Optimizing number of postoperative visits after cataract surgery: Safety perspective

Application of 3D printing surgical training models in the preoperative assessment of robot-assisted partial nephrectomy

BACKGROUND

To explore the application effect of 3D printing surgical training models in the preoperative assessment of robot-assisted partial nephrectomy.

METHODS

Eighty patients who underwent robot-assisted partial nephrectomy surgery between January 2022 and December 2023 were selected and divided into two groups according to the chronological order. The control group (n = 40) received preoperative assessment with verbal and video education from January 2022 to December 2022, while the observation group (n = 40) received preoperative assessment with 3D printing surgical training models combined with verbal and video education from January 2023 to December 2023. The preoperative anxiety, information demand score, and surgical awareness were compared between the two groups. The physiological stress indicators, including interleukin-6 (IL-6), angiotensin II (AT II), adrenocorticotropic hormone (ACTH), cortisol (Cor), mean arterial pressure (MAP), and heart rate (HR), were also measured at different time points before and after surgery.They were 6:00 am on the day before surgery (T0), 6:00 am on the day of the operation (T1), 6:00 am on the first day after the operation (T2), and 6:00 am on the third day after the operation (T3).The preparation rate before surgery was compared between the two groups.

RESULTS

The anxiety and surgical information demand scores were lower in the observation group than in the control group before anesthesia induction, and the difference was statistically significant (P < 0.001). Both groups had lower scores before anesthesia induction than before preoperative assessment, and the difference was statistically significant (P < 0.05). The physiological stress indicators at T1 time points were lower in the observation group than in the control group, and the difference was statistically significant (P < 0.05). The overall means of the physiological stress indicators differed significantly between the two groups (P < 0.001). Compared with the T0 time point, the T1, T2, and T3 time points in both groups were significantly lower, and the difference was statistically significant (P < 0.05). The surgical awareness and preparation rate before surgery were higher in the observation group than in the control group, and the difference was statistically significant (P < 0.05).

CONCLUSION

The preoperative assessment mode using 3D printing surgical training models combined with verbal and video education can effectively reduce the psychological and physiological stress responses of surgical patients, improve their surgical awareness, and enhance the preparation rate before surgery.

Incidence of unplanned visits after cataract surgery in two large cohorts with different anti-inflammatory treatment protocols

PURPOSE

To compare incidences and reasons for unplanned extra visits after phacoemulsification surgery in two unselected clinical populations with different postoperative treatment protocols.

DESIGN

Retrospective cohort study.

METHODS

We reviewed medical records of 1000 patients that underwent cataract surgery at two adjacent clinics in Sweden. At each clinic, 500 consecutive surgeries were included. Preoperatively recorded comorbidities were registered. One clinic used a non-steroidal anti-inflammatory drug (NSAID) in combination with steroids as postoperative treatment, the other used steroids in monotherapy. Main outcome was the number of patients that returned within 6 months after surgery for at least one unplanned visit. Reasons for unplanned visits were secondary outcomes.

RESULTS

Among patients receiving combined treatment 84 cases (16.8%) returned for at least 1 extra visit, compared with 63 cases (12.6%) in the group treated with steroids only (RR = 1.33 [95% CI 0.99-1.80, p = 0.061]). No significant differences were found regarding any underlying reasons for the visits, including cystoid macular oedema (CME). We found increased risks for CME in patients with diabetes mellitus (RR = 3.83 [95% CI 1.18-12.41, p = 0.016]) and patients with epiretinal membrane (ERM) (RR = 10.76 [95% CI 3.14-36.89, p < 0.0001]).

CONCLUSIONS

Postoperative anti-inflammatory treatment with NSAID in combination with steroids did not reduce need for unplanned postoperative visits or incidence of visually disturbing CME after cataract surgery compared with steroids alone. Patient groups with elevated risks for CME are of interest in future research regarding benefits and optimal use of NSAID treatment after cataract surgery.

