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Roizenblatt M, Gehlbach PL, Marin VDGB, Roizenblatt A, Fidalgo TM, Saraiva VS, Nakanami MH, Noia LC, Watanabe S, Yasaki ES, Passos RM, Magalhães Junior O, Fernandes RAB, Stefanini FR, Caiado R, Jiramongkolchai K, Farah ME, Belfort Junior R, Maia M. Vitreoretinal surgical performance after acute alcohol consumption and hangover. Br J Ophthalmol 2024:bjo-2023-324044. [PMID: 39089845 DOI: 10.1136/bjo-2023-324044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 07/14/2024] [Indexed: 08/04/2024]
Abstract
AIM Routine alcohol testing of practicing physicians remains controversial since there are no uniform guidelines or legal regulations in the medical field. Our aim was to quantitatively study the acute and next-morning effects of breath alcohol concentration (BAC)-adjusted alcohol intake on overall simulated surgical performance and microtremor among senior vitreoretinal surgeons. METHODS This prospective cohort study included 11 vitreoretinal surgeons (>10 years practice). Surgical performance was first assessed using the Eyesi surgical simulator following same-day alcohol consumption producing a BAC reading of 0.06%-0.10% (low-dose), followed by 0.11%-0.15% (high-dose). Dexterity was then evaluated after a 'night out' producing a high-dose BAC combined with a night's sleep. Changes in the total score (0-700, worst-best) and tremor (0-100, best-worst) were measured. RESULTS Surgeon performance declined after high-dose alcohol compared with low-dose alcohol (-8.60±10.77 vs -1.21±7.71, p=0.04, respectively). The performance during hangover was similar to low-dose alcohol (-1.76±14.47 vs -1.21±7.71, p=1.00, respectively). The performance during hangover tended to be better than after high-dose alcohol (-1.76±14.47 vs -8.60±10.77, p=0.09, respectively). Tremor increased during hangover compared with low-dose alcohol (7.33±21.65 vs -10.31±10.73, p=0.03, respectively). A trend toward greater tremor during hangover occurred compared with high-dose alcohol (7.33±21.65 vs -4.12±17.17, p=0.08, respectively). CONCLUSION Alcohol-related decline in simulated surgical dexterity among senior vitreoretinal surgeons was dose-dependent. Dexterity improved the following morning but remained comparable to after low-dose alcohol ingestion. Tremor increased during hangover compared with same-day intoxication. Further studies are needed to investigate extrapolations of these data to a real surgical environment regarding patient safety and surgeon performance.
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Affiliation(s)
- Marina Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
- Johns Hopkins Wilmer Eye Institute, Baltimore, Maryland, USA
| | | | | | - Arnaldo Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | | | - Luciana Cruz Noia
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Sung Watanabe
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Erika Sayuri Yasaki
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | | | | | - Rafael Caiado
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Michel Eid Farah
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Mauricio Maia
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
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Karampouga M, Karagianni M, Mihaylova S, Aydin AE, Salokorpi N, Lambrianou X, Tsianaka E, Janssen IK, Duran SH, Ivan DL, Rodríguez-Hernandez A, Broekman ML, Gazioglu N, Tasiou A, Murphy M. Caffeine, Alcohol, and Drug Use as Work Adjuncts Among Neurosurgeons. Prevalence, Contributing Factors, and Proposed Strategies. World Neurosurg 2024:S1878-8750(24)01289-0. [PMID: 39069131 DOI: 10.1016/j.wneu.2024.07.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 07/19/2024] [Accepted: 07/20/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Neurosurgeons may resort to caffeine, alcohol, and various drugs to maintain peak performance as they grapple with work demands and escalated stress. The prevalence of this controversial strategy remains largely unexplored. METHODS An anonymous survey of 23 questions formulated by our research group was distributed through personal contacts and neurosurgical societies. Inquiries revolved around the use of medications and other substances for job-related reasons. Data were analyzed via regression and descriptive statistics in python. RESULTS In total, 215 neurosurgeons (43 residents) were included, with 213 disclosing their gender (94 females). Out of all, 9.3% were <30, 38.1% were 30-39, 44.6% were 40-59, and 7.9% were >60 years old. Most (70.7%) practiced in Europe, 18.6% in Asia, 6.5% in North and South America, and the rest in Africa or Australia. While 132 participants stated they consume caffeine to manage challenging schedules, drugs for cognitive and mood enhancement were utilized by 18 and 35 respectively. Alcohol was employed for stress relief by 28 with 4 reporting as heavy drinkers. Drugs posed a solution to sleep disorders for 82, and helped 8 others in strengthening their hand dexterity. Notably, 12 of those claiming drug use initiated it in medical school. Exercise, self-care activities, and relational support were the main alternatives sought. Ultimately, most responders recommended extending mental health assistance and raising awareness about drug use. CONCLUSIONS Reflecting on our results on job-associated drug use by neurosurgeons, we propose the judicious use of pharmacological or nonpharmacological adjuncts, alongside the prioritization of neurosurgeons' well-being.
