Long-Term Satisfaction of Oral Sedation versus Standard-of-Care Intravenous Sedation for Ocular Surgery

Purpose

Long-term patient satisfaction may influence patients' perspectives of the quality of care and their relationship with their providers. This is a follow up to a comparative effectiveness study investigating oral to intravenous sedation (OIV study). The OIV study found that oral sedation was noninferior in patient satisfaction to standard intravenous (IV) sedation for anterior segment and vitreoretinal surgeries. This study aims to determine if patient satisfaction with oral sedation remained noninferior long term.

Patients and Methods

Patients were re-interviewed using the same satisfaction survey given during the OIV study. Statistical analysis involved t-tests for noninferiority of the long-term mean satisfaction score of oral and IV sedation. We also compared the original mean satisfaction score and the follow-up mean satisfaction score for each type of sedation and for both groups combined.

Results

Participants were interviewed at a median of 1225.5 days (range 754-1675 days) from their surgery. The original mean satisfaction score was 5.26 ± 0.79 for the oral treatment group (n = 52) and 5.27 ± 0.64 for the intravenous treatment group (n = 46), demonstrating noninferiority with a difference in mean satisfaction score of 0.015 (p < 0.0001). The follow-up mean satisfaction score was 5.23 ± 0.90 for oral sedation and 5.60 ± 0.61 for IV sedation, with a difference in the mean satisfaction score of 0.371 (p = 0.2071). Satisfaction scores did not differ between the original mean satisfaction score and the follow-up mean satisfaction score for the oral treatment group alone (p = 0.8367), but scores in the intravenous treatment group increased longitudinally (p = 0.0004).

Conclusion

In this study, long-term patient satisfaction with oral sedation was not noninferior to satisfaction with IV sedation, unlike our findings with short-term patient satisfaction in our original study. Patient satisfaction also remained unchanged over time for the oral treatment group, but patients in the intravenous treatment group reported higher long-term satisfaction with their anesthesia experience compared to the immediate post-operative period.

Exogenous Endophthalmitis

PURPOSE

Exogenous endophthalmitis (ExE) results from microbial infection as a complication of ocular surgery, penetrating ocular trauma, and intraocular foreign bodies. We herein review the classification of ExE, etiological agents, differential diagnosis and therapeutic challenges.

METHODS

Narrative Literature Review.

RESULTS

Identification of the causative agent through ocular fluid analysis is central in the diagnostic work-up of ExE. Prompt intravitreal antimicrobial therapy is key to successful management of ExE and vitrectomy is essential in severe cases. In culture-negative cases, and in the presence of specific features, a diagnosis of sterile intraocular inflammation or toxic syndrome should be suspected.

CONCLUSION

Strict adherence to treatment guidelines may improve outcomes of ExE, however the ultimate prognosis, especially in severe cases, may depend more on the virulence of the causative organism and associated ocular complications. Accurate differential diagnosis and effective treatment are crucial elements in the management and prognosis of non-infectious masquerades of ExE.

Oxidative Stress and Antioxidant-Based Interventional Medicine in Ophthalmology

The different anatomical compartments of the eye are highly subjected to reactive oxygen species (ROS) generation due to internal factors, such as metabolic high oxygen consumption, as well as environmental factors, including UV light. An antioxidant defense system is endowed in the eye tissues to regulate ROS quantity and activity. When this homeostatic system is overwhelmed, oxidative stress occurs, causing cellular damage, chronic inflammation, and tissue degeneration. It also plays a significant role in the development and progression of various ocular diseases. Understanding the mechanisms underlying oxidative stress in ocular conditions is thus crucial for the development of effective prevention and treatment strategies. To track marketed products based on antioxidant substances as active ingredients, the databases of the European Medicines Agency and the U.S. Food and Drug Administration were consulted. Only a limited number of items were identified, which were either used as therapeutic treatment or during ocular surgery, including antioxidants, synthetical derivatives, or pro-drugs designed to enhance tissue permeation and activity. This review aims to provide an overview of the primary ocular pathologies associated with oxidative stress and of the available pharmacological interventions centered around antioxidant molecules. Such insights are essential for advancing the development of effective prevention and novel treatment approaches.

