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Bandage Lenses in the Postoperative Care for Cataract Surgery Patients: A Substitute for Eye Patch? J Ophthalmol 2018; 2018:1493967. [PMID: 29887990 PMCID: PMC5977021 DOI: 10.1155/2018/1493967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/05/2018] [Accepted: 04/17/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose To explore whether bandage lenses could be a safe and effective substitute for eye patch in the postoperative care for cataract surgery patients in terms of infection prevention, ocular impacts, and patient satisfaction. Methods Patients who underwent cataract surgery were randomly divided into the eye patch group (Group A) and the bandage lens group (Group B). Bacterial culture samples were collected perioperatively from different sites. Evaluations of anterior segment condition and patient satisfaction were conducted on the first day of postoperative follow-up. Results The positive rate of bacterial cultures in Group A was higher than that in Group B, but the difference was not statistically significant. Group B had significantly longer tear breakup time, higher tear meniscus height, and slightly better patient satisfaction than Group A. Conclusion Bandage lenses can be used as a safe and effective substitute for eye patch in the postoperative care for cataract surgery patients. The Clinical Study registration number is ChiCTR-IOC-17012167.
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The Safety, Efficacy, and Potential Complications of Intracameral Antibiotics. CURRENT OPHTHALMOLOGY REPORTS 2018. [DOI: 10.1007/s40135-018-0174-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Paul SR, Qureshi D, Yogalakshmi Y, Nayak SK, Singh VK, Syed I, Sarkar P, Pal K. Development of Bigels Based on Stearic Acid-Rice Bran Oil Oleogels and Tamarind Gum Hydrogels for Controlled Delivery Applications. J SURFACTANTS DETERG 2018. [DOI: 10.1002/jsde.12022] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Suprio R. Paul
- Department of Biotechnology and Medical Engineering; National Institute of Technology; Rourkela 769008 India
- Amity Institute of Biotechnology; Amity University; Noida 201313 India
| | - Dilshad Qureshi
- Department of Biotechnology and Medical Engineering; National Institute of Technology; Rourkela 769008 India
| | - Yamini Yogalakshmi
- Department of Biotechnology and Medical Engineering; National Institute of Technology; Rourkela 769008 India
| | - Suraj K. Nayak
- Department of Biotechnology and Medical Engineering; National Institute of Technology; Rourkela 769008 India
| | - Vinay K. Singh
- Department of Biotechnology and Medical Engineering; National Institute of Technology; Rourkela 769008 India
| | - Irshaan Syed
- Department of Food Process Engineering; National Institute of Technology; Rourkela 769008 India
| | - Preetam Sarkar
- Department of Food Process Engineering; National Institute of Technology; Rourkela 769008 India
| | - Kunal Pal
- Department of Biotechnology and Medical Engineering; National Institute of Technology; Rourkela 769008 India
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Radish AJ, Smith C, Parks AM, LaDisa AG. A Financial Evaluation of the Centralized Repackaging of Intracameral Moxifloxacin for Cataract Surgery and Its Impact on Cost Reduction. Hosp Pharm 2018; 53:321-325. [PMID: 30210150 DOI: 10.1177/0018578718757516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Extensive evidence-based literature supports the use of intracameral (IC) moxifloxacin for the prevention of postoperative endophthalmitis after cataract surgery. The Aurora Pharmacy Packaging Center (APPC) has developed a process for centrally preparing IC moxifloxacin. Purpose: The aim of this study was to evaluate the centralized preparation of IC moxifloxacin production for quality assurance and to quantify a potential reduction in costs. Methods: The APPC's compounding procedure of IC moxifloxacin was evaluated using United States Pharmacopeia (USP) Convention 797 standard and compared with practices described in evidence-based literature. Patients who received IC moxifloxacin intraoperatively from one of 3 ophthalmologists during cataract surgery performed between February 15, 2016, and August 15, 2016, were identified using electronic health records. Cost savings were calculated by reviewing costs associated with drug supplies used by the APPC. Results: The APPC process for the centralized preparation of IC moxifloxacin was deemed compliant with USP 797's sterile compounding standards. USP 797 validation criteria included proper sterile technique, equipment, room sterility and pressure, beyond use dating, and storage. Implementation of the centralized production of moxifloxacin reduced the direct product cost per surgery from $140 to $20 (a cost savings of $120 per surgery). There were 459 cataract surgeries analyzed during the study period, resulting in a savings of $55 080 over 6 months. Conclusion: The APPC's centralized compounding procedure was found to be compliant with pharmacy compounding standards and to yield significant cost savings.