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Affiliation(s)
- Maria Karampouga
- Department of Neurological Surgery, Center for Cranial Base Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Department of Neurological Surgery, Nicosia General Hospital, Nicosia, Cyprus.
| | - Maria Karagianni
- Department of Neurosurgery, University Hospital of Larissa, Larissa, Greece
| | - Stiliana Mihaylova
- Clinic of Neurosurgery, St. Ivan Rilski University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Aysegul Esen Aydin
- Department of Neurosurgery, Arnavutkoy State Hospital, Istanbul, Türkiye
| | - Niina Salokorpi
- Department of Neurosurgery, Oulu University Hospital, Oulu, Finland, and Research Unit of Clinical Neuroscience, Medical Research Center, Oulu University, Oulu, Finland
| | | | - Eleni Tsianaka
- Neurosurgery Department, International Hospital, Salmiya, Kuwait
| | - Insa K Janssen
- Department of Neurosurgery, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | | | - Daniela Luminita Ivan
- Department of Neurosurgery, Bucharest Emergency University Hospital, Carol Davila University of Medicine, Bucharest, Romania
| | - Ana Rodríguez-Hernandez
- Department of Neurological Surgery, Germans Trias i Pujol University Hospital, Universidad Autónoma, Barcelona, Spain
| | - Marike Ld Broekman
- Department of Neurosurgery, Haaglanden Medical Center and Leiden University Medical Center, Leiden, The Netherlands
| | - Nurperi Gazioglu
- Medical Faculty, Department of Neurosurgery, Istinye University, Istanbul, Türkiye
| | - Anastasia Tasiou
- Department of Neurosurgery, University Hospital of Larissa, Larissa, Greece
| | - Mary Murphy
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Roizenblatt M, Gehlbach PL, Marin VDG, Roizenblatt A, Saraiva VDS, Nakanami MH, Noia LDC, Watanabe SES, Yasaki ES, Passos RM, Magalhães O, Fernandes RAB, Stefanini FR, Caiado R, Jiramongkolchai K, Farah ME, Belfort R, Maia M. ASSESSMENT OF SIMULATED SURGICAL DEXTERITY AFTER MODIFIABLE EXTERNAL EXPOSURES AMONG NOVICE VERSUS EXPERIENCED VITREORETINAL SURGEONS. Retina 2024; 44:820-830. [PMID: 38194677 DOI: 10.1097/iae.0000000000004045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
PURPOSE To evaluate novice and senior vitreoretinal surgeons after various exposures. Multiple comparisons ranked the importance of these exposures for surgical dexterity based on experience. METHODS This prospective cohort study included 15 novice and 11 senior vitreoretinal surgeons (<2 and >10 years' practice, respectively). Eyesi-simulator tasks were performed after each exposure. Day 1, placebo, 2.5 mg/kg caffeine, and 5.0 mg/kg caffeine; day 2, placebo, 0.2 mg/kg propranolol, and 0.6 mg/kg propranolol; day 3, baseline simulation, breathalyzer readings of 0.06% to 0.10% and 0.11% to 0.15% blood alcohol concentrations; day 4, baseline simulation, push-up sets with 50% and 85% repetitions maximum; and day 5, 3-hour sleep deprivation. Eyesi-generated score (0-700, worst-best), out-of-tolerance tremor (0-100, best-worst), task completion time (minutes), and intraocular pathway (in millimeters) were measured. RESULTS Novice surgeons performed worse after caffeine (-29.53, 95% confidence interval [CI]: -57.80 to -1.27, P = 0.041) and alcohol (-51.33, 95% CI: -80.49 to -22.16, P = 0.001) consumption. Alcohol caused longer intraocular instrument movement pathways (212.84 mm, 95% CI: 34.03-391.65 mm, P = 0.02) and greater tremor (7.72, 95% CI: 0.74-14.70, P = 0.003) among novices. Sleep deprivation negatively affected novice performance time (2.57 minutes, 95% CI: 1.09-4.05 minutes, P = 0.001) and tremor (8.62, 95% CI: 0.80-16.45, P = 0.03); however, their speed increased after propranolol (-1.43 minutes, 95% CI: -2.71 to -0.15 minutes, P = 0.029). Senior surgeons' scores deteriorated only following alcohol consumption (-47.36, 95% CI: -80.37 to -14.36, P = 0.005). CONCLUSION Alcohol compromised all participants despite their expertise level. Experience negated the effects of caffeine, propranolol, exercise, and sleep deprivation on surgical skills.
