Oculoplastic surgery involves the orbit, eyelids, tear ducts and the face. Many patients experience droopy eyelids (ptosis), eyelid malposition (entropion/ectropion & Bell’s palsy) and lacrimal plumbing issues (inadequate drainage). This webinar reviews the diagnosis, surgical repair as well as the nurse’s role in the pre/post-operative care of the patient.
Lecturer: “Nurse Sandy”, Sandy Burnett, RN, BA Former Orbis Staff Nurse (1990-1992) and an Orbis Volunteer Faculty since 1992.
MS BURNETT: Welcome to Cybersight. Good morning. My name is Nurse Sandy, and I’m from the USA. Today I’m going to talk about some common oculoplastic surgeries we perform in our procedure room. At the end of this talk, you’ll be able to identify the anatomic deficit causing the eye malposition, you’ll be able to describe the surgical techniques to repair it, and also discuss the nursing care before and after surgery. For centuries, ophthalmic patients have been troubled with more than just cataracts and glaucoma. Ptosis, lower lid laxity, and even a lacrimal fistula have been a nuisance for patients, as these drawings show. And even now we’re dealing with these issues. Minor surgical procedures that use only a local anesthetic have proven to be safe and cost effective. Here’s a list of the different medical practices using minor surgical procedures, and I just wish to comment on the intravitreal injections and the research I’ve done for this lecture there were millions of these procedures done two years ago. We’re able to perform minor surgeries in this room. Here are two types of surgeries being performed. The slide on the right shows surgeons with full drape and sterile gowns, for blepharoplasties or ptosis, but most other procedures are as shown in the first slide. It’s like going into the dentist. We walk in, we wear street clothes, we have a local injection, there’s slight discomfort, but no IV or anesthesia gases or sedation. These two slides are giving you an idea of what our minor procedure room looks like. We have a glass cabinet where our supplies are located, an electric surgical chair that reclines the patient, and we often sit them up, particularly during a ptosis surgery, to evaluate the height of the eyelid and the symmetry of it, with the unoperated eye, and then recline the patient. We have overhead surgical lamps, a cautery machine, Mayo stands, a back table, when we do a full drape, and you’ll notice a red emergency cart with an oxygen tank, suction, and an automated external defibrillator, as well as IV supplies, an Ambu bag, because we are health care providers and the unexpected can happen. During our procedures we’ll monitor the patients with a pulse oximeter and automated blood pressure monitoring machine. And now let’s have a look at some of the ocular anatomy that we’re going to be reviewing today. We’re focusing on what’s called the ocular adnexa, the accessory structures to the eye, not the eye itself. And in particular the eyelids and the lacrimal system. The eyelids are movable folds of skin which cover the eye, and they function to protect from trauma, to reduce excess light from entering the eye, and to spread the tear film across the cornea. We blink our eyes on average from four to six times a minute. The palpebral fissure is measured horizontally from corner to corner. The medial canthus is next to our nose and the lateral canthus is directly opposite. More importantly is the fissure height, which in the adult is ten to twelve millimeters, measured through the pupil from the upper to lower eyelid. As you’re looking at this normal eye, the white sclera is covered with the conjunctiva, a mucous membrane that lines the eyelids. Goblet cells secrete a mucus to help with tear lubrication. In the medial canthal area you see the plica semilunaris, a modified conjunctiva, and the caruncle is a modified form of canthal tissue, which has some sweat glands. The upper eyelid is covering perhaps one to two millimeters of the cornea, and the lower eyelid is just touching the limbus. And this tells me that this eyelid is in good position to have an effective blink, and when people are troubled with eyelid lesions or such, they’re not going to be able to moisten their eye. The first layer, as I mentioned, was skin. We’re now looking at the orbicularis oculi muscle, which we use to blink, and beneath it is the septum, a fibrous tissue that forms our eyelids with thickened plates of tissue we call tarsus. Upon the tarsal plates are these groupings of glands. The glands of Zeis for the ciliary follicle or eyelash, which secretes a sebaceous oil, the gland of Moll is a modified sweat glands, and the meibomian glands secrete a substance called meibum, which reduces the tear film from evaporating. And the black arrows here are pointing to the openings of the meibomian gland on the tarsal edge. There are orbital fat pads that serve to protect the eye and be a reserve of energy, and the gentleman has a pooching in his upper orbit that indicates a prolapse of his orbital fat, because the septum has weakened with age, as all things will, and the septum no longer contains the orbital fat in its pouch. There are tendons and muscles of the eyelids. The medial canthal and lateral canthal tendons help support the eyelids, and the medial canthal tendon is attached to the bone of the maxilla, the facial bone, and the lateral canthal tendon is attached to Whitnall’s tubercle. The levator muscle of the