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Affiliation(s)
- Alexander J Radish
- Aurora Health Care, Milwaukee, WI, USA.,Concordia University Wisconsin, Mequon, USA
| | | | - Ann M Parks
- Aurora Health Care, Milwaukee, WI, USA.,Concordia University Wisconsin, Mequon, USA
| | - Anne Graff LaDisa
- Aurora Health Care, Milwaukee, WI, USA.,Concordia University Wisconsin, Mequon, USA
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Kindle T, Ferguson T, Ibach M, Greenwood M, Schweitzer J, Swan R, Sudhagoni RG, Berdahl JP. Safety and efficacy of intravitreal injection of steroid and antibiotics in the setting of cataract surgery and trabecular microbypass stent. J Cataract Refract Surg 2018; 44:56-62. [DOI: 10.1016/j.jcrs.2017.10.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 09/09/2017] [Accepted: 10/14/2017] [Indexed: 10/17/2022]
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Kelkar AS, Chang DF, Kelkar JA, Mehta HM, Lahane T, Parekh R. Antibiotic prophylaxis practice patterns for cataract surgery in India - Results from an online survey. Indian J Ophthalmol 2017; 65:1470-1474. [PMID: 29208837 PMCID: PMC5742985 DOI: 10.4103/ijo.ijo_842_17] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: The aim of this study is to assess the current antibiotic prophylaxis practice patterns for cataract surgery in India. Methods: This was a questionnaire-based E-survey carried out at a tertiary eye care center in India. An E-mail invitation to complete an online 20 point questionnaire survey was sent to all members of the All India Ophthalmological Society with valid E-mail addresses using a digital E-mail service. Duplicate entries were prevented. Results: Out of 1228 total respondents (8.2%) who completed the survey 38% reported using routine intracameral (IC) antibiotic prophylaxis. Another 7% place antibiotics in the irrigating solution. Of those using IC antibiotic prophylaxis, 91% adopted this practice within the past 2 years; 92% are using moxifloxacin with 56% using a commercially available moxifloxacin formulation. Those predominantly performing phacoemulsification (43% vs. 25% performing mostly manual small incision cataract surgery, P < 0.001) and more than 500 cataract surgeries annually (45% vs. 33%, P < 0.001) reported greater use of IC moxifloxacin. Self-reported endophthalmitis rates were statistically significantly greater in those not using IC antibiotics (0.045% vs. 0.036, P = 0.04). Although a majority of respondents believe that IC antibiotics are an important option (54%) and that it is important to have a commercially available solution (68%), many believe that other antibiotic prophylaxis methods are sufficient (31%). Conclusion: IC antibiotic prophylaxis for cataract surgery has sharply increased in India. In contrast to the West, intraocular moxifloxacin, which is commercially available in India, is preferred by the vast majority of users.
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Affiliation(s)
- Aditya S Kelkar
- Department of Ophthalmology, National Institute of Ophthalmology, Pune, Maharashtra, India
| | - David F Chang
- Department of Ophthalmology, Altos Eye Physicians, Los Altos, California, USA
| | - Jai A Kelkar
- Department of Ophthalmology, National Institute of Ophthalmology, Pune, Maharashtra, India
| | - Hetal M Mehta
- Department of Ophthalmology, National Institute of Ophthalmology, Pune, Maharashtra, India
| | - Tatyarao Lahane
- Department of Ophthalmology, Grand Medical College and JJ group of Hospitals, Mumbai, Maharashtra, India
| | - Ragini Parekh
- Department of Ophthalmology, Grand Medical College and JJ group of Hospitals, Mumbai, Maharashtra, India
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Das T. Redefining evidence in the management of acute post-cataract surgery endophthalmitis in India - The 2014 Adenwalla Oration, All India Ophthalmological Society. Indian J Ophthalmol 2017; 65:1403-1406. [PMID: 29208821 PMCID: PMC5742969 DOI: 10.4103/ijo.ijo_755_17] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The current evidence of postoperative endophthalmitis management in three important components of care-infection control, inflammation control, and prevention was reviewed, and their current relevance and application in an Indian context were evaluated. The publications from India indicated that Gram-negative bacterial and filamentous fungal infections are relatively higher. There are increasing instances of resistance to ceftazidime by Gram-negative microorganisms. Intravitreal dexamethasone limits inflammation in bacterial endophthalmitis when given together with the intravitreal antibiotics. Intracameral antibiotic could reduce postcataract surgery infection at least in less rigorous surgical environment. Systematic collection of data and periodic evaluation of the current practice against the new evidence are necessary to prevent or treat postcataract surgery endophthalmitis.
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Affiliation(s)
- Taraprasad Das
- Srimati Kanuri Santhamma Center of Vitreo retinal Disease, L V Prasad Eye Institute, Hyderabad, Telangana, India
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Haripriya A. Antibiotic prophylaxis in cataract surgery - An evidence-based approach. Indian J Ophthalmol 2017; 65:1390-1395. [PMID: 29208819 PMCID: PMC5742967 DOI: 10.4103/ijo.ijo_961_17] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Various protocols are being followed for endophthalmitis prophylaxis in cataract surgery, and this subject continues to be a matter of debate. We summarize the most recent evidence-based studies on this topic with additional stress on intracameral (IC) antibiotic prophylaxis. Here, we discuss several large, international clinical studies which discuss the efficacy, adoption, safety, cost, and newer trends in antibiotic prophylaxis. Majority of these studies report a significant reduction in endophthalmitis rates with IC antibiotic prophylaxis. Efficacy data have been reported for IC cefuroxime, vancomycin, and moxifloxacin. Surgeons are now looking for alternatives to vancomycin for IC prophylaxis because of its association with the rare but sight-threatening complication of hemorrhagic occlusive retinal vasculitis. A recent large clinical study shows convincing efficacy with IC moxifloxacin prophylaxis. Two large studies have also reported significant endophthalmitis reduction following use of IC antibiotic prophylaxis, in eyes with posterior capsule tear which are at highest risk for infection. Except for one randomized controlled trial, there is a lack of prospective data on this subject; however, considering the complexity of performing such studies, surgeons have to rely on the mounting evidence from other recent big data studies. Availability of approved intraocular antibiotic formulations will see a much higher adoption in the future.