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Affiliation(s)
- Marina Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
- Vision Institute, IPEPO, Universidade Federal de São Paulo, São Paulo, Brazil
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter L Gehlbach
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vitor D G Marin
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Arnaldo Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vinicius da S Saraiva
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
- Vision Institute, IPEPO, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mauricio H Nakanami
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luciana da C Noia
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Sung E S Watanabe
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Erika S Yasaki
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Renato M Passos
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
- Vision Institute, IPEPO, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Octaviano Magalhães
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Rodrigo A B Fernandes
- Keck School of Medicine, University of Southern California, Los Angeles, California; and
| | | | - Rafael Caiado
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Michel E Farah
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
- Vision Institute, IPEPO, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Rubens Belfort
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
- Vision Institute, IPEPO, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mauricio Maia
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
- Vision Institute, IPEPO, Universidade Federal de São Paulo, São Paulo, Brazil
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Roizenblatt M, Gehlbach PL, Marin VDG, Roizenblatt A, Saraiva VS, Nakanami MH, Noia LC, Song Watanabe SE, Yasaki ES, Passos RM, Magalhães Junior O, Fernandes RAB, Stefanini FR, Caiado R, Jiramongkolchai K, Farah ME, Belfort R, Maia M. A Polysomnographic Study of Effects of Sleep Deprivation on Novice and Senior Surgeons during Simulated Vitreoretinal Surgery. Ophthalmol Retina 2023; 7:940-947. [PMID: 37164313 DOI: 10.1016/j.oret.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 04/22/2023] [Accepted: 05/02/2023] [Indexed: 05/12/2023]
Abstract
PURPOSE To assess the impact of a 3-hour polysomnography (PSG)-recorded night of sleep deprivation on next-morning simulated microsurgical skills among vitreoretinal (VR) surgeons with different levels of surgical experience and associate the sleep parameters obtained by PSG with Eyesi-generated performance. DESIGN Self-controlled cohort study. PARTICIPANTS Eleven junior VR surgery fellows with < 2 years of surgical experience and 11 senior surgeons with > 10 years of surgical practice. METHODS Surgical performance was assessed at 7am after a 3-hour sleep-deprived night using the Eyesi simulator and compared with each subject's baseline performance. MAIN OUTCOME MEASURES Changes in Eyesi-generated score (0-700, worst to best), time for task completion (minutes), tremor-specific score (0-100, worst to best), and out-of-tolerance tremor percentage. Polysomnography was recorded during sleep deprivation. RESULTS Novice surgeons had worse simulated surgical performance after sleep deprivation compared with self-controlled baseline dexterity in the total score (559.1 ± 39.3 vs. 593.8 ± 31.7; P = 0.041), time for task completion (13.59 ± 3.87 minutes vs. 10.96 ± 1.95 minutes; P = 0.027), tremor-specific score (53.8 ± 19.7 vs. 70.0 ± 15.3; P = 0.031), and out-of-tolerance tremor (37.7% ± 11.9% vs. 28.0% ± 9.2%; P = 0.031), whereas no performance differences were detected in those parameters among the senior surgeons before and after sleep deprivation (P ≥ 0.05). Time for task completion increased by 26% (P = 0.048) in the post-sleep deprivation simulation sessions for all participants with a high apnea-hypopnea index (AHI) and by 37% (P = 0.008) among surgeons with fragmented sleep compared with those with normal AHI and < 10 arousals per hour, respectively. Fragmented sleep was the only polysomnographic parameter associated with a worse Eyesi-generated score, with a 10% (P = 0.005) decrease the following morning. CONCLUSIONS This study detected impaired simulated surgical dexterity among novice surgeons after acute sleep deprivation, whereas senior surgeons maintained their surgical performance, suggesting that the impact of poor sleep quality on surgical skills is offset by increased experience. When considering the 2 study groups together, sleep fragmentation and AHI were associated with jeopardized surgical performance after sleep deprivation. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Marina Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil; Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia (IPEPO), Universidade Federal de São Paulo, São Paulo, Brazil; The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Peter L Gehlbach
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vitor D G Marin
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Arnaldo Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vinicius S Saraiva
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil; Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia (IPEPO), Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mauricio H Nakanami
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luciana C Noia
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Sung E Song Watanabe
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Erika S Yasaki
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Renato M Passos
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil; Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia (IPEPO), Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | | | - Rafael Caiado
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Michel E Farah
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil; Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia (IPEPO), Universidade Federal de São Paulo, São Paulo, Brazil
| | - Rubens Belfort
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil; Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia (IPEPO), Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mauricio Maia
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil; Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia (IPEPO), Universidade Federal de São Paulo, São Paulo, Brazil
