a self-sealing one, with the trap door style incision, has made a world of difference to ophthalmology, and led to the onward crusade to day care surgery.

In the earlier days it was only a few intrepid surgeons who carried their Phaco machines to the rural eye centres for eye camps. However, the tremendous safety of the procedure and the immediate return of vision combined with stability of the vision led to many rural centres adopting this procedure as the standard procedure. It became common for village tehsildars to tell the visiting doctors that they were free to do an eye camp, in their village or tehsil, only if the visiting surgeon do the procedure utilizing so-called ‘sutureless’ technique of surgery.

Unfortunately, the art of phacoemulsification requires a certain element of skill and the ability to be trained at a centre where adequate practice under the direct supervision of a senior ophthalmologist is required. In an effort to bypass this problem, a number of ophthalmic surgeons reverted to an alternate technique known as ‘a small incision cataract surgery’ whereby, utilizing an incision of 5.5 to 6 mm, a lens nucleus was literally dragged out using either a spoon or flushed out utilizing high-pressure liquid. This enabled the procedure to be done relatively safer in the majority of cases.

Perhaps the biggest advantage of this procedure was that the spectacle number which was achieved following the surgery remained stable for a prolonged period of time and did not need to have repeated spectacle changes. Interestingly, since the input of the additional resources like sutures and the overnight stay, washing facilities, toilet facilities, etc., were now no longer required, the procedure of cataract surgery became cheaper.

It thus became easier to do a larger and larger number of cases in the eye camp milieu with greater and greater safety and efficiency. Thus, for practical purposes the common indication became literally instant return of vision with a relative quantum of safety. If there was no infection at the time of doing the surgery, the chances of infection developing later on, became a highly unlikely, as properly conducted incisions were self-sealing.

Advances in retinal surgery
As with cataract surgery, the retinal two-handed sterns, subsequently was now done through smaller and smaller opening, utilizing 21G, 23G, 25G gauge cutters, fibreoptic lightpipes and aspirating equipment. Essentially the application of the simple three sutures utilizing the 21 and 23 gauge systems and no sutures for the 25 gauge system enabled the retinal surgery to become almost an outpatient procedure. The only disadvantage in retinal surgery as compared to cataract surgery is that to be able to handle complicated procedures, the instrumentation has to be superlative. It would not be out of place to say that for retinal surgery the dictum is “As is your instrumentation, so is your surgery”. Retinal surgery became to a large extent, out patient.Now the original concept of placing a person in the ward for prolonged periods of time was no longer required.

Advances in glaucoma surgery
In the 1970’s glaucoma surgery involved the making of hole in the eye with a round trephine and covering the opening with the conjunctiva. The biggest disadvantage was that the slightest quantum of infection in the eye led to the infection tracking its way into the eye leading to endophthalmitis and often permanent loss in vision. Newer techniques utilized a trapdoor system to close the opening and prevent the infective risk to the eye, but still the risk potentially remained, necessitating at least a day in the hospital as an in-patient. Newer advances like the new Non penetrating deep sclerectomy permit the entire procedure to be done without opening an eye, permit recovery almost instantly, enabling the patient to resume his activities the very same day, watch TV, have a bath the next day, and simultaneously obviate the risk of infection, thus contributing to its true application as a day-care surgery.

The role of Anaesthesia in day-care surgery
The evolution in anaesthesia in cataract surgery was an ongoing process. Until a few years ago the operation was frequently being performed under local anaesthesia involving one or more interorbital injections accompanied with a total block of the seventh cranial nerve to eliminate interoperative blinking. This complex procedure was associated with heavy pharmacological sedation of the patient. All these measures were aimed at achieving the best surgical conditions, total analgesia and akinesia of the eye ball, analgesia of the conjunctiva and the orbital tissue, akinesia of the eyelids, and stability of the vitreous by means of prolonged high-pressure.

In recent times, the considerable improvement of the surgical techniques and its applied technology, in this type of surgery, has more than halved the surgical time and has made the operation less traumatic. As a result, today, there is more widespread use of topical and local anaesthesia which permits a rapid visual rehabilitation and an equally rapid discharge from the surgical structure, in addition to eliminating the complications associated with the interorbital injections and the injections of local anaesthesia. Cataract surgery gradually therefore evolved from general anaesthesia to local anaesthesia which in turn reverted to a bulbar anaesthesia. In bulbar anaesthesia, the anaesthetic is injected into the sub-tenon space following an incision of the conjunctiva and the tenon capsule utilizing a blunt cannula. It produces a rapid bulbar anaesthesia but rarely produces oculopalpebral akinesia with the normal volumes used.

Day-care surgery truly came into its being with the advent of tropical anaesthesia. Simple application of Xylocaine 4% (Lidocaine) eye drops four times at 2 minute intervals usually suffice for a surgery lasting 8-10 minutes. Corneal analgesia is optimal; anaesthesia of the conjunctiva is adequate, however, the oculopalpebral area is not altered.