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Affiliation(s)
- Aravind Haripriya
- Cataract and IOL Services, Aravind Eye Hospital, Chennai, Tamil Nadu, India
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Espiritu CRG, Bolinao JG. Prophylactic intracameral levofloxacin in cataract surgery - an evaluation of safety. Clin Ophthalmol 2017; 11:2199-2204. [PMID: 29276375 PMCID: PMC5731440 DOI: 10.2147/opth.s144625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose To evaluate posterior and anterior segment safety of an intracameral injection of levofloxacin 0.5% ophthalmic solution as prophylaxis for patients undergoing cataract extraction and intraocular lens implantation. Setting This study was conducted at Manila Doctors Hospital, Ermita, Manila, Philippines. Design This was a prospective interventional study. Methods Eyes undergoing standard phacoemulsification cataract surgery with intraocular lens implantation were treated with intracameral levofloxacin 0.5% at the conclusion of surgery. Safety parameters, including best-corrected visual acuity (BCVA), endothelial cell counts, anterior chamber cells and flare, and central foveal thickness, were evaluated preoperatively and at 1 day and 1 week postoperatively. Results A total of 50 eyes of 50 patients were included in the analysis. At 1 week postoperatively, all eyes demonstrated BCVA of 20/30 or better and 19 eyes (38%) achieved BCVA of 20/20 or better. On the first postoperative day, no corneal edema was observed, and trace to +2 cells and flare in the anterior chamber were noted in all eyes. After 1 week, all eyes had a quiet anterior chamber and endothelial cell counts decreased by an average of 225 cells/mm2, which was marginally significant (p=0.0525) when compared to other time points. Optical coherence tomography results showed no statistically significant differences between central foveal thickness measurements before and after surgery. There were also no statistically significant differences in preoperative and postoperative pachymetry. No study-related adverse events occurred. Conclusion There were no safety concerns associated with intracameral injection of levofloxacin 0.5%, prophylactically, following cataract surgery. Further study is required to demonstrate effectiveness in endophthalmitis prevention.
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Affiliation(s)
- Cesar Ramon G Espiritu
- American Eye Center, Mandaluyong.,Department of Ophthalmology, Manila Doctors Hospital, Manila, Philippines
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Sahinoglu-Keskek N, Pelit A. Intracameral moxifloxacin for prophylaxis of postoperative endophthalmitis. SPEKTRUM DER AUGENHEILKUNDE 2017. [DOI: 10.1007/s00717-017-0350-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Haripriya A, Baam ZR, Chang DF. Endophthalmitis Prophylaxis for Cataract Surgery. Asia Pac J Ophthalmol (Phila) 2017; 6:324-329. [PMID: 28780782 DOI: 10.22608/apo.2017200] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 07/19/2017] [Indexed: 11/08/2022] Open
Abstract
Endophthalmitis after cataract surgery is a rare but potentially devastating complication. There is great variability in endophthalmitis prophylaxis practice patterns worldwide. Treatment varies globally and is based on the microbiological profile and availability of formulations. Periocular povidone-iodine antisepsis is universally adopted and considered the standard of care in most practices. Perioperative topical antibiotics are also very popular despite the lack of level 1 evidence confirming efficacy. Based on growing observational evidence, routine intracameral antibiotic prophylaxis is increasing, especially where approved commercial intraocular preparations are available. This review updates recent trends and evidence regarding endophthalmitis prophylaxis and the preferred choice of intracameral antibiotics.
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Young MT, Melvani RT, Khan FA, Braich PS, Bansal S. Association of Intraocular Pressure With Human Immunodeficiency Virus. Am J Ophthalmol 2017; 176:203-209. [PMID: 28147228 DOI: 10.1016/j.ajo.2017.01.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 01/19/2017] [Accepted: 01/20/2017] [Indexed: 11/15/2022]
Abstract
PURPOSE Prior studies have shown an association between human immunodeficiency virus (HIV) and reduced intraocular pressures (IOP). The purpose of this study was to determine if patients with HIV on highly active antiretroviral therapy (HAART) had any difference in their IOP compared with patients without HIV or with HIV who are not on HAART. DESIGN Retrospective cross-sectional study. METHODS We included 400 patients from our academic eye center between 2000 and 2016. Group 1 (G1) consisted of patients with HIV on HAART (n = 176), Group 2 (G2) consisted of patients with HIV who were not on HAART (n = 48), and Group 3 (G3) consisted of controls without HIV (n = 176). An analysis of variance (ANOVA) was performed to compare mean IOP values. Multivariate linear and logistic regression models were performed to assess factors impacting IOP. Difference in IOP was the primary outcome being measured. RESULTS The mean IOPs in mm Hg were 13.7 ± 5.1 (G1), 13.1 ± 3.6 (G2), and 17.3 ± 3.8 (G3), P < .01. In regression modeling, having a CD4 count ≤700 cells/mm3 contributed to a 2.1 mm Hg decrease in IOP. Patients with HIV were 7 times more likely to have an IOP ≤10 mm Hg, and patients with a CD4 count ≤700 cells/mm3 were 13 times more likely to have an IOP ≤10 mm Hg. CONCLUSIONS Absolute CD4 counts may play a role in IOP fluctuations. This association was found in patients with HIV regardless of whether patients were on HAART.