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5
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Roizenblatt M, Gehlbach PL, da Silveira Saraiva V, Nakanami MH, da Cruz Noia L, Watanabe SES, Yasaki ES, Passos RM, Magalhães Junior O, Fernandes RAB, Stefanini FR, Caiado R, Jiramongkolchai K, Wolf M, Eid Farah M, Belfort Junior R, Maia M. Weight-adjusted caffeine and β-blocker use in novice versus senior retina surgeons: a self-controlled study of simulated performance. Eye (Lond) 2023; 37:2909-2914. [PMID: 36782058 PMCID: PMC10517115 DOI: 10.1038/s41433-023-02429-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 12/16/2022] [Accepted: 01/25/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND/OBJECTIVES Tremor and expertise are potentially influenced variables in vitreoretinal surgery. We investigated whether surgeon experience impacts the association of microsurgical performance with caffeine and β-blockers weight-adjusted intake. SUBJECTS/METHODS Novice and senior surgeons (<2 and >10 practice years, respectively) were recruited in this self-controlled, cross-sectional study. A simulator's task sequence was repeated over 2 days, 30 min after the following exposures: day 1, placebo, 2.5 mg/kg caffeine, 5.0 mg/kg caffeine, and 0.6 mg/kg propranolol; and day 2, placebo, 0.2 mg/kg propranolol, 0.6 mg/kg propranolol, and 5.0 mg/kg caffeine. Outcomes were total score (0-700, worst-best), simulation time (minutes), intraocular trajectory (centimeters), and tremor-specific score (0-100, worst-best). RESULTS We recruited 15 novices (9 men [60%], 1.33 ± 0.49 practice years) and 11 seniors (8 men [72.7%], 16.00 ± 4.24 practice years). Novices performed worse after 2.5 mg/kg caffeine and improved following 0.2 mg/kg propranolol in total score (557 vs. 617, p = 0.009), trajectory (229.86 vs. 208.07, p = 0.048), time (14.9 vs. 12.7, p = 0.048), and tremor-score (55 vs. 75, p = 0.009). Surgical performance improved with propranolol post-caffeine but remained worse than 0.2 mg/kg propranolol in total score (570 vs. 617, p = 0.014), trajectory (226.59 vs. 208.07, p = 0.033), and tremor-score (50 vs. 75, p = 0.029). Seniors' tremor-score was lower after 2.5 mg/kg caffeine compared to 0.2 mg/kg propranolol (8 vs. 37, p = 0.015). Tremor-score following propranolol post-caffeine remained inferior to 0.6 mg/kg propranolol alone (17 vs. 38, p = 0.012). CONCLUSION While caffeine and propranolol were associated with performance changes among novices, only tremor was affected in seniors, without dexterity changes. The pharmacologic exposure impact on surgical dexterity seems to be offset by increased experience.
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Affiliation(s)
- Marina Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil.
- Vision Institute, IPEPO, Universidade Federal de São Paulo, São Paulo, Brazil.
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Peter Louis Gehlbach
- The Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Vinicius da Silveira Saraiva
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
- Vision Institute, IPEPO, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Luciana da Cruz Noia
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Erika Sayuri Yasaki
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Renato Magalhães Passos
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
- Vision Institute, IPEPO, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | | | - Rafael Caiado
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Mitchell Wolf
- Department of Ophthalmology and Visual Science, University of Wisconsin School of Medicine, Madison, WI, USA
| | - Michel Eid Farah
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
- Vision Institute, IPEPO, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Rubens Belfort Junior
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
- Vision Institute, IPEPO, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Mauricio Maia
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil
- Vision Institute, IPEPO, Universidade Federal de São Paulo, São Paulo, Brazil
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Liu J, Qiao X, Xiao Y, Deng Z, Cui J, Wu M, Zhang H, Ran K, Luo H, Tang B. Physical and mental health impairments experienced by operating surgeons and camera-holder assistants during laparoscopic surgery: a cross-sectional survey. Front Public Health 2023; 11:1264642. [PMID: 37744484 PMCID: PMC10512950 DOI: 10.3389/fpubh.2023.1264642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/25/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction Surgeons may experience physical and mental health problems because of their jobs, which may lead to chronic muscle damage, burnout, or even withdrawal. However, these are often ignored in camera-holder assistants during laparoscopic surgery. We aimed to analyze the differences between operating surgeons and camera-holder assistants. Methods From January 1, 2022, to December 31, 2022, a cross-sectional survey was conducted to evaluate the muscle pain, fatigue, verbal scolding, and task load for operating surgeons and camera-holder assistants. The Nordic Musculoskeletal Questionnaire, the Space Administration Task Load Index, and the Surgical Task Load Index (SURG-TLX) were combined in the questionnaire. Results 2,184 operations were performed by a total of 94 operating surgeons and 220 camera assistants. 81% of operating surgeons and 78% of camera-holder assistants reported muscle pain/discomfort during the procedure. The most affected anatomic region was the shoulders for operating surgeons, and the lower back for camera-holder assistants. Intraoperative fatigue was reported by 41.7% of operating surgeons and 51.7% of camera-holder assistants. 55.2% of camera-holder assistants reported verbal scolding from the operating surgeons, primarily attributed to lapses in laparoscope movement coordination. The SURG-TLX results showed that the distributions of mental, physical, and situational stress for operating surgeons and camera-holder assistants were comparable. Conclusion Like operating surgeons, camera-holder assistants also face similar physical and mental health impairments while performing laparoscopic surgery. Improvements to the working conditions of the camera-holder assistant should not be overlooked.