upper eyelid is attached to the upper eyelid tarsal plate, and fibrous tissue formation from the inferior rectus is the capsulopalpebral fascia. A closer look at all this muscle structure — the levator is also called the levator palpebrae superioris, and it changes from a skeletal muscle to a pearly white tissue called aponeurosis, which is attaching the tissue to the eyelid. Next to that is a smooth muscle that contributes one to two millimeters of eyelid elevation, called Muller’s muscle. The lower eyelid retractor is a fibrous piece of tissue from the inferior rectus, and its true job is just to help hold the lower eyelid erect. The lacrimal system has a lacrimal gland in the superior temporal orbit area, and has ducts that open onto the eye. We blink, and the tear moves over to the lacrimal drainage system. In the medial aspect of your upper and lower eyelids, there are two drains, puncta, and they have pipings into the common canaliculus and into the lacrimal sac and eventually into our nose. So here’s a question that we’ll give you a few seconds to respond to, and that is: Included in the ocular adnexa are all but one of the following. Lacrimal apparatus, glands of Moll, Zees, and Meibomian, retina, or tarsal plate of eyelids. All righty! One hundred percent! We have a really smart crew on board. Thank you for responding. So we’re always going to do a complete eye exam on our patient to make sure there’s no other ocular problems. We need to know their medical history, medicines they’re taking, and proceed to evaluate and determine what their eye problem is from an oculoplastic standpoint. This person has come to us with a chalazion. I’ve heard it pronounced in different ways. It’s all correct. It’s a constipated meibomian gland. She’s had it two weeks. It’s painless but annoying. She did use the warm compresses, but it didn’t resolve her problem, so we’re going to schedule her for an incision and drainage of the chalazion. Our minor surgery instructions are in this format, to check with the patient and confirm that they’re not taking any blood thinners. Otherwise we’ll need them to stop that. We want them to not use aspirin, ibuprofen, Alka-Seltzer, Bufferin, or Ecotrin, vitamin E, or alcohol for two weeks before surgery. Vitamin E and alcohol also make your platelets less sticky. We want them to take routine meds on the day of surgery and have a light meal and drink. We don’t want them wearing makeup or fingernail polish. We want them to wear comfortable clothing and have someone to drive them home. This young lady doesn’t take medications and has no allergies and has agreed to use Tylenol. This is Nurse Keenan. He’s from Kenya, working on the Flying Eye Hospital as we speak. He has a thumbs up because she has taken her meds, blood thinners are not part of her lifestyle, and she did go to the restroom beforehand. Her operative eye is marked, consent is signed, vital signs are stable, and we’re completing the surgical safety checklist. You can see these patients are wearing street clothes, they just have a surgical hat on to keep their hair out of the way. We have our masks on, we’ve opened up the instruments, and these are some of the instruments we’ll use for an incision and drainage of a chalazion. Westcotts, forceps. A curette — often called a spoon, a chalazion clamp, Bard-Parker blade handle, and just plain lidocaine Xylocaine with no additives. I wanted you to see a bottle of lidocaine two percent with epinephrine, one to a hundred thousand dilution. My surgeons prefer to use this because of the vasoconstrictive properties of epinephrine. It helps to minimize the bleeding. You’ll find what your surgeons prefer to use. We’ll also have a number eleven blade, cautery, Q-Tips, and four by fours. So we’re injecting the local anesthetic into the patient’s eyelid, and while this happens, we have them hold our hand, so that we can count down to when they don’t feel any discomfort. The surgeon is also gently talking to them. And I go into kind of a trance talk in terms of… Ten, nine, eight. You’re doing great. The medicine is getting absorbed into your tissue. You’re doing wonderfully. Seven, six. And usually by the time we reach one, the medication has taken effect. I can feel my hand again, because their grip has relaxed. And we can proceed can surgery. We can proceed with surgery. It’s very effective to hold their hands. So we apply the chalazion clamp and flip the lid so we can work from the conjunctival side. That’s the meibum that’s congealed, the gland cannot excrete it, and we remove it with our chalazion spoon. We’ll maybe do a little cautery, apply steroid antibiotic ointment, pressure patch the eye, and ask them to remove it in six hours, or before going to bed. We’ll ask them to use the ointment three times a day for a week, and see them back in two weeks. We always call our patients day one, postop. How are you feeling? Is the pain manageable? Swelling, issues with bleeding? Or any other questions they might have. Many people say: I didn’t want to call. But you’ve just lifted a burden off their shoulder. Sometimes we have to call them a second time, and if we need them to talk with the doctor, we will. Here’s another question. The levator aponeurosis attaches to the upper eyelid at Whitnall’s tubercle, Lockwood’s ligament, or the tarsal plate. All righty. Gold star for everybody. Tarsal plate is the correct answer. Let’s have a look at this problem, called ptosis. Which