Parametric Drug Release Optimization of Anti-Inflammatory Drugs by Gold Nanoparticles for Topically Applied Ocular Therapy

Eye drops represent 90% of all currently used ophthalmic treatments. Only 0.02% of therapeutic molecules contained in eye drops reach the eye anterior chamber despite their high concentration. The tear film efficiently protects the cornea, reducing access to the target. Thereby, the increase in the drug bioavailability and efficiency must come from the mucoadhesion optimization of the drug delivery system. The gold nanoparticles, used as a drug delivery system in this study, already showcased ultrastable and mucoadhesive properties. The goal was to study the gold nanoparticles' ability to release two specific ophthalmic drugs, flurbiprofen and ketorolac. The parameters of interest were those involving the loading conditions, the gold nanoparticles properties, and the release experimental conditions. The drug release was measured using an in vitro model based on dialysis bags coupled with UV-visible spectroscopy. Gold nanoparticles showed an ability to release different molecules, whether hydrophobic or hydrophilic, in passive or active drug release environments. Based on these preliminary results, gold nanoparticles could represent a promising drug delivery system for ketorolac and flurbiprofen when topically applied through eye drops.

Incidence of postoperative week 1 management changes after resident-performed phacoemulsification cataract surgery

BACKGROUND

The goal of this study was to investigate the incidence of departures from routine care at the postoperative week 1 (POW1) visit following uneventful resident-performed cataract surgery in asymptomatic patients who had a normal postoperative day 1 (POD1) examination.

METHODS

A retrospective chart review of phacoemulsification surgeries performed by the senior resident class at Montefiore Medical Center between June 20, 2018 and April 1, 2019 was performed. The most recent preoperative visit note, operative report, POD1 visit note, and POW1 visit note were evaluated and variables were recorded. Exclusion criteria consisted of any complications that would have necessitated close follow-up and a POW1 visit, whether discovered preoperatively, intraoperatively, at the POD1 visit, or leading up to the POW1 visit. The primary outcome measure was the incidence of unanticipated management changes at the POW1 visit following resident-performed cataract surgery.

RESULTS

The charts of 292 surgical cases of 234 patients that underwent phacoemulsification with intraocular lens implantation were reviewed. 226 cases (77%) had an uncomplicated pseudophakic fellow-eye history, with a routine surgery, and POD1 examination. 19 of these patients had symptomatic presentations at the POW1 timepoint, and an additional 30 had no POW1 visit at all. In total, 177 cases were included in the study, and only 4 of these cases (2.3%) had an unexpected management change at the POW1 visit.

CONCLUSIONS

Asymptomatic patients who underwent uncomplicated cataract surgeries performed by resident surgeons followed by a routine POD1 visit had a low incidence of unexpected management changes at the POW1 visit. These results suggest that regularly scheduled POW1 visits could potentially be omitted for patients deemed to be at low risk for complications, and instead performed on an as-needed basis.

Can a Set of Questions after Routine Cataract Surgery Predict Unexpected Findings and Avoid an Unnecessary Follow-Up Visit?

Background and Objectives: to evaluate whether a set of questions after a routine cataract surgery can predict unexpected findings and avoid an unnecessary follow-up visit. Materials and Methods: single-center, prospective, cohort study included 177 routine cataract surgery cases of two experienced surgeons between November 2019 and December 2020. Inclusion criteria included unremarkable postoperative day one follow-up examination. A set of seven questions regarding complaints with positive or negative answers was presented at the second follow-up visit (PV2)—one week (mean 8.34 ± 1.73 days) after the surgery. The outcome measures were the incidence of unexpected management changes (UMCs) at the PV2 visit (change or addition from a prescribed postoperative drop plan, extra procedures, an urgent referral to an ophthalmologist) and UMCs associations with the answers to a question set. Results: 81.4% of patients had no complaints about postoperative ocular status and answered with negative answers, 18.6% reported one or more complaint (positive answer): dissatisfaction with postoperative visual acuity (6.2%, 11 cases), eye pain (4.0%, 7 cases), increase in floaters after the surgery (4.0%, 7 cases), red eye (4.0%, 7 cases) and others. The prevalence of UMCs at PV2 was 1.7% (3 cases), of which 0.6% (1 case) was the prolonged antibiotic prescription due to conjunctivitis, 0.6% (1 case) was the addition of IOP lowering medication and 0.6% (1 case) was additional medication due to uveitis management. None of the complaints (positive answers) at PV2 were associated with the incidence of UMCs (p > 0.05). Conclusions: there were no associations of UMCs determined with positive answers to the questions. The prediction of UMCs incidence based on the positive answers was not obtained. Thus, we cannot exclude the necessity of a postoperative week one follow-up visit.