Clinical and Histopathological Effects of Intracameral Ranibizumab in Experimental Trabeculectomy

Post-surgical scarring is a known cause of trabeculectomy failure. The aim of this study was to investigate the effectiveness of ranibizumab as an adjuvant anti-scarring agent in experimental trabeculectomy. Forty New Zealand white rabbits were randomised into four eye treatment groups: groups A (control), B (ranibizumab 0.5 mg/mL), C (mitomycin C [MMC] 0.4 mg/mL), and D (ranibizumab 0.5 mg/mL and MMC 0.4 mg/mL). Modified trabeculectomy was performed. Clinical parameters were assessed on post-operative days 1, 2, 3, 7, 14, and 21. Twenty rabbits were euthanised on day 7, and the other twenty were euthanised on day 21. Eye tissue samples were obtained from the rabbits and stained with haematoxylin and eosin (H&E). All treatment groups showed a significant difference in IOP reduction compared with group A (p < 0.05). Groups C and D showed a significant difference in bleb status on days 7 (p = 0.001) and 21 (p = 0.002) relative to group A. H&E staining showed significantly low fibrotic activity (p < 0.001) in group C on both days and inflammatory cell grade in group B on day 7 (p < 0.001). The grade for new vessel formation was significantly low in groups B and D on day 7 (p < 0.001) and in group D on day 21 (p = 0.007). Ranibizumab plays a role in reducing scarring, and a single application of the ranibizumab-MMC combination showed a moderate wound-modulating effect in the early post-operative phase.

Effects of slanted bilateral lateral recession vs conventional bilateral lateral recession on convergence insufficiency intermittent exotropia: a prospective study

AIM

To observe the surgical effects of slanted bilateral lateral recession (S-BLR) versus conventional bilateral lateral recession (C-BLR) in convergence insufficiency intermittent exotropia (CI-IXT).

METHODS

Using a randomized, double-blind, prospective design, 22 patients with CI-IXT who were admitted to Renmin Hospital of Wuhan University from July 2019 to December 2020 were included. Patients were randomly divided into either S-BLR or C-BLR group for their subsequent strabismus surgery. All patients were followed up for 12mo. Near deviation, distant deviation, and near-distance difference (NDD) were measured in all patients.

RESULTS

Twelve months after surgery, NDD improvement was 10 (8, 13) prismatic degrees (PD) in S-BLR group and 3 (1, 6) PD in C-BLR group (P=0.011). The near deviation of S-BLR group was 0 (-2, 2) PD, while that of C-BLR group was -4 (-6, -3) PD (P=0.005). Before and after surgery, the difference in the distant deviation between the two groups was not statistically significant. There was no statistically significant difference in near stereopsis between the two groups (P=0.380) at 12mo. The success rate at 12mo after operation was 90.91% and 72.73% in the two groups (P=0.280).

CONCLUSION

CI-IXT patients treated with S-BLR have better surgical outcomes than those treated with C-BLR, which indicates S-BLR is a safe and effective operation pattern.

Povidone-Iodine Adverse Effects and Alternatives for Ocular Procedures

Purpose: Povidone-iodine (PVI), also known as Betadine, is a widely used antiseptic agent used in several fields of medicine. In ophthalmology, it is applied as a preoperative antiseptic to prevent infectious complications that can result from surgical procedures. PVI's safety and efficacy have been extensively studied and represented in the literature; however, the incidence of adverse effects has been reported in conjunction. The aim of this paper is to compile information regarding PVIs use, safety profile, adverse effects, and possible alternatives through a review of the existing literature. Methods: Literature was compiled utilizing the database PubMed and Google Scholar using specified keywords with a total of 86 reviewed articles, after excluding search results that did not meet the inclusion criteria. Results: While the allergic potential to PVI is a highly contested topic, there are several nonallergic adverse effects of PVI that should not be overlooked. These effects include chemical burn, cytotoxic effects, and general patient discomfort. In light of these adverse effects, alternatives to PVI may be considered. However, there has been little research identifying feasible alternatives in preoperative intraocular procedures. Alternatives including chlorhexidine, polyhexamethylene biguanide (polyhexanide), and octenidine were identified as potential substitutes for PVI. Conclusions: Further study is needed to provide robust evidence regarding the efficacy profiles of these alternatives in comparison with PVI and to demonstrate comparable tolerance to PVI in intraocular procedures.

Eye enucleation and exenteration in -cattle: a retrospective study of 38 cases (2013-2020)

