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.
OR Roles: COA vs. Scrub vs. Circulator
COA as Circulator
- Operates outside the sterile field
- Opens sterile packages aseptically
- Retrieves additional supplies
- Documents the case
- Communicates with team
- Manages the OR environment
Scrub Tech (Sterile Scrub)
- Within the sterile field
- Gowned and double-gloved
- Sets up the sterile instrument table
- Passes instruments to surgeon
- Maintains instrument count
- Handles sterile irrigation and supplies
COA as Scrub Assistant
- Requires additional training and certification
- Directly assists surgeon
- Holds tissue, provides irrigation
- Role varies by facility and state regulations
- Must be trained in sterile technique
- Facility credentialing required
Sterile Technique Principles
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.
Core Sterile Technique Principles
- 1. Only sterile touches sterile: Sterile items may only contact other sterile items. A sterile drape contacting the non-sterile floor or a non-gloved hand is immediately contaminated.
- 2. Sterility zones: The sterile field includes the draped patient, the sterile instrument table, and gowned/gloved personnel from the chest to table level and fingertip to elbow. Below the table level is not sterile. Gown backs are not sterile.
- 3. Contamination recognition: Any item of questionable sterility must be treated as non-sterile. When in doubt, throw it out. Never rationalize that an item "probably" remained sterile -- the standard is absolute.
- 4. Breaking scrub protocol: If a scrubbed team member contaminates themselves (e.g., touches a non-sterile surface), they must immediately remove themselves from the sterile field, rescrub, and re-gown. The scrub is never rationalized away.
- 5. Movement near sterile field: Non-sterile personnel must not lean over or reach across the sterile field. Pass items to the scrub area by holding the non-sterile outer packaging and allowing the scrubbed person to take the sterile contents, or by placing them on the sterile field using the package outer wrapper as a sterile delivery surface.
- 6. Wet sterility: Strike-through contamination occurs when moisture passes from a non-sterile surface through a sterile drape to the sterile field. A wet sterile package or drape is considered contaminated.
Key Ophthalmic Surgical Instruments
| 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) |
Pre-Operative Preparation
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.
Biometry Review
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.
Surgical Site Marking
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.
Universal Protocol Timeout
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.
Draping Technique
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.
Draping Steps
- 1.Instill topical anesthetic and dilating drops as ordered. Irrigate the cul-de-sac with dilute povidone-iodine (Betadine) 5% solution -- standard antisepsis for ophthalmic surgery.
- 2.Place the body drape over the patient. For pediatric patients, ensure the airway is accessible for anesthesia personnel.
- 3.Apply the adhesive ophthalmic drape to isolate the operative eye. The adhesive edge seals against the skin surrounding the orbit. The drape has a clear fenestration that aligns over the eye.
- 4.Fold or tuck the lashes under the adhesive edge so they are excluded from the operative field. Lashes harbor bacteria and must not contact the surgical field.
- 5.Insert the eyelid speculum under the drape to hold the lids open. Ensure the speculum does not apply pressure to the globe.
- 6.Connect the irrigation/aspiration line and confirm BSS bottle level and flow. Attach the drape to the Mayo stand to create a sealed pocket that channels fluids away from the patient's face.
Intraoperative Duties
Circulator Duties (Non-Sterile)
- Open sterile supplies aseptically onto the sterile field
- Monitor BSS irrigation level and replace as needed
- Document surgical events, instrument counts, and implant lot numbers
- Retrieve additional instruments or supplies from sterile storage
- Communicate with anesthesia and surgical team
- Monitor sterile field integrity and report any breaks
Scrub Assistant Duties (Sterile)
- Pass instruments using neutral zone technique
- Hold tissue, provide retraction as directed by surgeon
- Handle BSS irrigation tubing within sterile field
- Load viscoelastic syringe and pass when requested
- Prepare IOL injector cartridge under sterile conditions
- Maintain instrument count throughout the case
Practice COA Surgical Assisting Questions
The COA exam tests sterile technique, instrument identification, and OR protocol. Build confidence with AI-explained practice questions.
Post-Operative Responsibilities
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.
End-of-Case Confirmations
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.
Dressing and Shield Application
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 Bloodborne Pathogen and Sharps Safety
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
- Never recap needles two-handed -- use one-handed scoop or mechanical recapper
- Never bend or break needles by hand
- Place all sharps directly in sharps container after use -- do not pass to another person
- Use neutral zone (hands-free zone) for passing sharps between team members
- If punctured: wash with soap and water immediately, report exposure, seek post-exposure prophylaxis evaluation
- Sharps containers must be accessible at point of use and changed when three-quarters full