Can the postoperative follow-up visit be deferred up to four weeks after an uneventful cataract surgery? - A randomized controlled trial

Purpose:

The aim of this study was to compare the postoperative visual outcome after a Day 0 examination in patients with two follow-ups, one between Day 3 to Day 7 and other between Day 25 to Day 30 to those with a single ophthalmic follow-up directly after 25–30 Days and to assess the safety of deferral of the first follow-up visit at 1 week.

Methods:

Randomized Controlled Trial was conducted at a tertiary eye care hospital, with 848 patients enrolled for the study. Patients meeting the inclusion criteria were selected. Their pre-operative and post-operative data was collected and the patients were divided into groups based on the type of cataract surgery and the postoperative follow-up protocol through randomization.

Results:

No significant difference was observed in the postoperative visual outcome in patients that underwent postoperative review at Day 3–7 and Day 25–30 as opposed to those that followed up directly at Day 25–30 after a mandatory Day 0 examination for all patients.

Conclusion:

In patients with no preexisting ocular or systemic comorbidity undergoing an uneventful cataract surgery, the postoperative follow-up visit can be safely deferred until 4 weeks, without any impact on the postoperative visual outcome, thereby conserving the available resources which can be deviated towards better eye care services.

Resident Performed Sutureless Manual Small Incision Cataract Surgery (MSICS): Outcomes

Purpose

To show the surgical and visual outcomes of a resident-performed manual small incision cataract surgery.

Study Type

Retrospective observational case series.

Study Setting

Ruby Eye Hospital.

Materials and Methods

Manual small incision cataract surgery was performed on 339 uncomplicated cataract cases by three in-house residents. Preoperative visual acuity and vision with a pinhole were meticulously noted in the record sheets. All patients underwent thorough preoperative evaluation with the help of a slit lamp. Eyes with corneal guttae, un-dilated pupils, pseudo-exfoliation, raised intraocular pressure and posterior segment abnormalities were excluded from the study. The mean patient age was 59 years (min: 47 years and max: 85 years). Forty-seven percent were males, and the rest were females. The mean uncorrected preoperative visual acuity recorded was 1.3 logMAR units (max: 1 and min: 1.6, Std dev: 0.4). Forty-two percent of the eyes had dense nuclear cataracts (≥ Nuclear Sclerosis grade III from LOCS II).

Results

The mean postoperative visual acuity recorded was 0.4 logMAR units [standard deviation 0.3 logMAR units (max: 1 and min: 0.1 p-value <0.001)]. Forty-three cases (12.6%) had tunnel-related complications (premature entry/button hole). Thirty-six cases (10.6%) had iatrogenic prolapse of the iris tissue. Eight cases (2.3%) had a runaway capsulorhexis, while 18 cases (5.3%) had iatrogenic posterior capsular rupture. Two cases (0.58%) had a large zonular dialysis. Ten cases (2.9%) were retaken to the operating room again for repeat intervention.

Conclusion

The ophthalmic resident learning curve for manual small incision cataract surgery is steep, unlike what is reported in the literature. A good training program with a special emphasis on wound construction is of paramount importance for future residents.

Follow-Up After Cataract Surgery - Comparison of the Practice in Two Institutions with the Aim of Optimize the Routine

Purpose

To evaluate the number of postoperative visits after cataract surgery in two institutions with different routines.

Patients and Methods

A population-based prospective, observational, cohort study was conducted at two institutions in northern Sweden. All cataract surgery cases during a 1-year period were included. The study group was 1249 cases, who followed the standard routine at the Sunderby clinic, ie, no planned postoperative visit for patients without comorbidity who had uncomplicated surgery. All cases (n=1162) having surgery during the same 1-year period at the Umeå clinic were selected as the control group. The routine in Umeå was a planned postoperative visit for all patients after first eye surgery, and on second eye surgery patients with other ocular comorbidity.