INTRODUCTION

The study aimed to describe clinical indications for eye enucleation and exenteration, the occurrence of complications and long-term outcome in cattle, and examine owners' attitude towards enucleation and exenteration and their satisfaction with the surgical outcome. Medical records from the two veterinary teaching hospitals in Switzerland were reviewed to identify cattle that underwent unilateral enucleation or exenteration between January 2013 and December 2020. Data extracted included medical history, ocular examination, clinical diagnosis, surgical procedure including anesthesia, suture material and pattern used, complications, and treatment thereof. Long-term follow-up was evaluated via national animal database inquiries to determine survival time and via owners' interviews with the use of a standardized questionnaire that included questions regarding the occurrence of complications and reason for culling, production performances and perceived quality of life after surgery, concerns, factors affecting the decision to proceed with surgery, and general satisfaction with the outcome. Descriptive statistics, Fisher's exact tests and unpaired t-test were used to summarize the data and assess association between variables. Association was considered significant if p < 0,05. Thirty-eight cases were identified, with a median age of 5 years. More than half of the cases (55,3 %) were diagnosed with non-neoplastic ocular lesions represented by severe trauma with loss of globe content, globe rupture with history of infectious keratoconjunctivitis or hypopyon, or congenital malformations. The remaining cases were diagnosed with neoplastic lesions, including ocular squamous cell carcinoma (OSCC), melanoma, or sarcoma. Complications following surgery were reported in 29 % of cases and included postoperative infection and recurrence of OSCC. There was no significant association between ocular diagnosis and the occurrence of postoperative complications or survival time. Surgery did not seem to influence the animals' postoperative production performance or the perceived quality of life. Most owners (92 %) were satisfied with the surgical outcome. The occurrence of postoperative complications leading to increased overall costs and culling was the main reason for lower owner satisfaction.

Early and delayed suture adjustments after adjustable suture strabismus surgery: a randomized controlled trial

Background

Adjustable sutures increase the success rate of strabismus surgery. However, the optimal timing of postoperative suture adjustment remains controversial. This trial was aimed at comparing the surgical outcomes and pain scores of early or 2 - 4 h and delayed or 24 h postoperative suture adjustment in adult patients undergoing strabismus surgery.

Methods

An open-label, prospective, randomized, comparative interventional study was performed in consecutive adult patients scheduled for eye muscle surgery. Patients were randomized into two groups: the early group, with suture adjustment 2 - 4 h postoperatively, and the delayed group, with suture adjustment 24 h postoperatively. Subjective pain scores during the adjustment were also analyzed. The angles of misalignment at 1 and 3 months and the success rate at 3 months postoperatively were compared.

Results

Forty-five (90%) patients completed the follow-up, including 23 (92%) in the early adjustment group and 22 (88%) in the delayed adjustment group, with a mean (standard deviation) age of 25.6 (9.5) years and a male-to-female ratio of 46.7:53.3. Thirty patients (66.7%) had exotropia, and 15 (33.3%) patients had esotropia. Both groups had comparable baseline characteristics (all P > 0.05). The mean pain scores during adjustment did not differ significantly between groups (P > 0.05). The postoperative angles of alignment were comparable between the groups before suture adjustment and at the 1- and 3-month follow-ups (all P > 0.05). The success rate in the early adjustment group was slightly higher (87.0% versus 63.6%), but the difference was not statistically significant (P > 0.05). The success rate was comparable between the groups in patients with esotropia or exotropia (both P > 0.05).

Conclusions

Although the early adjustment group had a slightly higher success rate, the difference was not significant. Both groups had comparable subjective pain scores during adjustment, final motor alignment, or success rate. Future clinical trials should be performed different time intervals for postoperative suture adjustment, and subjective and objective outcomes, such as diplopia and stereopsis, should be compared between patients with a first strabismus surgery and those who underwent reoperation. This could better resolve the persistent controversy related to the optimal time for suture adjustment.

Effectiveness and safety of intravenous dexmedetomidine sedation for ophthalmic surgery under regional anesthesia

PURPOSE

To assess the effectiveness and safety of intravenous (IV) dexmedetomidine for sedation in ophthalmic surgery.

METHODS

Prospective, observational, uncontrolled, single-center study. Patients were sedated with a continuous dexmedetomidine IV infusion started 15 min before regional anesthesia administration and maintained up to the end of surgery. Effectiveness of dexmedetomidine was assessed by the Modified Observer's Assessment of Alertness and Sedation (MOAA/S) targeted at 5. Safety was assessed by the incidence of patients' movements/snoring and by the incidence of respiratory and haemodynamic complications. An eleven-point numerical rating scale (NRS) was used to assess the level of satisfaction of both the surgeon and the patient.

RESULTS

123 patients (73 males, mean age: 63 ± 13) were included; 81 (81/123; 65.8%) patients reached the requested MOAA/S score of 5. Any intraoperative movement - mostly voluntary - occurred in 34 (34/123; 27.6%) cases with no need for a switch to general anaesthesia; no ocular complications related to the intraoperative movements occurred. Intraoperative snoring occurred in 30 (30/123; 24.4%) patients and it did not affect the surgical manoeuvres. Respiratory drive depression requiring manual or mechanical ventilation never occurred. Bradycardia occurred in 14 (14/123; 11.3%), cases but only 4 (4/123; 3.2%) patients required atropine administration, which was always effective. Intraoperative analgesia was consistently obtained and both the surgeons and the patients reported a high NRS satisfaction score.