is drooping of the upper eyelid. In this older gentleman, we can see that the left eye, the palpebral fissure, is much smaller than the normal ten to twelve millimeters. And the black arrows on the right are showing the white aponeurosis. And it’s detached. It’s not where it needs to be to hold the eyelid in place. Acquired aponeurotic ptosis is the most common form, whether it’s stretching or dehiscence of the aponeurosis. Frequently patients rub their eyes a lot, or if they are contact lens wearers, the hard contact lens, where they have to pull on the upper eyelid to help push the contact lens out of their eye, that can contribute to the aponeurosis weakening its hold, and also a lot of times patients will notice, after they’ve had intraocular surgery, particularly cataracts, they can see better and go… Wow, that eyelid is really droopy! I want to have it fixed. So they’ll come in for their complete eye examination. We’ll be reviewing an older lady who has ptosis. And she does take a baby aspirin, eighty one milligrams. We do need for her to check with her doctor about stopping that. We need the prescribing doctor to recommend that she can stop the aspirin, because we don’t want to compromise her health. And we instruct her about aspirin and ibuprofen, Ecotrin, vitamin E. She doesn’t drink alcohol. And all the rest of the items listed here. We will tentatively book her appointment, but we need her to confirm that she can stop the baby aspirin. Keenan’s got his thumbs up. She called back to confirm she can be off the baby aspirin for a week. So scheduling of surgery is going to happen. She has a driver, and we can confirm there are no other medicines that can thin her blood. The consent is signed. It’s a unilateral procedure, so we are marking the eye, her vital signs are stable, and we’re completing our surgical safety checklist. The local anesthetic is injected along the marked skin crease, and the instruments you’re looking at include a number 15 blade, Desmarres retractor, and a few more forceps and Q-Tips. The skin is incised. The second picture is showing you the septum being open to the levator aponeurosis. The skin and orbicularis are retracted with the forceps, and the first needle is pointing to the yellow fat pad, and beneath it, the other needle is pointing to the pearly white aponeurosis. The slide on the right is showing how the levator aponeurosis needs to be dragged back down onto the tarsal plate. We have placed five-O tarsal sutures, and we need to sit the patient up to see how the contour is, before we place the suture in a permanent tie. We’re satisfied, so we recline the patient, we’re finished with our suturing, we close the orbicularis, and then close the skin with a 6-0 nylon, and after surgery we have the patient recline in a chair with cold compresses twenty minutes off and on for forty eight hours. It’s comforting. We teach them how to get gauze wet, wring it out, and place it in the freezer, where it gets really cold. You can also do it with a washcloth. Some people like using frozen peas. So whatever works for them. We’ll ask them to use antibiotic ointment to the incision, suture sites three times a day for a week, and come back for suture removal. We’ll give them some Tylenol, because it is normal to have some discomfort, and a prescription for percocet, should they need something stronger. We ask them to not use ibuprofen, but this young lady is going to resume her aspirin, per the instructions from her doctor. And whenever patients do have to stop a medication, we check with our surgeon, when they report back that they can be off it for X amount of days to confirm that is satisfactory for us to deal with in the minor procedure room. Should the patient continue to have discomfort in spite of using percocet, we’ll want them to call the office so we can determine what’s going on. We continue with that post-op day number one phone call to see how are you doing, is the pain manageable, how is the swelling. Sometimes there’s lower lid swelling, just due to the lymphatic drainage system, so there may be some puffiness there, which is normal. But if there are any questions that we can’t answer, we’ll have the doctor speak with them directly. The next problem we’re going to look at is called ectropion, and that is laxity in the horizontal dimension of the eyelids. It can be the medial canthal and/or the lateral canthal tendons. Now, as you look at this gentleman’s lower eyelid, there is no way — all that sclera showing — that his eyeballs can be comfortable. The lower eyelid bilaterally is not touching the limbal space. So when you look at someone, you can begin to tell what their problem might be. In the case of this gentleman, I’m showing laxity of the lateral canthal tendon. So his procedure is to tighten the lateral canthal tendon. We’ve completed our eye examination. This is a patient who takes a blood pressure medicine and something for his cholesterol, so that’s fine. Just continue to take those medicines. Please no aspirin, ibuprofen, or Ecotrin, et cetera. This gentleman likes a cocktail every evening, so we asked him to stop that, and we’re going to schedule him two weeks out from having stopped his alcohol intake. He can have someone drive him, wear comfortable clothing, et cetera. The day of surgery, the patient has not had a drink for the two weeks, he’s taken his usual meds, his vital signs are stable, he’s been to the restroom. The procedure