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Affiliation(s)
- Junjie Liu
- Vascular, Hernia & Abdominal Wall Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xi Qiao
- Precision Medicine Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Municipality Clinical Research Center for Geriatrics and Gerontology, Chongqing, China
| | - Yi Xiao
- Gastrointestinal Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhuofan Deng
- Hepatobiliary Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ji Cui
- Obstetrics & Gynecology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Mingdong Wu
- Vascular, Hernia & Abdominal Wall Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haolong Zhang
- Vascular, Hernia & Abdominal Wall Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Kun Ran
- Vascular, Hernia & Abdominal Wall Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hailong Luo
- Vascular, Hernia & Abdominal Wall Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Tang
- Hernia and Abdominal Wall Surgery, The Fourth Clinical College of Chongqing Medical University, Chongqing, China
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Singh G, Jie WWJ, Sun MT, Casson R, Selva D, Chan W. Overcoming the impact of physiologic tremors in ophthalmology. Graefes Arch Clin Exp Ophthalmol 2022; 260:3723-3736. [PMID: 35788893 DOI: 10.1007/s00417-022-05718-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/26/2022] [Accepted: 05/27/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Ophthalmic surgery involves the manipulation of micron-level sized structures such as the internal limiting membrane where tactile sensation is practically absent. All humans have physiologic tremors that are of low amplitude and not discernible to the naked eye; they do not adversely affect the majority of the population's daily functioning. However, during microsurgery, such tremors can be problematic. In this review, we focus on the impact of physiological tremors on ophthalmic microsurgery and offer a comparative discussion on the impact of such tremors on other surgical specialties. METHODS A single investigator used the MEDLINE database (via PubMed) to search for and identify articles for inclusion in this systematic review. Ten key factors were identified as potentially having an impact on tremor amplitude: beta-blockers, muscle fatigue, robotic systems, handheld tools/micromanipulators, armrests/wrist supports, caffeine, diet, sleep deprivation, consuming alcohol, and workouts (exercise). These key terms were then searched using the advanced Boolean search tool and operators (i.e., AND, OR) available on PubMed: (*keyword*) AND (surgeon tremor OR microsurgery tremor OR hand steadiness OR simulator score). RESULTS Ten studies attempted to quantify the baseline severity of operator physiologic tremor. Approximately 89% of studies accessing the impact of tremors on performance in regards to surgical metrics reported an improvement in performance compared to 57% of studies concluding that tremor elimination was of benefit when considering procedural outcomes. CONCLUSIONS Robotic technology, new instruments, exoskeletons, technique modifications, and lifestyle factors have all demonstrated the potential to assist in overcoming tremors in ophthalmology.
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Affiliation(s)
- Gurfarmaan Singh
- School of Medicine, University of Adelaide, Health & Medical Sciences Building, 4 North Terrace, Adelaide, SA, 5000, Australia.