CONCLUSION

Dexmedetomidine provided adequate sedation in patients undergoing ocular surgery under local anaesthesia and showed a good effectiveness and safety profile. Upper airway obstruction, apnoea and snoring can occur.

Endoscopic transconjunctival optic nerve sheath fenestration for progressive idiopathic visual field deficit: a case report

Intra-orbital optic nerve sheath fenestration (ONSF) is an effective option in patients with progressive vision loss due to idiopathic intracranial hypertension. Most proposed techniques involve surgical trauma and require disinsertion of the medial rectus muscle; thus, less invasive surgical procedures are needed. Here, a feasible and effective technique of endoscopic intra-orbital ONSF through a conjunctival incision is presented, in a patient with a progressively compromised visual field, papilloedema, and distended subarachnoid space around the optic nerves. The retrobulbar segment of the optic nerve was exposed for incision, avoiding manipulation of the lateral orbital rim bones and irritation of the ciliary microvessels and nerves. The patient regained the entire visual field. ONSF was safely and effectively performed endoscopically through a narrow corridor gained by brushing away the orbital fat with minimal traction on the medial rectus muscle. The small postoperative wound was associated with faster and easier convalescence, and less tissue trauma versus conventional open approaches.

Eye-tunes: role of music in ophthalmology and vision sciences

Although the healing effect of music has been recognized since time immemorial, there has been a renewed interest in its use in modern medicine. This can be attributed to the increasing focus on holistic healing and on the subjective and objective aspects of well-being. In ophthalmology, this has ranged from using music for patients undergoing diagnostic procedures and surgery, as well as for doctors and the operation theatre staff during surgical procedures. Music has proven to be a potent nonpharmacological sedative and anxiolytic, allaying both the pain and stress of surgery. This review aims to explore the available evidence about the role of music as an adjunct for diagnostic and surgical procedures in current ophthalmic practices.

Advances in Understanding the Mechanism of Ophthalmic Viscosurgical Device Retention in the Anterior Chamber or on the Corneal Surface during Ocular Surgery

Retention durability, especially in the eye, is one of the most important properties of ophthalmic viscosurgical devices (OVDs) during ocular surgery. However, the information on the physical properties of OVDs is insufficient to explain their retention durability. The purpose of this study is to clarify the mechanism of OVD retention to improve understanding of the behavior of OVDs during ocular surgery. To elucidate the mechanism of OVD retention, we have developed a new test method for measuring repulsive force. As a result, the maximum repulsive force of OVDs was positively and well correlated with the retention durability of investigated OVDs. Consequently, we demonstrated that the repulsive force could be used as an index of retention durability on the ocular surface and in the eye. We directly compared the intraocular retention durability of three OVDs (Shellgan, Viscoat, and Opegan-Hi) in ex vivo porcine eyes. Opegan-Hi was immediately removed from the anterior chamber, but Shellgan and Viscoat remained largely in the anterior chamber as determined by fluorescence imaging. These results showed that the intraocular retention behavior of OVDs was similar to their ocular surface behavior in our previous report, suggesting that retention durability is dependent on the OVD itself. The retention durability of Shellgan seemed to be higher than that of Viscoat, and the maximum repulsive force of Shellgan was 1.35-fold higher than that of Viscoat. Therefore, the repulsive force might be a useful index for assessing the difference in the retention durability between OVDs such as Shellgan and Viscoat.

KPI-121 1% for pain and inflammation in ocular surgery

Pain and inflammation are common experiences following ocular surgery and, if uncontrolled, can compromise patients' vision, functioning and quality of life. Corticosteroid drugs are available to manage inflammation and discomfort but have limitations in penetrating the ocular mucus barrier to reach the target ocular tissues. KPI-121 1% (INVELTYS^®) is a novel formulation of loteprednol etabonate that employs innovative proprietary technology to deliver nanoparticle-sized mucus-penetrating particles to the cornea. Results from clinical trials demonstrate that KPI-121 1% is effective and well tolerated. KPI-121 1% uses mucopenetrative technology for ophthalmic use and is the only US FDA-approved twice-daily ocular corticosteroid indicated for the treatment of inflammation and pain after ocular surgery.