is bilateral, so we don’t need to mark the eye, and he has signed a consent, and we’re completing the surgical safety checklist. After the injection of local anesthetic, we perform a lateral canthotomy so we can view the orbital rim, and then we cut the lateral canthal tendon. This frees up the lower eyelid, because we need to split it to open up an anterior and posterior lamella, so that we can get to the tarsal plate and fashion a strip, a new canthal tendon from the tarsus. And you see in portion D of this slide that tarsal strip being pulled towards the periosteum and attached. We’ll use a 4-0 vicryl suture, close the skin with 6-0 nylon, and this is what the patient looks like. Look at the limbus. This eye is in a much better place than what the before picture shows. We’ll call the patient, see how they’re doing, any questions, any issues. If we need to see them, we ask them to come in right away. So here’s a new question. A lateral tarsal strip surgery is used to correct: Punctal stenosis, obstructed meibomian gland, lateral canthal tendon laxity, or esotropia. All righty. Gold stars for everyone. Let’s look at another problem of the lower eyelid. Again, I’m first looking at this patient, and I see that the lower eyelid is not touching the limbus. Something is wrong there. Whether it’s lax… You can even see in his case, the eyelashes are rolled up against the conjunctiva and perhaps even rubbing onto the cornea, which gives a foreign body sensation and causes tearing. In this case, the problem with entropion is that oftentimes in the entire eyelid — it has a rotation towards the globe. It indicates to me that the capsulopalpebral fascia has lost its positioning to the lower eyelid tarsus, and we need to reattach it. In this gentleman’s case, there’s also lower lid laxity. So he is going to have two procedures combined in one surgery. Now, this gentleman does not take coumadin, but he’s diabetic and he uses insulin. That’s not a problem. Please take that as you normally would. Your usual dose. Please eat lightly. That’s not a restriction. He does not use any ibuprofen or aspirin. He only likes Tylenol for discomfort. He does not drink or use vitamin E. So he can complete the checklist here, and it’s written down for them to take with them as well. And on the day of surgery, Keenan has his thumbs up. We’re doing good. He’s had a light meal with his insulin this morning. No blood thinners, the eye is marked, and the consent is signed. The vital signs are stable, and we’ve completed our surgical safety checklist. So we’ve called the eyelid muscles that raise and lower the eye in the upper eyelid and in the lower eyelid retractors, because they have specific duties in holding the eyelids in place, and to raise and lower them. The capsulopalpebral fascia is what we’re going to get and reattach. We’ve done our injection and made our skin incision, and we’re showing the retractors and the forceps. This is a better view of forceps holding the retractors that we’re going to reattach to the tarsal plate to correct that rotation of the lower eyelid into the eye. We’ll use a 6-0 fast absorbable suture, place 6 to 8 of them. Sometimes these surgeries need to be combined to repair the malposition they’re having. We like to do our incision just under the eyelashes, because that camouflages the incision line. And you can see how nicely it’s healing up a week later. Look at that nice tightness of the lower eyelid. It’s touching the corneal limbus. It looks a little swollen, but that should come down. That eye looks much more comfortable. A phone call to see how things are, any questions, and life is good. Epiphora. Excessive watering. Why is the eye doing that? Is it the lacrimal gland on hypermode? Or is there obstruction in the drainage system? In the case of this patient, we’re looking at stenosis, maybe scarring of the punctum. In the screen on the right, you can see how the mouth of the punctum is swollen, irregular, almost. It makes it difficult for the tear to enter into there. It can be due to repeated probings, use of glaucoma medications such as Eserine, infections such as herpes zoster, and in short, the punctum can’t take the fluid in, the tear. We’ve done our complete eye exam. This patient is perfectly healthy. She doesn’t take any blood thinners. She does take metoprolol for blood pressure. That’s fine. Take that on the day of surgery, as you normally would. She only uses Tylenol. She doesn’t drink nor take any vitamin E. She satisfies and understands all the questions here and instructions of what to do and what not to do. The day of surgery, Keenan’s got his thumbs up. She’s eaten a light meal, taken her metoprolol, she’s got a good blood pressure, someone is there to drive her home, she’s consented, the operative eye is marked, and we’ve completed our surgical safety checklist. The three snip punctoplasty is completed after we injected anesthetic. Remember, hold your patient’s hand. It is really comforting and builds some trust and confidence that they’re glad that they are where they are. The three snip punctoplasty is a triangular or rectangular cutting into the punctum. And you can see how it is two vertical cuts with a horizontal, and the triangular cut is more invasive into the horizontal canaliculus of a punctum. Either way, we’re trying to open the punctum to allow more tears to enter. And to minimize secondary closure with healing, or scar tissue developing, we’re