In a further modification, 1% lignocaine, preservative-free or half per cent lignocaine can be injected into the anterior chamber which leads to complete analgesia of the anterior intraocular tissues. When regional anaesthesia is utilized reducing the acidity of the anaesthetic solution by adding sodium bicarbonate or BSS plus, significantly diminishes pain.

Advantages of Day Care ophthalmic surgery
Day-care surgery reduces the waiting list, time and is a very cost-effective health care system. It significantly enhances visual rehabilitation, favoring, both, the doctor and the patient alike. Nurses to patient contact time have been reduced creating new approaches to nursing care. From the patient point of view the ability to return to his home has significant advantages. Various studies have found the patients to be very happy with day-care surgery, mentioning that 87% of patients are relieved to return to their workplaces earlier and there is a strong element of “let’s get it over with fast” and return home.

Patient suitability for day-care surgery
It is imperative that the patient is deemed suitable, as the day case and the criteria of the suitability be integral to the assessment procedure. A cataract surgery requires much less time and therefore, can be done comfortably even on a medium risk patient, whereby, a squint surgery or oculoplasty surgery or lacrymal surgery, would need to be reconsidered. In a similar manner, the basic nursing requirements to be followed are also the criteria for selection on a day care mode.

Maintaining a safe environment
Any preoperative assessment must assess the patient’s ability to maintain his or her own safe environment. One needs to assess any problems, linked to respiratory, diabetes, heart or kidney, and to evaluate in advance, drugs to be utilized. It is imperative that a pre-operative assessment include the final plan of the standby anaesthetist, which must be mapped out in advance, on a sheet which accompanies the patient to the theatre. Outpatient surgery is surgery in a hurry with a high turnover and the operating room is not the place for evaluating a patient. In addition, the patient’s allergies must also be evaluated and noted in the chart.

Detailed medical history
Unfortunately, thanks to Mediclaim, it has become popular for the patient at the first time when enquired, to simply say that he is absolutely normal- has never had any health problems, has a perfect BP and has never suffered from diabetes and is for all practical purposes, in the pink of health. The patient often feels that if he or she mentions any problems, it would be noted and he may not get his mediclaim. Discovering that a patient has multiple medical problems on the table, is an anaesthetists, and to a lesser extent, the surgeons nightmare. It therefore, requires painstaking care to evaluate the information, explain to the patient why it is important that we have this information and to note it down.

Often a simple assumption that surgery done elsewhere in the body is unrelated to the ophthalmic surgery in hand, can lead to complication. For example, previous history of orthopaedic surgery for fracture repair may be a useful indication of the patient having metal pins or plates in his or her body. If she undergoes oculoplastic surgery with the use of a cutting diathermy the presence of metal plates can result in serious burns. In a similar manner, the use of a pacemaker may be affected by the new phacoemulsification machines and diode laser endocauteries, which often lack the necessary shielding.
Effective communication is imperative in all episodes of patient care. However, patients with impaired hearing or inadequate cerebration may not clearly understand your instructions relating to the operation or what to do when discharged to go home. In a similar vein a patient who has had a stroke may have communication and comprehension difficulties so it is important to ensure that relevant information is understood and supported by hard copy and written notes. This is all the more imperative due to activism of the consumer courts.

Postoperative examination
Following surgery it is customary that the patient be seen the next day, however, all patients should be given in writing, a detailed note telling them as to what is normal and what complication on the first day is unacceptable. To give an example cataract surgery is a relatively painless surgery, if there is severe pain in the eye, it might indicate a catastrophe of rise in intraocular pressure or accompanied falling vision may signal the presence of an haemorrhage or even commencing infection, both of which, should be tended to as urgently as possible. It is imperative that a 24 hour contact number be provided to all patients.

All mobility permissive patients should be taught to take extreme care of their eyes at home. It would not be out of place to say that the most common cause for the injury to a postoperative eye is playing with children who inadvertently jabbed the eye or injury which occurs in the bathroom where one should be careful of protuberant taps and knobs which have a disconcerting tendency to damage the eye.

Summary
Day-care surgery has many advantages to the patient as well as to the doctor; however, care should be taken to provide adequate information to the patient, and analytical assessment of the patients’ physical condition prior to the procedure, a well-trained and attentive day-care staff to look after the patient following the surgery.

Adequate preparation of the patient for a day case surgery will contribute to a safe surgical journey. Pre-assessment and provision of day-care services are the innovative areas with exciting challenges for all workers in this field.

GLUCOSAMINE AND CHONDROITIN SULPHATE FOR KNEE OSTEOARTHRITIS In this 24-week trial, glucosamine and chondroitin sulphate were not more effective, alone or in combination, than placebo in controlling pain in patients with osteo-arthritis of the knee. In secondary analyses, however, in the subgroup of patients with moderate-to-severe osteoarthritis, those given both glucosamine and chondroitin sulphate were more likely than those given placebo to have a decrease in pain (79 per cent vs 54 per cent). N Engl J Med 2006; 354 : 795, 858, 886.