The ideal intravitreal injection setting: office, ambulatory surgery room or operating theatre? A narrative review and international survey

PURPOSE

This study reviews evidence and provides recommendations for the ideal setting of intravitreal injection (IVI) administration of vascular endothelial growth factor (VEGF) inhibitors.

METHODS

A multi-step approach was employed, including content analysis of regulations and guidelines, a systematic literature review, and an international survey assessing perioperative complications and endophthalmitis incidence in relation to injection settings. The literature review searched PubMed and Cochrane databases from 2006 to 2022, focusing on studies reporting correlations between complications and treatment settings. The survey utilized a web-based questionnaire distributed to clinical sites and the international ophthalmic community, with data managed using electronic capture tools.

RESULTS

We reviewed regulations and guidelines from 23 countries across five continents, finding significant variation in IVI administration settings. In most countries, IVI is primarily administered in outpatient clean rooms (96%) or offices (39%), while in others, it is restricted to ambulatory surgery rooms or hospital-based operating theatres (4%). The literature review found that endophthalmitis risk after IVI is generally low (0.01% to 0.26% per procedure), with no significant difference between office-based and operating room settings. The international survey (20 centers, 96,624 anti-VEGF injections) found low overall incidences of severe perioperative systemic adverse events and endophthalmitis, independent of injection settings.

CONCLUSION

No significant differences in perioperative complications were observed among various settings, including operating theatres, ambulatory surgery rooms, offices, hospitals, or extra-hospital environments. Choosing the appropriate clinical setting can optimize patient management, potentially increasing effectiveness, quality, productivity, and capacity.

In-office needle arthroscopy is a cost-effective alternative for operating room diversion in medial meniscectomy: a financial analysis

BACKGROUND

In-office needle arthroscopy (IONA) has been described as a diagnostic alternative to magnetic resonance imaging (MRI) for intra-articular pathology. However, few studies have analyzed its impact on cost and wait times when used as a therapeutic intervention. The purpose of this study was to investigate the impact on cost and wait times associated with offering IONA for partial medial meniscectomy as an alternative to traditional operating room (OR) arthroscopy for patients with irreparable medial meniscus tears on MRI.

METHODS

Two models were created comparing the existing care pathway (current state) to a proposed future state utilizing IONA. Data sources were accounting data from an academically affiliated hospital in Canada and supplemented with literature values. A Monte Carlo simulation combined with DuPont analysis running 10,000 simulations was conducted to calculate the revenue, expenses, profits, and effect on surgical waitlists (i.e., throughput) between the states. Sensitivity analyses examined the influence of patient preference and revision rates on profit and throughput. Two-sample Student's t test was performed (p < .05).

RESULTS

An average of 198 (standard deviation (SD) 31) patients underwent arthroscopic meniscectomy or repair each year from 2016 to 2020. The IONA revision rate was calculated as 20.3%. Compared to the current state, annual expenses in the IONA pathway were significantly reduced ($266,912.68 versus $281,415.23, p < .0001), while improving throughput by 21.2% (3.54%). Sensitivity analysis revealed 10% of patients need to select IONA over traditional OR arthroscopy with the revision rate remaining below 40% for the proposed state profit to be higher than the current state.

CONCLUSIONS

IONA is a cost-effective alternative to traditional OR arthroscopy in patients undergoing partial medial meniscectomy. The next steps are to assess patients' perceptions of IONA as an alternative to traditional OR arthroscopy, and to carry out clinical trials to determine the efficacy, patient-reported outcome metrics, and complications of IONA.

Incorporating Sialendoscopy into the Otolaryngology Clinic

Simple sialendoscopy procedures may be performed in the outpatient clinic with few complications. This process spares patients the risks, increased cost, and time burdens of sialendoscopy under general anesthesia. Sialendoscopy procedures may be incorporated into the outpatient practice after gaining experience with these procedures in the operating room. Diagnostic sialendoscopy, dilation of stenosis, and endoscopic sialolithotomies of small, freely mobile stones are appropriate for in-office sialendoscopy in many instances.