going to place a silicone stent, and we’re going to use a pigtail probe. And we use the probe to insert gently into the upper punctum and rotate out of the lower punctum. It has an eyelet that we thread a proline suture, and then thread it back through the punctum. We’re going to take the silicone stent, and apply a small amount of antibiotic ointment, and rotate that through the upper punctum, along the proline suture, to be in place, that it totally encircles the canaliculus track of the two punctums and bring that silastic tubing together, tie the prolene into a knot, trim the excess, and cover it, so it comes together enough to close over the prolene knot. We then rotate that 120 degrees into the canaliculus area, and it will remain there for several weeks. The patient’s tears will pass over the tubing, they’ll come in to get the tubing removed. We’ll untie the knot and pull the tubing out, and hopefully that will eliminate her problems with epiphora permanently. We’ll call them afterwards to see how they’re doing, if there are any questions, and deal with what is happening for our patient. Here is the final question. Patients with excessive tearing and blurry vision may have a cataract, entropion, punctal stenosis, or ectropion and punctal stenosis. 15 seconds. Let us know what you think. All righty, gold stars for everyone. It is punctal stenosis and entropion. A cataract is really not going to cause you to have tearing and blurry vision. I say yes to the blurry vision, but it’s not gonna have the tearing. That’s the clue right here. Thank you so much. Finally, we’re going to look at a facial paralysis called bell’s palsy. We don’t know why it happens. Sometimes viral meningitis or something traumatic like a skull fracture. In the case of Sylvester Stallone, when he was born, the doctors had to use forceps, and that affected his face and the manner in which he speaks. There’s lagophthalmos, drooping of the mouth, drooling, ear pain and jaw pain, because the seventh cranial nerve serves those organs as well. It can come out of nowhere, last three to six months, be very transient, or be permanent. Here is another actor with bell’s palsy, and I did try to find a good picture of Angelina Jolie with her episode of Bell’s palsy, but there weren’t any. So a gold weight is an option to help close the eye. These patients are very tired of using ocular lubricants as frequently as they have to. If the option of a gold weight is viable for them, we go for it. One drawback with a gold weight is that the patient has to be aware that they may have a ptotic eyelid after the gold weight is placed, but for many, that’s not the problem they’ve been living with, in terms of lagophthalmos and the ocular discomfort of an exposed cornea and eye. Gold weights come in a variety of sizes. 0.6 to 1.6 grams. Gold or platinum can be used. They’re both inert metals, well tolerated by the body. And this just shows how we’re going to place it beneath the orbicularis muscle. We’ll make a pocket. This young man has had it for three months and is doing well with complete closure. First we’re going to do a complete eye exam, make sure there’s no medical reason that needs to be treated first. And then schedule them for surgery. We’ve done a trial wearing of the gold weight to determine which one will be the best fit for them. We’re completing our minor surgery instructions. This patient does not take a blood thinner. She does not use aspirin or any of these other products. She does drink wine, so we’ll have to wait two weeks before scheduling her for surgery. She is willing to do that. She does not take any vitamin E. We complete the rest of the instruction sheet here. She’s stayed away from her wine for two weeks, looking forward to it later today. Keenan has a thumbs up. She’s been to the restroom, only used Tylenol, consent is signed, vital signs are stable, and we’ve completed the surgical safety checklist. We marked the eyelid crease, but we’re only going to open a small section, because we only need a small pocket to fill with the gold weight. The lidocaine has been injected, and you can see the gold weight getting ready to be inserted. Here it is tied into the pocket with 7-0 nylon suture. We’ll close the orbicularis and the skin. The patient will use an antibiotic ointment for the next week. We like them to use a cold compress immediately afterwards to minimize swelling and aid in discomfort. Here are some patients, post-gold weight placement, who have their before pictures, and afterwards you see nice closure. You really don’t notice that they have a bulge or that they’re wearing something on their upper eyelid. And certainly this gentleman — look at the amount of lagophthalmos there. That poor left eye is miserable. I know they had a lot of relief from their surgeries. So if the Bell’s palsy resolves, we just remove the gold weight, and they now have a new piece of jewelry. We’ll make our postprocedure phone call, see what problems they’re having, and if they need to come in, we’re certainly going to have them do that. Well, there you have it. Common oculoplastic procedures performed in the minor OR. I hope this information will enhance your nursing care and take your skills to another level of expertise, and do remember to hold the patient’s hand while the local injection is given. It will comfort and reassure them more than you know. I would be happy to answer any questions, and thanks for stopping by.