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Affiliation(s)
- Matthew T Young
- Department of Ophthalmology, Virginia Commonwealth University, Richmond, Virginia.
| | - Rakhi T Melvani
- Department of Ophthalmology, Virginia Commonwealth University, Richmond, Virginia
| | - Faraaz A Khan
- Department of Ophthalmology, Virginia Commonwealth University, Richmond, Virginia
| | - Puneet S Braich
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida
| | - Surbhi Bansal
- Department of Ophthalmology, Virginia Commonwealth University, Richmond, Virginia
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Havnaer AG, Greenberg PB, Cockerham GC, Clark MA, Chomsky A. Cataract surgery practices in the United States Veterans Health Administration. J Cataract Refract Surg 2017; 43:543-551. [DOI: 10.1016/j.jcrs.2017.01.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 01/17/2017] [Accepted: 01/17/2017] [Indexed: 10/19/2022]
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Haripriya A, Chang DF, Ravindran RD. Endophthalmitis Reduction with Intracameral Moxifloxacin Prophylaxis: Analysis of 600 000 Surgeries. Ophthalmology 2017; 124:768-775. [PMID: 28214101 DOI: 10.1016/j.ophtha.2017.01.026] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 01/12/2017] [Accepted: 01/17/2017] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To compare the postoperative endophthalmitis rate before and after initiation of intracameral (IC) moxifloxacin prophylaxis for both phacoemulsification and sutureless, manual small-incision cataract surgery (M-SICS), as well as in patients with posterior capsular rupture (PCR). DESIGN Retrospective, clinical registry. PARTICIPANTS All cataract surgeries (617 453) performed during the 29-month period from January 2014 to May 2016 at the 10 regional Aravind eye hospitals were included. METHODS The electronic health record data for all study eyes were analyzed. Endophthalmitis rates before and after moxifloxaxin were statistically compared for all eyes and separately for both phacoemulsification and M-SICS, and for the eyes complicated by PCR. MAIN OUTCOME MEASURES The postoperative endophthalmitis rates before and after initiation of IC moxifloxacin prophylaxis. RESULTS Overall, 302 815 eyes did not receive IC moxifloxacin and 314 638 eyes did, and there was a significant decline in the endophthalmitis rate, from 0.07% (214/302 815) to 0.02% (64/314 638) (P < 0.001), with moxifloxacin. For the 194 252 phacoemulsification eyes, the endophthalmitis rate was 0.07% (75/104 894) without IC moxifloxacin prophylaxis, compared with 0.01% (11/89 358) with moxifloxacin (P < 0.001). For the 414 657 M-SICS eyes, the endophthalmitis rate was 0.07% (135/192 149) without IC moxifloxacin prophylaxis, compared with 0.02% (52/222 508) with moxifloxacin (P < 0.001). Approximately half of the 8479 eyes that had PCR received IC moxifloxacin, and half did not. Without IC moxifloxacin, PCR increased the endophthalmitis rate nearly 7-fold to 0.48% (20/4186); IC moxifloxacin reduced the endophthalmitis rate with PCR to 0.21% (9/4293) (P = 0.034). No adverse events were due to IC moxifloxacin. CONCLUSIONS Routine IC moxifloxacin prophylaxis reduced the overall endophthalmitis rate by 3.5-fold (3-fold for M-SICS and nearly 6-fold for phacoemulsification). There was also a statistical benefit for eyes complicated by PCR, and IC antibiotic prophylaxis should be strongly considered for this high-risk population. These conclusions are strengthened by the high volume of cases analyzed at a single hospital network over a comparatively short time frame. Considering the association of hemorrhagic occlusive retinal vasculitis with vancomycin and the commercial unavailability of IC cefuroxime in many countries, moxifloxacin appears to be an effective option for surgeons electing IC antibiotic prophylaxis.