In-office Functional Nasal Surgery

Nasal airway obstruction is a common complaint encountered by the otolaryngologist. In-office nasal procedures are becoming increasingly popular and should be considered for patients desiring immediate treatment without the adverse effects of general anesthesia, operating room costs, or scheduling delays. This article discusses the factors in patient selection, room setup, and other considerations. The options available for in-office treatment of nasal valve repair are discussed, including turbinoplasty, septoplasty, and nasal valve repair/functional rhinoplasty-type techniques described in the literature.

Office-Based Procedures for Nasal Airway Obstruction

Treatment of common rhinologic problems with in-office surgical procedures has increased dramatically in response to patient preference, evolving insurance patterns, and changes in coding and reimbursement. Because this is an emerging practice, there is not a lot of evidence published about how to best perform these techniques. This article provides practical advice from experienced surgeons related to logistics and anesthetic techniques for conducting in-office surgical treatment of nasal airway obstruction; an overview of office set-up and necessary equipment; and specific procedural considerations. Attention also is paid to pharmacologic issues. Logistics and clinical considerations for common office-based procedures for obstructive pathology are reviewed.

The effect of long-term use of tooth bleaching products on the human enamel surface

The aim of this in vitro study was to evaluate the long-term effect of bleaching on human enamel. Four groups of enamel specimens were prepared (n = 20): group 1: bleaching with Opalescence Boost [40% hydrogen peroxide (H₂O₂), 3 × 20 min/week]; group 2: control group (the specimens were stored in human saliva); group 3: beaching with Vivastyle Paint on Plus (6% H₂O₂, 2 × 10 min/day), and group 4: bleaching with Opalescence PF 16% [16% carbamide peroxide (CP), 6 h/day]. After each bleaching session the specimens were stored in human saliva. Knoop microhardness and surface roughness were measured: before bleaching, after 2-week and after 8-week bleaching. After 2-week treatment, surface roughness was significantly increased in all experimental groups (p < 0.05), while among them no significant difference was found (p > 0.05). The roughness changes exerted after 8-week bleaching were not significantly higher than the ones after 2 weeks (p > 0.05). After 8-week treatment, the increase in roughness caused by 16% CP was significantly higher (p < 0.05) than the one caused by 40% H₂O₂. Microhardness increased in all groups including control; however, only 40% H₂O₂ increased the microhardness significantly (p < 0.05). The effect of bleaching on enamel was not shown to be dependent on the method or the H₂O₂ concentration. Bleaching with CP 16% resulted in higher roughness than bleaching with H₂O₂, while 40% H₂O₂ caused the higher microhardness increase. The present study showed that in-office bleaching with 40% H₂O₂ seems to be at least as safe as home bleaching as far as their effects on human enamel are concerned.

[Evaluation of satisfaction after in-office conization under local anesthesia]

OBJECTIVES

Treating cervical intraepithelial neoplasia is essential in cervix carcinoma prevention and conization is the standard treatment. In the current medical and economic context, which advocates the simplification of procedures, loop excision conization is well adapted to an in-office procedure. Therefore, we evaluated the patient satisfaction after an in-office conization.

METHOD

We conducted an observational study at the Besançon University Medical Centre. Between November 2013 and October 2014, all patients treated by an in-office conization were included. Global satisfaction of patient was retrospectively collected by answering a telephone questionnaire.

RESULTS

Seventy patients were treated by in-office conization and answered the questionnaire. Global satisfaction was 88.6%. Moreover, 75.7% of patients declared to have felt no pain or moderate pain during the conization. Most of the patients (91.4%) would advise this in-office care to their relatives. The rate of positive margins for dysplasia was 31.4% and postoperative haemorrhage occurred in 7.1%.

CONCLUSION

In this context of medical care cost reduction, conization seems to be perfectly adapted to in-office surgery. It was also found to be well accepted by patients without raising neither positive margins rate nor postoperative haemorrhage risk.