Effectiveness of 0.66% Povidone-Iodine Eye Drops on Ocular Surface Flora before Cataract Surgery: A Nationwide Microbiological Study

A multicenter, nonrandomized, prospective, controlled study was conducted to evaluate, as perioperative prophylactic treatment, the anti-infective effectiveness of 0.66% povidone-iodine eye drops (IODIM^®) against the bacterial flora of the conjunctival surface of patients who undergo cataract surgery. Eye drops containing 0.66% povidone-iodine were applied to the eye undergoing cataract surgery; the untreated contralateral eye was used as control. One hundred and twenty patients set to receive unilateral cataract surgery were enrolled in 5 Italian Ophthalmology Centers and pretreated for three days with 0.66% povidone-iodine eye drops. The contralateral eye, used as control, was left untreated. Conjunctival swabs of both eyes were collected at the baseline visit and after three days of treatment, just before the cataract surgery. A qualitative and quantitative microbiological analysis of bacterial presence was evaluated by means of bacterial culture, followed by identification. Methicillin resistance determination was also performed on staphylococci isolates. Bacterial load before and after treatment of the eye candidate for cataract surgery was evaluated and compared to the untreated eye. A reduction or no regrowth on the culture media of the bacterial load was observed in 100% of the study subjects. A great heterogenicity of bacterial species was found. The 0.66% povidone-iodine eye drops, used for three days prior to cataract surgery, were effective in reducing the conjunctival bacterial load. The 0.66% povidone-iodine eye drops (IODIM^®) might represent a valid perioperative prophylactic antiseptic adjuvant treatment to protect the ocular surface from microbial contamination in preparation of the surgical procedure.

Subthreshold Nanosecond Laser, from Trials to Real-Life Clinical Practice: A Cohort Study

Background

Age-related macular degeneration (AMD), a degenerative disorder, is a major cause of irreversible severe visual deterioration in the older Western population. Thus, treatments that resolve drusen may prove helpful in limiting the progression of AMD. The study aimed to evaluate the clinical outcome of sub-threshold nanosecond laser therapy (SNL) using a double-frequency nanosecond-pulsed laser with discontinuous energy beam distribution in the early stages of age-related macular degeneration (AMD).

Methods

In a single-center cohort study, 64 eyes with early or intermediate AMD were treated using SNL and then compared to 77 untreated, control eyes. The primary outcome measures included the area and amount of drusen, and the secondary outcome measures included change in visual acuity and rate of drusen progression within 6 months of follow-up.

Results

A total of 64 patients’ eyes following SNL treatment showed a significant reduction in the area and amount of drusen after 6 months in comparison to the corresponding values in the control group (p<0.001, respectively). There was no significant difference in visual acuity change after 6 months in both groups (p\documentclass[12pt]{minimal} \usepackage{wasysym} \usepackage[substack]{amsmath} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage[mathscr]{eucal} \usepackage{mathrsfs} \DeclareFontFamily{T1}{linotext}{} \DeclareFontShape{T1}{linotext}{m}{n} {linotext }{} \DeclareSymbolFont{linotext}{T1}{linotext}{m}{n} \DeclareSymbolFontAlphabet{\mathLINOTEXT}{linotext} \begin{document} $$ \ge $$ \end{document}0.59, respectively). Within the 6-month follow-up, the rate of progression in drusen size and number was significantly lower in the SNL group (26%) than in the control group (69%; p<0.001).

Discussion

SNL therapy is a novel, promising approach for improving the macular morphology in patients with early and intermediate AMD. Further studies are necessary to reveal the potential to reduce the risk of transformation into advanced or wet AMD and to retain vision.

The clinical and pathogenic spectrum of surgically-induced scleral necrosis: A review

The onset of scleral necrosis after ocular surgery may have catastrophic ocular and systemic consequences. The two most frequent surgeries causing surgically-induced scleral necrosis (SISN) are pterygium excision and cataract extraction. Several pathogenic mechanisms are involved in surgically induced scleral necrosis. All of them are poorly understood. Ocular trauma increasing lytic action of collagenases with subsequent collagen degradation, vascular disruption leading to local ischemia, and immune complex deposition activating the complement system represents some of the events that lead to scleral necrosis. The complex cascade of events involving different pathogenic mechanisms and the patient's abnormal immune response frequently leads to delayed wound healing that predisposes the development of scleral necrosis. The management of SISN ranges from short-term systemic anti-inflammatory drugs to aggressive immunosuppressive therapy and surgical repair. Therefore, before performing any ocular surgery involving the sclera, a thorough ophthalmic and systemic evaluation must be done to identify high-risk patients that may develop SISN.