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Gower EW, Lindsley K, Tulenko SE, Nanji AA, Leyngold I, McDonnell PJ. Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery. Cochrane Database Syst Rev 2017; 2:CD006364. [PMID: 28192644 PMCID: PMC5375161 DOI: 10.1002/14651858.cd006364.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Endophthalmitis is a severe inflammation of the anterior or posterior (or both) chambers of the eye that may be sterile or associated with infection. It is a potentially vision-threatening complication of cataract surgery. Prophylactic measures for endophthalmitis are targeted against various sources of infection. OBJECTIVES To evaluate the effects of perioperative antibiotic prophylaxis for endophthalmitis following cataract surgery compared with no prophylaxis or other form of prophylaxis. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 12), Ovid MEDLINE, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily (January 1946 to December 2016), Embase (January 1980 to December 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to December 2016),the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We used no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 6 December 2016. We also searched for additional studies that cited any included trials using the Science Citation Index. SELECTION CRITERIA We included randomized controlled trials that enrolled adults undergoing cataract surgery (any method and incision type) for lens opacities due to any origin. We included trials that evaluated preoperative antibiotics, intraoperative (intracameral, subconjunctival or systemic), or postoperative antibiotic prophylaxis for acute endophthalmitis. We excluded studies that evaluated antiseptic preoperative preparations using agents such as povidone iodine or antibiotics for treating acute endophthalmitis after cataract surgery. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed abstracts and full-text articles for eligibility, assessed the risk of bias for each included study, and abstracted data. MAIN RESULTS Five studies met the inclusion criteria for this review, including 101,005 adults and 132 endophthalmitis cases. While the sample size was very large, the heterogeneity of the study designs and modes of antibiotic delivery made it impossible to conduct a formal meta-analysis. Interventions investigated included the utility of adding vancomycin and gentamycin to the irrigating solution compared with standard balanced saline solution irrigation alone, use of intracameral cefuroxime with or without topical levofloxacin perioperatively, periocular penicillin injections and topical chloramphenicol-sulfadimidine drops compared with topical antibiotics alone, and mode of antibiotic delivery (subconjunctival versus retrobulbar injections; fixed versus separate instillation of gatifloxacin and prednisolone). The risk of bias among studies was low to unclear due to information not being reported. We identified one ongoing study.Two studies compared any antibiotic with no antibiotic. One study, which compared irrigation with antibiotics in balanced salt solution (BSS) versus BSS alone, was not sufficiently powered to detect differences in endophthalmitis between groups (very low-certainty evidence). One study found reduced risk of endophthalmitis when combining intracameral cefuroxime and topical levofloxacin (risk ratio (RR) 0.14, 95% confidence interval (CI) 0.03 to 0.63; 8106 participants; high-certainty evidence) or using intracameral cefuroxime alone (RR 0.21, CI 0.06 to 0.74; 8110 participants; high-certainty evidence) compared with placebo, and an uncertain effect when using topical levofloxacin alone compared with placebo (RR 0.72, CI 0.32 to 1.61; 8103 participants; moderate-certainty evidence).Two studies found reduced risk of endophthalmitis when combining antibiotic injections during surgery and topical antibiotics compared with topical antibiotics alone (risk ratio (RR) 0.33, 95% confidence interval (CI) 0.12 to 0.92 (periocular penicillin and topical chloramphenicol-sulfadimidine; 6618 participants; moderate-certainty evidence); and RR 0.20, 95% CI 0.04 to 0.91 (intracameral cefuroxime and topical levofloxacin; 8101 participants; high-certainty evidence)).One study, which compared fixed versus separate instillation of gatifloxacin and prednisolone, was not sufficiently powered to detect differences in endophthalmitis between groups (very low-certainty evidence). Another study found no evidence of a difference in endophthalmitis when comparing subconjunctival versus retrobulbar antibiotic injections (RR 0.85, 95% CI 0.55 to 1.32; 77,015 participants; moderate-certainty evidence).Two studies reported any visual acuity outcome; one study, which compared fixed versus separate instillation of gatifloxacin and prednisolone, reported only that mean visual acuity was the same for both groups at 20 days postoperation. In the other study, the difference in the proportion of eyes with final visual acuity greater than 20/40 following endophthalmitis between groups receiving intracameral cefuroxime with or without topical levofloxacin compared with no intracameral cefuroxime was uncertain (RR 0.69, 95% CI 0.22 to 2.11; 29 participants; moderate-certainty evidence).Only one study reported adverse events (1 of 129 eyes had pupillary membrane in front of the intraocular lens and 8 eyes showed posterior capsule opacity). No study reported outcomes related to quality of life or economic outcomes. AUTHORS' CONCLUSIONS Multiple measures for preventing endophthalmitis following cataract surgery have been studied. High-certainty evidence shows that injection with cefuroxime with or without topical levofloxacin lowers the chance of endophthalmitis after surgery, and there is moderate-certainty evidence to suggest that using antibiotic eye drops in addition to antibiotic injection probably lowers the chance of endophthalmitis compared with using injections or eye drops alone. Clinical trials with rare outcomes require very large sample sizes and are quite costly to conduct; thus, it is unlikely that many additional clinical trials will be conducted to evaluate currently available prophylaxis. Practitioners should rely on current evidence to make informed decisions regarding prophylaxis choices.