>> Thank you, Nurse Sandy. If you want to go ahead and stop sharing your screen, we’ve got one Q and A question so far.
MS BURNETT: How do I… Stop share. Okay.
>> So if you can open the Q and A box, which is right next to share screen.
MS BURNETT: Yes.
>> There’s one question so far. Do you see that?
MS BURNETT: Yes, I do. So I talk and answer? Okay. Let’s move this here. How much lidocaine is enough. Well, your surgeon is going to have that expertise of when they’re training, and they’ll know how much. We generally use a three CC syringe, but we don’t necessarily have to inject the whole three CC or three milliliters. It also depends on your patient and the type of surgery that you’re doing. Some procedures don’t need a lot, but until we have akinesia or where they’re not sensating, you’re not gonna start cutting. When the patient doesn’t feel the needle, pointed edge in, you’re going to continue to give medication, and the surgeon will decide when enough is enough.
>> Thank you. So that seems like the only live question. We had some questions asked at the time of registration, and since we have about ten to fifteen minutes, do you mind maybe going through these?
MS BURNETT: Sure. Can I move this box out of here? Okay. There were some questions posted when y’all registered, and I’m looking at one that says: I’m setting up an oculoplastics nurse-led clinic. I wonder if you have any advice. My comments would be… No, your facility, depending if you’re a hospital or a private office — what are the regulations that your country or medical institute or regulatory boards of your government require you to be licensed as a physician’s office? I would certainly look to the AORN guidelines, and look at other facilities that have already been set up. Why work so hard when somebody else has already gone down this path? You need to just network with people, to know what they did, and be sure those are the present guidelines in your particular country. Next question here. I would like to know all the steps, one by one, to all the surgeries, and what we need to prepare for all of the surgeries. Well, I think I’ve given you some ideas for minor surgery procedures. Certainly for oculoplastics, the docs like 0.3 forceps, Westcott scissors, double pronged skin hooks, and that’s about as far as I can go with that. But please look online to see samples of things, because you can build what you discover, as well as what the preferences are for your doctors and the resources that you have available. I’m gonna skip number four. I would like to go to: Which of the countries can I get an offer for oculoplastic nursing and management? Anywhere you want. You just have to go out there and look and offer yourself up. Good luck! Which stent do you prefer for drainage issues? I have no real preference. Again, it’s our surgeons. We use Crawford. Monoka also makes products. What you can get that’s affordable and your surgeons like to use — that will be the preference. I’m not really understanding the glaucoma question. That wasn’t a topic we covered today, so I’d like to leave that. Reference book… Yes, there are some good ophthalmic reference books, and Cybersight has one of the ophthalmic practices for nursing or perioperative theater in lower resource countries. Am I answering this live here, Lawrence?
>> I’ll take care of that.
MS BURNETT: Okay. And the next question… Oh, good, thank you. Here’s a question about: When do you use medial conjunctivoplasty? Well, whenever your surgeon feels like that’s the correction that the patient needs. I’m not as fluent in that particular procedure, but that would be up to the surgeon. They know and have been trained to correct the patient’s problem as oculoplastic surgeons. So you’ll have to trust what they’re dictating and wish to do on a patient, and help the patient to understand how this procedure will correct and go from there.
>> Great. Thank you, Nurse Sandy. Maybe we’ll give thirty seconds to a minute, in case there are any final questions.
MS BURNETT: Absolutely.
>> All right. So I think that’s it for today. Thank you again, Nurse Sandy.
MS BURNETT: Thank you, Lawrence.
>> Thank you to everyone who joined. Have a good day.
MS BURNETT: All righty. Y’all too! Bye-bye.