- Royal Adelaide Hospital, Adelaide, SA, Australia.
| | | | - Michelle Tian Sun
- School of Medicine, University of Adelaide, Health & Medical Sciences Building, 4 North Terrace, Adelaide, SA, 5000, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Robert Casson
- School of Medicine, University of Adelaide, Health & Medical Sciences Building, 4 North Terrace, Adelaide, SA, 5000, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Dinesh Selva
- School of Medicine, University of Adelaide, Health & Medical Sciences Building, 4 North Terrace, Adelaide, SA, 5000, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - WengOnn Chan
- School of Medicine, University of Adelaide, Health & Medical Sciences Building, 4 North Terrace, Adelaide, SA, 5000, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
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Torkamani-Azar M, Lee A, Bednarik R. Methods and Measures for Mental Stress Assessment in Surgery: A Systematic Review of 20 Years of Literature. IEEE J Biomed Health Inform 2022; 26:4436-4449. [PMID: 35696473 DOI: 10.1109/jbhi.2022.3182869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Real-time mental stress monitoring from surgeons and surgical staff in operating rooms may reduce surgical injuries, improve performance and quality of medical care, and accelerate implementation of stress-management strategies. Motivated by the increase in usage of objective and subjective metrics for cognitive monitoring and by the gap in reviews of experimental design setups and data analytics, a systematic review of 71 studies on mental stress and workload measurement in surgical settings, published in 2001-2020, is presented. Almost 61% of selected papers used both objective and subjective measures, followed by 25% that only administered subjective tools - mostly consisting of validated instruments and customized surveys. An overall increase in the total number of publications on intraoperative stress assessment was observed from mid-2010 s along with a momentum in the use of both subjective and real-time objective measures. Cardiac activity, including heart-rate variability metrics, stress hormones, and eye-tracking metrics were the most frequently and electroencephalography (EEG) was the least frequently used objective measures. Around 40% of selected papers collected at least two objective measures, 41% used wearable devices, 23% performed synchronization and annotation, and 76% conducted baseline or multi-point data acquisition. Furthermore, 93% used a variety of statistical techniques, 14% applied regression models, and only one study released a public, anonymized dataset. This review of data modalities, experimental setups, and analysis techniques for intraoperative stress monitoring highlights the initiatives of surgical data science and motivates research on computational techniques for mental and surgical skills assessment and cognition-guided surgery.
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Jacobsen MF, Konge L, Cour M, Sørensen RB, Park YS, Thomsen ASS. The learning curve of robot-assisted vitreoretinal surgery - A randomized trial in a simulated setting. Acta Ophthalmol 2021; 99:e1509-e1516. [PMID: 33650326 DOI: 10.1111/aos.14822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE To investigate the learning curve of robot-assisted vitreoretinal surgery compared to manual surgery in a simulated setting. METHODS The study was designed as a randomized controlled longitudinal study. Eight ophthalmic trainees in the 1st or 2nd year of their specialization were included. The participants were randomized to either manual or robot-assisted surgery. Participants completed repetitions of a test consisting of three vitreoretinal modules on the Eyesi virtual reality simulator. The primary outcome measure was time to learning curve plateau (minutes) for total test score. The secondary outcome measures were instrument movement (mm), tissue treatment (mm2 ) and time with instruments inserted (seconds). RESULTS There was no significant difference in time to learning curve plateau for robot-assisted vitreoretinal surgery compared to manual. Robot-assisted vitreoretinal surgery was associated with less instrument movements (i.e. improved precision), -0.91 standard deviation (SD) units (p < 0.001). Furthermore, robot-assisted vitreoretinal surgery was associated with less tissue damage when compared to manual surgery, -0.94 SD units (p = 0.002). Lastly, robot-assisted vitreoretinal surgery was slower than manual surgery, 0.93 SD units (p < 0.001). CONCLUSIONS There was no significant difference between the lengths of the learning curves for robot-assisted vitreoretinal surgery compared to manual surgery. Robot-assisted vitreoretinal surgery was more precise, associated with less tissue damage, and slower.