Results

A postoperative visit was planned in 44% (555/1249) of the study group and in 83% of all control group cases (966/1162). Significantly less patients in the study group (9% vs 16%; p=0.000036) initiated an unplanned contact. Patients with a distance to the hospital of 70 km or longer were less inclined to seek unplanned care (p=0.016). There was no difference in postoperative outcomes between the patients who initiated contact and those who did not in the study and control hospitals.

Conclusion

Without compromising patient safety, it is possible to reduce the burden of postoperative visits in cases with uncomplicated cataract surgery. A reduction in the number of visits is obtained only if the standard routine is no planned postoperative visits in uncomplicated cases without ocular comorbidity for both first and second eye surgery.

Optimization of cataract surgery follow-up: A standard set of questions can predict unexpected management changes at postoperative week one

PURPOSE

There is limited evidence to inform the optimal follow-up schedule after cataract surgery. This study aims to determine whether a standardized question set can predict unexpected management changes (UMCs) at the postoperative week one (POW1) timepoint.

SETTING

Massachusetts Eye and Ear, Harvard Medical School.

DESIGN

Prospective cohort study.

METHODS

Two-hundred-and-fifty-four consecutive phacoemulsification cases having attended an examination between postoperative days 5-14. A set of 7 'Yes' or 'No' questions were administered to all participants by a technician at the POW1 visit. Patient answers along with perioperative patient information were recorded and analyzed. Outcomes were the incidence of UMCs at POW1.

RESULTS

The incidence of UMCs was zero in uneventful cataract cases with unremarkable history and normal postoperative day one exam if no positive answers were given with the question set demonstrating 100% sensitivity (p<0.0001). A test version with 5 questions was equally sensitive in detecting UMCs at POW1 after cataract surgery.

CONCLUSION

In routine cataract cases with no positive answers to the current set of clinical questions, a POW1 visit is unlikely to result in a management change. This result offers the opportunity for eye care providers to risk-stratify patients who have had cataract surgery and individualize follow-up.

Preoperative anti-inflammatory treatment of diabetic patients does not improve recovery from cataract surgery when postoperatively treated with a combination of prednisolone acetate and nepafenac

PURPOSE

To examine preoperative anti-inflammatory treatment on recovery from cataract surgery in eyes of diabetic patients.

METHODS

A Prospective randomized clinical trial. One hundred and three eyes of 103 patients with diabetes undergoing routine cataract surgery were randomized (1:1) not to receive any preoperative anti-inflammatory medication or to receive preoperative topical anti-inflammatory medication with a combination of prednisolone acetate (10 mg/ml) and nepafenac (1 mg/ml). All eyes received postoperative anti-inflammatory combination therapy for 3 weeks. Recovery from surgery was recorded by a structured home questionnaire. Clinical outcome parameters were recorded at 28 days and 3 months.

RESULTS

Patient age and gender distribution, and all baseline ophthalmic and systemic parameters were comparable between the study groups. After surgery, conjunctival injection lasted 2.4 ± 1.7 days (mean ± SD) and irritation of the eye 3.3 ± 3.9 days in eyes without preoperative treatment, when compared to 1.6 ± 1.6 days (p = 0.067) and 2.4 ± 4.0 days (p = 0.431), respectively, in eyes with preoperative treatment. At 28 days, central subfield macular thickness (CSMT) increased 2.2 ± 20.2 μm in eyes without preoperative treatment, when compared 0.1 ± 25.2 μm (p = 0.670) in eyes with preoperative treatment. At 3 months, the respective CSMT change from baseline was -1.5 ± 26.9 μm and -3.4 ± 26.2 μm (p = 0.762). None of the eyes were reported with pseudophakic cystoid macular oedema (PCME) in either group.

CONCLUSION

Lack of preoperative anti-inflammatory treatment does not impair recovery from surgery or predispose diabetic patients to increased risk of PCME in eyes postoperatively treated with combination therapy of prednisolone acetate and nepafenac.

Incidence of Management Changes at the Postoperative Week 1 Visit after Cataract Surgery: Results from the Perioperative Care for IntraOcular Lens Study

PURPOSE

To ascertain the incidence of unexpected management changes at the postoperative week 1 visit in asymptomatic patients who have had an uncomplicated cataract surgery and a routine postoperative day 1 examination.