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Affiliation(s)
- Emily W Gower
- Gillings School of Global Public HealthUniversity of North Carolina135 Dauer Drive2102A McGavran Greenberg, CB#7435Chapel HillNorth CarolinaUSA27599
| | - Kristina Lindsley
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 North Wolfe Street, Mail Room E6132BaltimoreMarylandUSA21205
| | - Samantha E Tulenko
- Gillings School of Global Public HealthUniversity of North Carolina135 Dauer Drive2102A McGavran Greenberg, CB#7435Chapel HillNorth CarolinaUSA27599
| | - Afshan A Nanji
- Oregon Health & Science UniversityCasey Eye InstitutePortlandOregonUSA97239
| | - Ilya Leyngold
- Duke University Hospital Department of OphthalmologyDivision of Oculofacial Plastic and Reconstructive SurgeryDurhamNorth CarolinaUSA27710
| | - Peter J McDonnell
- Johns Hopkins University School of MedicineWilmer Eye Institute600 N. Wolfe StreetMaumenee 727BaltimoreMarylandUSA21287
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Clinical outcomes after injection of a compounded pharmaceutical for prophylaxis after cataract surgery: a large-scale review. Curr Opin Ophthalmol 2017; 28:73-80. [PMID: 27653606 PMCID: PMC5145248 DOI: 10.1097/icu.0000000000000329] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Purpose of review To evaluate relevant clinical outcomes following a transzonular intravitreal injection of a compounded triamcinolone–moxifloxacin–vancomycin (TMV) formulation for postoperative prophylaxis after cataract surgery in a retrospective review of medical records from a private practice, single-specialty ambulatory center in New Jersey, USA. Recent findings The analysis included 1541 cases from 922 patients who underwent cataract surgery with an intravitreal injection of TMV from November 2013 to December 2014. Cataract surgery was performed by a standard clear corneal phacoemulsification technique. Transzonular injection was used to deliver TMV directly into the anterior vitreous after implantation of an intraocular lens. Summary There were no major intraoperative complications associated with the transzonular injection technique. There were no cases of postoperative endophthalmitis. Nearly 92% of cases (n = 1413/1541) did not require supplemental medication after surgery. The rate of breakthrough inflammation at Days 14–21 was 9.2% (n = 132/1429). The rate of visually significant postoperative cystoid macular edema was 2.0% (n = 28/1429). The rate of clinically significant postoperative intraocular pressure increase was low: 0.9% (n = 13/1425) of cases had an at least 10 mmHg increase at Days 14–21 or 90. Four of these cases had intraocular pressure at least 30 mmHg. The rates of infection and inflammation reported in this retrospective review of a transzonular injection of TMV for prophylaxis after cataract surgery appear similar to reported rates with alternative prophylactic therapies such as topical drops. The transzonular injection of TMV may have advantages in terms of patient compliance.
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Endophthalmitis after cataract surgery: epidemiology, risk factors, and evidence on protection. Curr Opin Ophthalmol 2017; 28:67-72. [PMID: 27661662 DOI: 10.1097/icu.0000000000000326] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW After publication of the results of the European Society of Cataract and Refractive Surgery (ESCRS) study, there is a lot of enthusiasm for using intracameral antibiotics for the prevention of postcataract endophthalmitis. However, despite level 1 evidence, the practice has not been adopted universally. The aim of this review is to present a summary of the articles published in the last 18 months on this topic. RECENT FINDINGS The published literature highlights that the incidence rate of endophthalmitis declined after 2007. Simultaneously, there is a rising trend for using intracameral injection of antibiotics at the conclusion of cataract surgery. Although various drugs have been used for this purpose, nearly all provide comparable protection. Industry has started manufacturing formulations for commercial availability of intracameral injection. Innovations are also ongoing to use intraocular lens for drug delivery and developing other intraocular drug delivery devices. SUMMARY Endophthalmitis prevention is at an interesting crossroad. Although there is hesitation the intracameral injection of antibiotics is increasingly being adopted by physicians, which is likely to grow further with commercial availability of formulations. However, it will be important to be cautious and report all adverse reactions associated with this practice.
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Javitt JC. Reply. Ophthalmology 2017; 124:e9-e10. [DOI: 10.1016/j.ophtha.2016.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 04/18/2016] [Indexed: 11/30/2022] Open
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Haripriya A, Chang DF, Namburar S, Anand S, Ravindran RD. Reply. Ophthalmology 2016; 123:e69. [PMID: 27871399 DOI: 10.1016/j.ophtha.2016.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 04/08/2016] [Indexed: 10/20/2022] Open
Affiliation(s)
| | | | | | - Smita Anand
- Aravind Eye Hospital, Madurai, Tamilnadu, India
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Re: Haripriya et al.: Efficacy of intracameral moxifloxacin endophthalmitis prophylaxis at Aravind Eye Hospital (Ophthalmology 2016;123:302-308). Ophthalmology 2016; 123:e69. [PMID: 27871401 DOI: 10.1016/j.ophtha.2016.03.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 03/25/2016] [Indexed: 11/23/2022] Open
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Huang J, Wang X, Chen X, Song Q, Liu W, Lu L. Perioperative Antibiotics to Prevent Acute Endophthalmitis after Ophthalmic Surgery: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0166141. [PMID: 27824933 PMCID: PMC5100907 DOI: 10.1371/journal.pone.0166141] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 10/24/2016] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Post-operative endophthalmitis is a rare and dreaded complication in ophthalmic operations because it often induces irreparable vision loss. Although many ophthalmological studies aimed at reducing the rate of endophthalmitis have been performed around the world, controversy continues to surround some issues, including the choice of antimicrobials and their route of administration, duration and timing. The aim of this study is to investigate some of these unresolved issues. METHODS A systematic review and meta-analysis of randomized controlled trials and observational studies was performed. The PubMed, EMBASE, Cochrane Library and Clinical Trials databases were searched to identify studies published until Feb. 2016. The relative risk (RR) for each clinical outcome data is presented with 95% confidence intervals (CIs). Pooled estimates of effects were calculated using random-effect models. RESULTS Thirty-four studies from twenty-four reports involving 1264797 eyes were included in this analysis. Endophthalmitis occurred, on average, in one out of 6177 eyes when intracameral vancomycin/moxifloxacin were used and in one out of 1517 eyes when intracameral vancomycin/moxifloxacin were not used. The relative risk (95% CI) of endophthalmitis was reduced to 0.20 (0.10, 0.42) when intracameral antibiotics were used (p<0.0001). The subconjunctival injection of antibiotics was not superior to other administration routes included in this study (RR = 1.67, 95% CI (0.55, 5.05), p = 0.36). A statistically significant difference was found in the rate of endophthalmitis between the use and lack of use of topical antibiotics (RR = 0.65, 95% CI (0.43, 0.99), p = 0.04). However, no statistically significant difference was found in microbial isolation rates between these groups (RR = 0.77, 95% CI (0.34, 1.75), p = 0.53). When long-term and short-term use of topical antibiotics before surgery were compared, a statistically significant difference was found in microbial isolation rates (RR = 0.57, 95% CI (0.44, 0.74), p<0.0001). CONCLUSIONS This meta-analysis concluded intracameral antibiotics are effective at preventing endophthalmitis in ocular surgery. A randomized controlled trial confirms the efficacy of cefuroxime but recent large cohort studies support the efficacy of vancomycin/moxifloxacin intracamerally. Intracameral antibitoics are superior to subconjunctival injections but that irrigation antibitoic data are not of enough quality to make a comparison. Different results were found in two clinical outcomes between the use or lack of use of topical antibiotic therapy, we did not find sufficient evidence to conclude that its use prevents endophthalmitis.