Safety Recommendations and Medical Liability in Ocular Surgery during the COVID-19 Pandemic: An Unsolved Dilemma

Ocular surgery is one of the most performed medical procedures in the world. Its limitation or suspension, recursively extended over time, could be associated with a significant increase in the number of blind people worldwide. Indeed, cataract causes more than half of all cases of visual impairment in those countries with limited availability of means for performing eye operations (e.g., Africa or India). In this scenario, the pandemic of coronavirus disease 2019 (COVID-19) quickly resulted in the suspension or sharp reduction of various ophthalmic activities considered non-urgent, including lens replacement surgery or some intraocular injections. Despite the imperative need to continuously practice eye operations to avoid the abovementioned problems, there are currently little-shared and vague recommendations among the various countries on safety in operating rooms (for health care workers and patients) and poor legal protection for surgeons (potentially transmitting the COVID-19 infectious agent). Herein, we individuated and discussed some critical points in safety recommendations and medical liability. A paradigm shift for ocular surgery during the COVID-19 era is now mandatory. While telemedicine has been able to solve some problems in clinical ophthalmology, the lack of adequate health and legal protection for surgeons and patients may result in an excessive reduction in the volume of surgical interventions during a pandemic era and the immediately following period, thus determining inability to ensure health care to all patients.

Perioperative Management of Antiplatelet Therapy in Ophthalmic Surgery

Many patients undergoing ophthalmic surgery are elderly with comorbidities requiring antiplatelet therapy to prevent thromboembolic or atherothrombotic events. The use of antiplatelet therapy has expanded over the years, predisposing these patients to hemorrhagic complications perioperatively. The risk of hemorrhagic complications must be weighed against the risk of thromboembolic events with cessation of antiplatelet therapy. The decision to continue or interrupt antiplatelet therapy in the setting of ophthalmic surgery is based upon various factors, including the type of surgery and each patient’s comorbidities. This review examines the risks of thrombotic complications versus hemorrhagic complications in different types of ophthalmic surgeries with the use of antiplatelet medications and provides evidence-based recommendations regarding perioperative management of antiplatelet therapy

Visual and vestibular functioning, and age and surgery effects on postural control in healthy children with vertical strabismus

Purpose:

To describe visual and vestibular functioning and the effects of age and surgery effects on postural control in healthy children with vertical strabismus.

Design:

This is a comparative case series.

Methods:

We evaluated participants at the Scientific Institute Eugenio Medea during routine clinical activities. We enrolled 30 consecutive children/adolescents (age range 4–13 years) with isolated vertical strabismus, with and without corrective surgery. Participants were split into four subgroups according to age (4–8 years versus 9–13 years) and ocular surgery (surgery versus no surgery). The clinical protocol included ophthalmological, orthoptic, neurological, physiatrical, otolaryngological, and vestibular evaluations, and the instrumental protocol included ocular cyclotorsions assessment, posturography, and vestibular myogenic-evoked potentials. Main outcome measures of the study were the prevalence of study-relevant orthopedic, ocular, vestibular, and posturographic abnormalities.

Results:

Among the overall largely variable findings across patients’ groups, we found some interesting trends: larger binocular vision and convergence disorders in younger children, smaller prevalence of asymmetric vestibular-evoked potentials in operated children, less posturographic abnormalities in younger children. No clear-cut beneficial effect of surgery was found on all clinical and instrumental parameters considered, despite good re-alignment of the eyes.

Conclusion:

The pathophysiology of postural control in vertical strabismus is extremely complex and above the potential of this study design and should be specifically addressed in deeper experimental studies.

Nanoscale Topographical Characterization of Orbital Implant Materials

The search for an ideal orbital implant is still ongoing in the field of ocular biomaterials. Major limitations of currently-available porous implants include the high cost along with a non-negligible risk of exposure and postoperative infection due to conjunctival abrasion. In the effort to develop better alternatives to the existing devices, two types of new glass-ceramic porous implants were fabricated by sponge replication, which is a relatively inexpensive method. Then, they were characterized by direct three-dimensional (3D) contact probe mapping in real space by means of atomic force microscopy in order to assess their surface micro- and nano-features, which were quantitatively compared to those of the most commonly-used orbital implants. These silicate glass-ceramic materials exhibit a surface roughness in the range of a few hundred nanometers (S_q within 500–700 nm) and topographical features comparable to those of clinically-used “gold-standard” alumina and polyethylene porous orbital implants. However, it was noted that both experimental and commercial non-porous implants were significantly smoother than all the porous ones. The results achieved in this work reveal that these porous glass-ceramic materials show promise for the intended application and encourage further investigation of their clinical suitability.

Treatment with platelet-rich plasma of surgically related dormant corneal ulcers

PURPOSE

To assess the effectiveness of autologous platelet-rich plasma for the treatment of dormant corneal ulcers secondary to corneal surgery and unresponsive to conventional treatment.

SETTING

VISSUM, Ophthalmology Institute of Alicante, Alicante, Spain.

DESIGN

Prospective nonrandomized, observational consecutive study.

METHODS

A total of 44 eyes of 28 patients with dormant corneal ulcers secondary to corneal surgery were included in a prospective study and treated with autologous platelet-rich plasma during 6 weeks. Wilcoxon signed-rank test was used to compare the effect of the treatment.