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Affiliation(s)
- Mads F. Jacobsen
- Department of Ophthalmology Rigshospitalet Glostrup Denmark
- Copenhagen Academy for Medical Education and Simulation Centre for HR Copenhagen Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation Centre for HR Copenhagen Denmark
| | - Morten Cour
- Department of Ophthalmology Rigshospitalet Glostrup Denmark
| | - Rasmus B. Sørensen
- Copenhagen Academy for Medical Education and Simulation Centre for HR Copenhagen Denmark
| | - Yoon Soo Park
- Massachusetts General Hospital Harvard Medical School Boston Massachusetts USA
| | - Ann Sofia S. Thomsen
- Department of Ophthalmology Rigshospitalet Glostrup Denmark
- Copenhagen Academy for Medical Education and Simulation Centre for HR Copenhagen Denmark
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A MULTIFACTORIAL APPROACH FOR IMPROVING THE SURGICAL PERFORMANCE OF NOVICE VITREORETINAL SURGEONS. Retina 2021; 41:2163-2171. [PMID: 34543245 DOI: 10.1097/iae.0000000000003147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To quantitatively analyze and compare the novice vitreoretinal surgeons' performance after various types of external exposures. METHODS This prospective, self-controlled, cross-sectional study included 15 vitreoretinal fellows with less than 2 years of experience. Surgical performance was assessed using the Eyesi simulator after each exposure: Day 1, placebo, 2.5, and 5 mg/kg caffeine; Day 2, placebo, 0.2, and 0.6 mg/kg propranolol; Day 3, baseline simulation, breathalyzer reading of 0.06% to 0.10% and 0.11% to 0.15% blood alcohol concentration; Day 4, baseline simulation, push-up sets with 50% and 85% repetition maximum; Day 5, 3-hour sleep deprivation. Eyesi-generated total scores were the main outcome measured (0-700, worst to best). RESULTS Performances worsened after increasing alcohol exposure based on the total score (χ2 = 7; degrees of freedom = 2; P = 0.03). Blood alcohol concentration 0.06% to 0.10% and 0.11% to 0.15% was associated with diminished performance compared with improvements after propranolol 0.6 and 0.2 mg/kg, respectively (∆1 = -22 vs. ∆2 = +13; P = 0.02; ∆1 = -43 vs. ∆2 = +23; P = 0.01). Propranolol 0.6 mg/kg was positively associated with the total score, compared with deterioration after 2.5 mg/kg caffeine (∆1 = +7 vs. ∆2 = -13; P = 0.03). CONCLUSION Surgical performance diminished dose dependently after alcohol. Caffeine 2.5 mg/kg was negatively associated with dexterity, and performance improved after 0.2 mg/kg propranolol. No changes occurred after short-term exercise or acute 3-hour sleep deprivation.
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Coffee break has no impact on laparoscopic skills: a randomized double-blinded placebo-controlled parallel-group trial. Surg Endosc 2021; 36:3533-3541. [PMID: 34459976 PMCID: PMC9001621 DOI: 10.1007/s00464-021-08675-9] [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] [Received: 02/14/2021] [Accepted: 08/07/2021] [Indexed: 12/03/2022]
Abstract
Background Coffee is a widely consumed beverage. Surgeons often drink coffee before performing surgery. Caffeine intake leads to tremor which might have a negative effect on surgeons’ fine motor skills. Methods A double-blinded parallel-group trial was conducted in order to investigate if caffeinated coffee intake has a negative effect on laparoscopic skills and increases tremor, regardless of previous coffee consumption. 118 participants were selected during a congress of the German Society of Surgery. Exclusion criteria were immaturity and no given consent. Participants and investigators were blinded. Participants were randomized with a 1:1 allocation into interventional group receiving caffeinated coffee or placebo group receiving decaffeinated coffee. The motor skills were tested with two validated laparoscopic exercises at a laparoscopy simulator (LapSim®) before and 30 min after coffee intake. Data on influencing factors were recorded in a standardized questionnaire and tested for equal distribution in both groups. In both exercises four parameters were recorded: left and right hand path length and angular path. Their differences and the resulting effect scores were calculated for both groups as primary outcome to test which group showed greater improvement on the second round of exercises. Registration number DRKS00023608, registered retrospectively. Results Fifty nine subjects were assigned to each the interventional (54 analyzed) and placebo group (53 analyzed) with 11 drop outs. There was no significant difference between the placebo and interventional group in the two exercises in effect score 30 min after coffee intake [mean (SD); 38.58 (10.66) vs. 41.73 (7.40) and 113.09 (28.94) vs. 116.59 (25.63)]. A significant improvement from first to second measurement in the first exercise could be observed for both groups, demonstrating the training effect. Conclusion In our study, we verified that additional caffeinated coffee intake, e.g., during a coffee break, does not lead to deterioration of laparoscopic fine motor skills. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08675-9.