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Affiliation(s)
- Jinzhu Huang
- Department of Pharmacy, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Xiaofang Wang
- Department of Laboratory Medicine, Key Laboratory of Diagnostic Medicine (Ministry of Education), Chongqing Medical University, Chongqing, China
| | - Xiaohong Chen
- Department of Pharmacy, Chongqing Health Center for Women and Children, Chongqing, China
| | - Qiuyue Song
- Department of Health Statistics, Third Military Medical University, Chongqing, China
| | - Wen Liu
- Department of Pharmacy, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Laichun Lu
- College of Pharmacy, Third Military Medical University, Chongqing, China
- * E-mail:
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Schmier JK, Hulme-Lowe CK, Covert DW, Lau EC. An updated estimate of costs of endophthalmitis following cataract surgery among Medicare patients: 2010-2014. Clin Ophthalmol 2016; 10:2121-2127. [PMID: 27822008 PMCID: PMC5087791 DOI: 10.2147/opth.s117958] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Endophthalmitis, which can occur after ophthalmic surgery, is an inflammation of the intraocular cavity and causes temporary or permanent vision impairment. However, little is known about the cost of treatment. The objective of this analysis was to update and expand upon the results of a previously published report that estimated the direct medical cost of treatment for endophthalmitis. METHODS Retrospective data analysis using 2010 through 2014 United States Medicare Limited Data Sets. Procedure codes were used to identify beneficiaries who underwent cataract surgery; demographic and clinical characteristics at the time of diagnosis were determined. Patients were stratified into cases (those who developed endophthalmitis) and controls (those who did not develop endophthalmitis) in the 3 months following surgery. Claims (ie, charges) and reimbursements (ie, costs) for cases and controls in the 6 months following cataract surgery were identified and compared. Results are presented in 2015 US dollars. RESULTS Of a total of 153,860 cataract surgery patients, 181 were diagnosed with endophthalmitis following cataract surgery, at a rate of 1.2 per 1,000. Cases were more likely to be male and less likely to be white than controls; age was similar. Total medical claims and reimbursements as well as ophthalmic claims and reimbursements were significantly higher for cases compared with controls. Total reimbursements, adjusted for age, sex, and region, were $4,893 higher (83% greater) and adjusted ophthalmic reimbursements were $3,002 higher (156% greater) for cases than for controls. Claims and reimbursements were significantly higher across all types of Medicare cost components. CONCLUSION Postcataract surgery endophthalmitis is associated with a substantial cost. Successful prophylaxis with antibiotic agents would reduce the significant costs associated with treating endophthalmitis.