RESULTS

In all, 28 patients (65.1%) improved their visual acuity at least one line in Snellen chart, 26 (59.09%) had a decrease in the size of the ulcer or even a total closure, and 40 (90.9%) experienced an improvement in their symptoms. The results are also provided for the four groups of patients (keratoplasty, refractive surgery, cross-linking, and chronic postsurgical corneal edema).

CONCLUSION

Platelet-rich plasma eye drops shows to be a good option for the treatment of dormant corneal ulcers secondary to corneal surgery.

Rudolf Ulrich Krönlein (1847-1910): An Innovative General, Thoracic, Neuro, and Ocular Surgeon

The Swiss Professor Rudolf Ulrich Krönlein (1847-1910) was a pioneer in many fields of surgery, because he succeeded in introducing many innovations in different fields of surgery, for example, general surgery, thoracic surgery, neurosurgery, and ocular surgery. He was a reputable Professor of Surgery at Zurich University and was nominated for Nobel Prize in 1902.

Efficacy of sevoflurane as an adjuvant to propofol-based total intravenous anesthesia for attenuating secretions in ocular surgery

BACKGROUND

The incidence of nasal secretions into the operative field is as high as 5% in ophthalmic surgery under general anesthesia. It may induce postoperative endophthalmitis. Secretions under propofol-based total intravanous anesthesia (TIVA) are greater than sevoflurane anesthesia during surgery. Postoperative nausea and vomiting (PONV) after inhalational anesthesia is higher than TIVA and may increase intraocluar pressure. We investigated the effect of sevoflurane combination with propofol-based TIVA on nasopharyngeal secretions and PONV in ocular surgery.

METHODS

Fifty patients undergoing ocular operations were randomly assigned for propofol-based TIVA or propofol/sevoflurane anesthesia. In the TIVA group (n = 25), anesthesia was induced and maintained with propofol and fentanyl; in the propofol/sevoflurane group (n = 25), 1% sevoflurane anesthesia was added.

RESULTS

Nasopharyngeal excretion volume was significantly higher in the propofol-based TIVA group than in the propofol/sevoflurane group (31.0 ± 18.1 vs 13.7 ± 12.6 ml; P < .001). No significant difference in extubation time was noted (propofol-based TIVA: 6.4 ± 3.6 vs propofol/sevoflurane: 7.4 ± 3.0 minutes; P = .34). No postoperative endophthalmitis or PONV in both groups was observed.

CONCLUSION

Sevoflurane attenuated secretions under propofol-based TIVA and did not increase the incidence of PONV or prolonged extubation in ocular surgery.

The Effect of Chronic Alcoholism on the Conjunctival Flora

AIM

We aimed to investigate the effect of alcohol abuse on the conjunctival flora.

MATERIALS AND METHODS

The cases were evaluated as two groups. The study group consisted of 55 heavy-drinking males diagnosed with alcohol abuse, while the control group consisted of 55 males without a history of alcohol abuse. Samples were taken from the inferior fornix conjunctiva with sterile cotton-tipped swabs (Amies transport medium) for culture. The samples were inoculated into blood agar, chocolate agar, eosine methylene blue agar and Saboraud-Dextrose agar (Oxoid/UK) with the dilution method.

RESULTS

The microorganisms that grew in study group subjects were Coagulase Negative Staphylococcus (CNS) in 30 (54.5%), Staphylococcus aureus in 14 (25.5%), Moraxella spp. in 3 (5.5%), Streptococcus spp. in 3 (5.5), Bacillus spp. in 3 (5.5%), Corynebacterium spp. in 3 (5.5%), Candida spp. in 3 (5.5%), Haemophilus spp. in 2 (3.6%), Acinetobacter spp. in 2 (3.6%), Neisseria spp. in 1 (1.8%) and Micrococcus spp. in 1 (1.8%). The results for control group were CNS in 31 (56.4%), Bacillus spp. in 7 (12.7%), S. aureus in 5 (9.1%), and Corynebacterium spp. in 2 (3.6%). Moraxella spp., Streptococcus spp., Candida spp., Haemophilus spp., Acinetobacter spp., Neisseria spp. and Micrococcus spp. microorganisms grew in the conjunctival flora samples of the study group but not in the control group. S. aureus colonization was significantly higher in the study group than the control group (p < 0.05).

CONCLUSION

The S. aureus colonization rate was statistically significantly higher in the study group. Some microorganisms only grew in the conjunctival flora samples of the study group. These findings indicate that the conjunctival flora in persons with chronic alcoholism is different than the normal population.