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Vitreoretinale Chirurgie: Kaffeekonsum verschlechtert die Performance von Berufseinsteigern. AUGENHEILKUNDE UP2DATE 2021. [DOI: 10.1055/a-1419-9357] [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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Roizenblatt M, Gehlbach PL, Maia M. Studies of Microsurgical Skill-The Key Lies in the Design-Reply. JAMA Ophthalmol 2021; 139:127-128. [PMID: 33151292 DOI: 10.1001/jamaophthalmol.2020.4758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Marina Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil.,Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia, Paulista Medical School, Universidade Federal de São Paulo, São Paulo, Brazil.,Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter Louis Gehlbach
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mauricio Maia
- Department of Ophthalmology, Universidade Federal de São Paulo, São Paulo, Brazil.,Vision Institute, Instituto Paulista de Estudos e Pesquisas em Oftalmologia, Paulista Medical School, Universidade Federal de São Paulo, São Paulo, Brazil
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Volovici V, Dindelegan G. Studies of Microsurgical Skill-The Key Lies in the Design. JAMA Ophthalmol 2021; 139:127. [PMID: 33151277 DOI: 10.1001/jamaophthalmol.2020.4755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Victor Volovici
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Center for Medical Decision Making, Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Center for Microsurgical Training and Surgical Skill, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - George Dindelegan
- Center for Microsurgical Training and Surgical Skill, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Surgery, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Vitreoretinale Chirurgie: Kaffeekonsum verschlechtert die Performance von Berufseinsteigern. Klin Monbl Augenheilkd 2021. [DOI: 10.1055/a-1258-2351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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16
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Roizenblatt M, Fidalgo TM, Polizelli M, Cruz NFSD, Roizenblatt A, Jiramongkolchai K, Gehlbach PL, Farah ME, Belfort R, Maia M. Effect of chronic cocaine use on fine motor coordination tested during ophthalmic vitreoretinal simulated performance. J Psychiatr Res 2021; 132:7-12. [PMID: 33035762 DOI: 10.1016/j.jpsychires.2020.09.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/06/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022]
Abstract
We conducted a case-control study using the Eyesi simulator to assess the surgical performance of 24 chronic cocaine users (CCUs) and 24 sex-/age-matched controls to numerically quantify ophthalmic microsurgical simulator performance and fine motor deficiencies. The inclusion criteria were no exposure to illicit drugs other than cocaine, marijuana, or alcohol within the previous month and no health conditions that could impact manual task performance. The outcomes included surgical scores (0-100, worst-best) and task completion time (minutes). Fisher's exact test, analysis of variance, Mann-Whitney U test, and Kruskal-Wallis test followed by Dunn-Bonferroni post-hoc were conducted for statistical analysis. The Eyesi scores were lower among CCUs compared to controls for bimanual tasks (4.50 ± 14.30 vs. 18.46 ± 26.64, p = 0.012), for exercises demanding upper and lower limb coordination (both hands and two foot pedals, respectively) (74.13 ± 35.01 vs. 85.21 ± 24.1, p = 0.045), and in the overall score for all three tasks (27.38 ± 15.06 vs. 39.5 ± 18.66, p = 0.021). CCUs took longer to complete tasks when performing exercises demanding upper and lower limb coordination compared to controls (1.26 ± 0.38 vs. 1.02 ± 0.44 min, p = 0.006). Individuals who used cocaine during the previous month had an independent lower bimanual score compared to controls (1.42 ± 4.91 vs. 18.46 ± 26.64, p = 0.018). No differences in performance among the CCUs were attributable to sporadic cannabis or alcohol use. Chronic use of cocaine negatively impacted fine dexterity as measured by bimanual tasks or maneuvers that required simultaneous coordination of the upper and lower limbs. This was most notable among individuals who used cocaine during the 1-month period before the simulation.
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Affiliation(s)
- Marina Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil; Vision Institute, IPEPO, Paulista Medical School, 1083, 11 floor, Borges Lagoa Street, 04038-032, Administrative Office, São Paulo, Brazil; Wilmer Eye Institute, Johns Hopkins University, 600 N. Broadway, Maumenee 724, 21287, Baltimore, MD, USA.
| | - Thiago Marques Fidalgo
- Department of Psychiatry, Universidade Federal de São Paulo, 570, Borges Lagoa Street, 04038-000, Administrative Office, São Paulo, Brazil.
| | - Murilo Polizelli
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil.
| | - Natasha Ferreira Santos da Cruz
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil.
| | - Arnaldo Roizenblatt
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil.
| | - Kim Jiramongkolchai
- Wilmer Eye Institute, Johns Hopkins University, 600 N. Broadway, Maumenee 724, 21287, Baltimore, MD, USA.
| | - Peter Louis Gehlbach
- Wilmer Eye Institute, Johns Hopkins University, 600 N. Broadway, Maumenee 724, 21287, Baltimore, MD, USA.
| | - Michel Eid Farah
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil; Vision Institute, IPEPO, Paulista Medical School, 1083, 11 floor, Borges Lagoa Street, 04038-032, Administrative Office, São Paulo, Brazil.
| | - Rubens Belfort
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil; Vision Institute, IPEPO, Paulista Medical School, 1083, 11 floor, Borges Lagoa Street, 04038-032, Administrative Office, São Paulo, Brazil.
| | - Mauricio Maia
- Department of Ophthalmology, Universidade Federal de São Paulo, 821, Botucatu Street, 1st floor, 04023-062, Administrative Office, São Paulo, Brazil; Vision Institute, IPEPO, Paulista Medical School, 1083, 11 floor, Borges Lagoa Street, 04038-032, Administrative Office, São Paulo, Brazil.
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