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Affiliation(s)
| | | | | | - Edmund C Lau
- Exponent, Inc., Health Sciences, Menlo Park, CA, USA
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Prophylaxe und Therapie der akuten postoperativen Endophthalmitis nach Kataraktoperation – state of the art. SPEKTRUM DER AUGENHEILKUNDE 2016. [DOI: 10.1007/s00717-016-0306-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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77
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Le HG, Ehrlich JR, Venkatesh R, Srinivasan A, Kolli A, Haripriya A, Ravindran RD, Thulasiraj RD, Robin AL, Hutton DW, Stein JD. A Sustainable Model For Delivering High-Quality, Efficient Cataract Surgery In Southern India. Health Aff (Millwood) 2016; 35:1783-1790. [DOI: 10.1377/hlthaff.2016.0562] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Hong-Gam Le
- Hong-Gam Le is a medical student at the University of Michigan Medical School, in Ann Arbor
| | - Joshua R. Ehrlich
- Joshua R. Ehrlich is a clinical lecturer in the Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center, and the Institute for Healthcare Policy and Innovation, both at the University of Michigan
| | - Rengaraj Venkatesh
- Rengaraj Venkatesh is chief medical officer at the Aravind Eye Hospital in Pondicherry, India
| | - Aravind Srinivasan
- Aravind Srinivasan is an administrator at the Aravind Eye Care System, in Madurai, India
| | - Ajay Kolli
- Ajay Kolli is an undergraduate student at the University of Michigan and a research assistant at the university’s School of Public Health
| | - Aravind Haripriya
- Aravind Haripriya is chief of intraocular lens and cataract services at the Aravind Eye Care System
| | - R. D. Ravindran
- R. D. Ravindran is chairman and director of quality at the Aravind Eye Care System
| | - R. D. Thulasiraj
- R. D. Thulasiraj is director of operations at the Aravind Eye Care System
| | - Alan L. Robin
- Alan L. Robin is an adjunct clinical professor in the Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center, at the University of Michigan; a professor in the Department of Ophthalmology and Visual Sciences, University of Maryland School of Medicine, in Baltimore; and an associate professor of international health in the Johns Hopkins Bloomberg School of Public Health, also in Baltimore
| | - David W. Hutton
- David W. Hutton is an assistant professor in the Department of Health Management and Policy, School of Public Health, and Institute for Healthcare Policy and Innovation, all at the University of Michigan
| | - Joshua D. Stein
- Joshua D. Stein is an associate professor in the Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center; the Department of Health Management and Policy, School of Public Health; and the Institute for Healthcare Policy and Innovation, all at the University of Michigan
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Ng ALK, Tang WWT, Li PSH, Li KKW. Intracameral cefuroxime in the prevention of postoperative endophthalmitis: an experience from Hong Kong. Graefes Arch Clin Exp Ophthalmol 2016; 254:1987-1992. [DOI: 10.1007/s00417-016-3473-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/10/2016] [Accepted: 08/09/2016] [Indexed: 11/29/2022] Open
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Fisher BL, Potvin R. Transzonular vitreous injection vs a single drop compounded topical pharmaceutical regimen after cataract surgery. Clin Ophthalmol 2016; 10:1297-303. [PMID: 27486301 PMCID: PMC4957678 DOI: 10.2147/opth.s112080] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Purpose To compare the relative effectiveness of a Tri-Moxi-Vanc intraocular solution injected transzonularly into the vitreous with the topical formulation of Pred-Moxi-Ketor (given for the first week postoperatively) followed by Pred-Ketor (given for weeks 2–4 after surgery). Patients and methods This was a single-site, single-surgeon, prospective, randomized, subject-masked contralateral eye study with an active comparator and was approved by an appropriate ethics committee. Twenty-five subjects with uncomplicated cataract who were scheduled for cataract surgery were enrolled. If surgery was uneventful, subjects received either an injection in that eye or followed a minimum drop postoperative pharmaceutical regimen. The second eye surgery was performed with the opposite treatment. Subjects were followed for 1 month. Measures of interest were the changes in intraocular pressure (IOP) from baseline and the changes in corneal and macular thickness. Subjects were also asked to evaluate pain perception, visual quality, and overall satisfaction with surgery. They were also asked which regimen they preferred. Results IOP was not statistically significantly different between the groups (P=0.81); there was also no statistically significant difference in IOP over time (P=0.74). There was no statistically significant difference in central macular thickness at 1 week and 1 month between the groups (P=0.18). The central corneal thickness was significantly greater 1 day postoperatively relative to baseline, but there was no statistically significant difference between the groups at any time point (P=0.92). The difference in reported pain was also not statistically significantly different between the groups (P=0.67). Satisfaction with surgery was similar for both groups, but significantly more subjects preferred the injection for overall experience (P<0.01). Conclusion Cataract surgery completed with the two pharmaceutical regimens was similar in outcome. Significantly more subjects preferred the injection, presumably as a function of the greater convenience with no apparent difference in the therapeutic effect.
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Intracameral Antibiotics and Cataract Surgery: Endophthalmitis Rates, Costs, and Stewardship. Ophthalmology 2016; 123:1411-3. [DOI: 10.1016/j.ophtha.2016.03.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 03/11/2016] [Indexed: 11/18/2022] Open
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Intracameral Antibiotics Reduce the Risk of Endophthalmitis after Cataract Surgery: Does the Preponderance of the Evidence Mandate a Global Change in Practice? Ophthalmology 2016; 123:226-231. [PMID: 26802702 DOI: 10.1016/j.ophtha.2015.12.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 12/09/2015] [Accepted: 12/09/2015] [Indexed: 11/23/2022] Open
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Olson RJ. Has the Time Come for All to Routinely Use Intracameral Antibiotic Prophylaxis at the Time of Cataract Surgery? Am J Ophthalmol 2016; 166:xii-xiv. [PMID: 27178744 DOI: 10.1016/j.ajo.2016.04.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 04/19/2016] [Accepted: 04/20/2016] [Indexed: 11/27/2022]
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Das S, Bhende PS, Lam DSC. The Latest Updates and Management of Endophthalmitis. Asia Pac J Ophthalmol (Phila) 2016; 5:167-70. [PMID: 27183288 DOI: 10.1097/apo.0000000000000208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Sudipta Das
- From the *C-MER (Shenzhen) Dennis Lam Eye Hospital, Shenzhen, China; and †Medical Research Foundation, Sankara Nethralaya, Chennai, India
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Rhee MK, Mah FS. Cataract Drug Delivery Systems (Dropless vs. Nondropless Cataract Surgery). Int Ophthalmol Clin 2016; 56:117-136. [PMID: 27257727 DOI: 10.1097/iio.0000000000000122] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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