DESIGN

Retrospective observational study.

METHODS

A retrospective chart review was conducted of all cases of cataract extraction by phacoemulsification with intraocular lens insertion performed by the Comprehensive Ophthalmology Service at Massachusetts Eye and Ear between January 1, 2014 and December 31, 2014. The preoperative consultation, operative report, and postoperative day 1 and week 1 (postoperative days 5-14) visits were reviewed. Cases with intraoperative complications, as well as clinical findings at postoperative day 1 requiring close follow-up, were excluded. The main outcome measure was incidence of unexpected management changes at the postoperative week 1 visit after cataract surgery, defined as an unanticipated change in postoperative drops, additional procedures, or urgent referral to a specialty service.

RESULTS

Overall, 1938 surgical cases of 1471 patients were reviewed, and 1510 cases (77.9%) underwent uncomplicated phacoemulsification with intraocular lens implantation with a routine postoperative day 1 examination. Of these 1510 cases, 238 (15.8%) reported symptoms at the postoperative week 1 visit, including flashes, floaters, redness, pain, or decreased vision, which warranted an examination. In total, 1272 cases were asymptomatic, and only 11 of these cases (0.9%) had an unexpected management change at postoperative week 1. Eight of 11 patients were asymptomatic steroid responders requiring alteration of their postoperative drops. Two of these patients had an intraocular pressure >30 mm Hg.

CONCLUSIONS

Unexpected management changes at the postoperative week 1 timepoint after cataract surgery are rare in asymptomatic patients who have had uncomplicated cataract surgery and a routine postoperative day 1 examination. Limited data are available to outline an optimal postoperative regimen after cataract surgery. The results of this study suggest that postoperative week 1 examinations could potentially be performed on an as-needed basis in the appropriate subgroup of patients after cataract surgery.

Diabetes Alone Does Not Impair Recovery From Uneventful Cataract Surgery

PURPOSE

To study the outcomes of uneventful cataract surgery in diabetic patients without retinal complications.

DESIGN

A post hoc treatment analysis using data from 2 double-masked randomized clinical trials.

METHODS

Setting: Conducted at Kymenlaakso Central Hospital, Kotka, Finland.

PROCEDURE

A total of 276 eyes of 266 patients undergoing routine cataract surgery were included in the study. Patients with type I or II diabetes (n = 56 eyes) were compared to nondiabetic patients (n = 220 eyes). Clinical evaluation was conducted by the operating physician, and outcome measures taken before surgery and day 28 were recorded by a research technician.

RESULTS

Patient age, sex distribution, and all baseline ophthalmic and surgical parameters were comparable for the nondiabetic and diabetic patient groups. Increase in aqueous flare 6.3 ± 16.4 photon units (pu)/ms vs 3.7 ± 8.9 pu/ms (mean ± standard deviation; P = .282), central retinal thickness (CRT) 12.0 ± 38.2 μm vs 5.9 ± 15.8 μm (P = .256), corrected distance visual acuity 0.57 ± 0.31 decimals vs 0.53 ± 0.35 decimals (P = .259), and patient satisfaction 9.3 ± 0.9 vs 9.2 ± 1.1 (P = .644) were comparable for nondiabetic and diabetic patients. In eyes with steroid monotherapy (n = 64), CRT increased 38.1 ± 72.8 μm in nondiabetic patients compared to 7.8 ± 6.6 μm in diabetic ones (P = .010). In eyes with nonsteroidal anti-inflammatory drug (NSAID) monotherapy (n = 157), CRT increased 5.7 ± 18.4 μm in nondiabetic patients compared to 6.2 ± 20.5 μm in diabetic ones (P = .897). Among eyes with steroid and NSAID combination therapy (n = 55), CRT increased 3.6 ± 4.1 μm in nondiabetic patients compared to 2.9 ± 3.2 μm in diabetic ones (P = .606). At 28 days postsurgery, pseudophakic cystoid macular edema (PCME) was reported in 8 eyes, of which 7 were in nondiabetic patients (P = 1.000).

CONCLUSIONS

Diabetic patients showed less change in CRT when compared to controls in steroid monotherapy. Other outcome measurements shows no statistical differences.