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Surgical assisting is one of the most skill-intensive components of the COA exam. The Assisting with Interventions and Procedures domain accounts for 22% of the total exam, and OR duties form a significant portion of that content. You need to understand not just the mechanics of the role but the principles behind each protocol -- because in a real OR, deviating from those principles can harm patients.
Ophthalmic surgery is predominantly performed in ambulatory surgical centers (ASCs) or hospital-based ORs. Common procedures include cataract extraction (phacoemulsification with IOL implantation), laser procedures, strabismus repair, ptosis repair, and glaucoma surgery. The COA may serve as circulator, instrument runner, or in some facilities as a trained scrub assistant.
This guide covers the COA role in the OR, sterile technique principles, key instrument identification, the Universal Protocol timeout, draping technique, intraoperative duties, and post-operative responsibilities. These are all testable areas on the COA exam.
Sterile technique exists to prevent surgical site infections. In ophthalmic surgery, introducing even a small number of organisms into the eye can cause endophthalmitis -- a sight-threatening infection with a poor visual prognosis. Every member of the OR team, including the COA, is responsible for maintaining and monitoring the sterile field.
| Instrument | Purpose | Used In |
|---|---|---|
| Phacoemulsification handpiece | Ultrasonic emulsification and aspiration of the lens nucleus | Cataract surgery (phaco) |
| Cryer/vectis (lens loop) | Manual expression or delivery of the lens nucleus in ECCE | Extracapsular cataract extraction |
| Honan balloon | Preoperative IOP reduction; softens globe | Pre-cataract surgery prep |
| Keratome (paracentesis blade) | Creates corneal incisions for anterior segment access | Cataract and anterior segment surgery |
| Cystotome / capsulorhexis forceps | Creates the continuous curvilinear capsulorhexis (CCC) in the anterior lens capsule | Cataract surgery |
| Irrigation/aspiration (I/A) handpiece | Removes remaining cortical lens material after nucleus removal | Cataract surgery |
| IOL injector / cartridge | Injects the folded or rolled IOL through a small incision | Cataract surgery (IOL implantation) |
| Trabeculectomy instruments (punch, Vannas scissors) | Create sclerostomy and iridectomy for aqueous drainage | Trabeculectomy (glaucoma surgery) |
Thorough pre-operative preparation is essential for a smooth and safe surgery. The COA plays a key role in several pre-op steps, including reviewing biometry data, verifying the surgical site, and preparing the patient for the OR.
Before cataract surgery, confirm that the A-scan or optical biometry measurements (axial length, corneal power/K readings) match the IOL power calculation in the chart. Verify the IOL power and lens model selected by the surgeon. Check that lens implant inventory matches what is planned. Discrepancies must be flagged to the surgeon before the patient enters the OR.
The operative eye is marked with a surgical skin marker (a dot or small arrow) before the patient receives sedation or anesthesia. Marking must be done by the surgeon or a designated qualified person with the patient awake and able to confirm the correct eye. The mark must be visible through the drape or immediately before draping. This is part of the Universal Protocol requirements from The Joint Commission.
Immediately before the first incision, the entire team pauses for a verbal timeout. Confirm: patient identity (two identifiers), procedure, surgical site (correct eye), patient position, and availability of required implants and imaging. All team members verbally acknowledge. Document the timeout in the operative record. Any disagreement stops the case until resolved.
Ophthalmic draping isolates the operative eye from the surrounding skin, lashes, and upper airway secretions, which are sources of contamination. The drape must be applied correctly to achieve this isolation without placing pressure on the globe.
The COA exam tests sterile technique, instrument identification, and OR protocol. Build confidence with AI-explained practice questions.
After the procedure, the COA assists with immediate post-operative care and documentation. This includes confirming antibiotic or BSS injection at the end of the case, applying the eye shield or patch, and ensuring the patient is stable before transfer to the recovery area.
Document which antibiotic was injected at closure (typically intracameral moxifloxacin or cefuroxime for endophthalmitis prophylaxis), volume of BSS used, IOL model and lot number, and any intraoperative complications. The implant sticker (from the IOL package) goes directly in the patient's chart for traceability.
After the drapes are removed, a sterile shield (Fox shield or taped rigid shield) is applied to protect the eye. For most phaco cases, a clear shield is preferred so the eye can be observed without removing the dressing. Document application in the post-op record and instruct the patient to wear the shield as directed by the surgeon.
OSHA's Bloodborne Pathogens Standard (29 CFR 1910.1030) applies to all healthcare workers, including COAs in surgical settings. Key requirements include standard precautions for all patients, engineering controls (sharps containers, needleless systems), work practice controls (no two-handed recapping), PPE availability, training, and exposure reporting.
Sharps Safety Rules
Sterilization, disinfection, and infection control protocols for the eye clinic.
Clinical overview of cataracts, surgical options, and pre-op biometry.
IOL power calculation and pre-operative biometry for cataract surgery.
Format, domains, eligibility, and registration for the COA exam.
The scrub technician (sterile scrub) is directly within the sterile field -- they are gowned, gloved, and pass instruments to the surgeon with hands inside the operative area. The COA as circulator operates outside the sterile field: they open sterile packages, retrieve supplies, document the case, manage the environment, and coordinate with other OR staff. A COA can function as a scrub if the surgeon and facility grant that role and training, but circulating is the more common COA responsibility. Understanding the boundary between sterile and non-sterile roles is critical for patient safety.
Any item that is unsterile or of questionable sterility must be considered contaminated. Common violations include: a sterile package that has been torn, wet, or left open; a gowned team member turning their back on the sterile field; reaching over the sterile field from an unsterile position; a sterile item falling below table level (the sterile border is the table edge); any unsterile person reaching into the sterile field; or a glove puncture. When a break in sterile technique occurs, the COA or any team member must call it out immediately, without hesitation. The surgeon must be informed and corrective action taken.
The Universal Protocol (from The Joint Commission) requires a pre-procedure "time out" immediately before the first incision. All team members stop, and a designated person verbally confirms: correct patient identity (two identifiers: name and date of birth or MRN), correct procedure, correct surgical site (right or left eye), correct patient position, and that all relevant imaging and implants are available. Everyone must acknowledge. Any team member can call a time out or raise a concern. The timeout must be documented in the operative record. If there is ANY disagreement, the procedure does not proceed until resolved.
Sharp instruments should never be passed hand-to-hand directly. Use the "neutral zone" technique: place the instrument in a designated area on the sterile field (a basin, magnetic mat, or towel), announce it verbally, and the recipient picks it up. This prevents accidental needle sticks and scalpel injuries. Needles should always be recapped using a one-handed scoop technique or mechanical recapper -- never two-handed recapping. After use, sharps go directly into the sharps container; they are never left on the sterile field unattended or passed back without the neutral zone technique.
A Honan intraocular pressure reducer (Honan balloon) is a device that applies gentle pressure to the globe preoperatively to reduce intraocular pressure and vitreous volume before cataract or other anterior segment surgery. It consists of an inflatable balloon placed over the closed lid, typically inflated to 30 mmHg for 10-15 minutes. Lower IOP makes the globe softer, reduces the risk of positive vitreous pressure during surgery, and improves anterior chamber stability. It is more commonly used with retrobulbar or peribulbar anesthetic blocks and is less necessary with topical anesthesia. Contraindications include suspected or known globe rupture.