Incidence and Determinants of Endophthalmitis within 6 Months of Surgeries over a 2-Year Period at King Khaled Eye Specialist Hospital, Saudi Arabia: A Review

BACKGROUND

We present the incidence and determinants of endophthalmitis between July 2010 and June 2012 at King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia. On its basis, we recommended recommendations to strengthen the infection prevention and control strategies.

METHODS

This is a retrospective review of health records type of study. The details of cases reported having endophthalmitis among those operated in 2 years of study period were studied. The incidence of endophthalmitis was calculated for different eye surgeries and epidemiological variables. The causative organisms in vitreous tap were reviewed. The visual outcomes 6 weeks following intervention/treatment of endophthalmmitis were also studied.

RESULTS

Of the 22,554 cases operated, 17 developed endophthalmitis. The incidence was 0.08% (95% confidence interval [CI] 0.04-0.11). The incidence of endophthlamitis among cataract surgeries was 0.12% (95% CI 0.04-0.21). Five specimens did not show any bacteria or fungus. Staphylococcus epidermis (3 cases) was the main pathogen identified. In 8 (47%) eyes, vision deteriorated in spite of treatment. In 5 (29%) eyes, it became stable and in 4 (23.5%) eyes, it improved following treatment. Signs of infection were noted in 1(st) week, 3 weeks and 12 weeks in 4, 6 and 5 eyes respectively. Late presentation of infection (6 months postoperatively) was reported in two eyes.

CONCLUSIONS

A vigilant infection control unit in a large eye hospital helps in monitoring endophthalmitis related catastrophes and suggests timely preventive measures to reduce the occurrence and appropriate measures to limit visual disabilities following eye surgery related endophthalmitis.

HIV and HBsAg Seropositivity Amongst Patients Presenting for Ocular Surgery at a Tertiary Eye Care Hospital in Nigeria

BACKGROUND

The prevalence of HIV/AIDS and HBsAg sero-positivity is very high in sub-Saharan African. There is a risk of horizontal transmission of these diseases amongst ophthalmic patients.

AIM

To determine the proportion patients for eye surgery who are HIV/AIDS and HBsAg sero-positive at the National Eye Centre, Kaduna, Nigeria.

METHODS

Patients selected for eye surgery during a surgical camp at the National Eye Centre, Kaduna were counseled for Voluntary Counseling and Testing (VCT) and HBsAg to determine their viral status.

RESULTS

A total of 650 patients who were selected were screened. The distributions of the indications for selection were as follows: cataract 483 (74.3%); glaucoma 44 (6.8%) and pterygium 123 (18.9%). Two patients (0.2%) were found to be HIV seropositive while 11 (1.5%) were HbsAg positive.

CONCLUSION

Pre-operative screening of all patients going for ophthalmic surgery for HIV and HbsAg may be desirable in our environment.

Laser in situ keratomileusis in patients with collagen vascular disease: a review of the literature

PURPOSE

To evaluate the current United States Food and Drug Administration (FDA) recommendations regarding laser in situ keratomileusis (LASIK) surgery in patients with collagen vascular diseases (CVD) and assess whether these patients make appropriate candidates for laser vision correction, and offer treatment recommendations based on identified clinical data.

METHODS

A literature search was conducted using PubMed, Medline, and Ovid to identify all existing studies of LASIK in patients with collagen vascular diseases. The search was conducted without date limitations. Keywords used for the search included MeSH terms: laser in situ keratomileusis, LASIK, refractive surgery, ocular surgery, and cataract surgery connected by "and" with the following MeSH and natural-language terms: collagen vascular disease, rheumatic disease, systemic disease, rheumatoid arthritis, systemic lupus erythematosus, Sjögren's syndrome, seronegative spondyloarthropathy, HLA B27, ankylosing spondylitis, reactive arthritis, psoriatic arthritis. The abstracts for all studies meeting initial search criteria were reviewed; relevant studies were included. No prospective studies were found; however, four retrospective case studies were identified that examined LASIK surgery in patients with CVD. Several case reports were also identified in similar fashion.

RESULTS

The FDA considers CVD a relative contraindication to LASIK surgery, due largely to the ocular complications associated with disease in the CVD spectrum. However, recent studies of LASIK in patients with CVD indicate LASIK may be safe for patients with very well-controlled systemic disease, minimal ocular manifestations, and no clinical signs or history of dry-eye symptoms.

CONCLUSION

LASIK surgery may be safe in patients with rheumatoid arthritis or systemic lupus erythematosus and the seronegative spondyloarthropathies if stringent preoperative criteria are met. Evidence suggests patients with Sjögren's syndrome are not suitable candidates for LASIK.

Evaluation of nepafenac in prevention of macular edema following cataract surgery in patients with diabetic retinopathy

Background

The purpose of this study was to evaluate nepafenac ophthalmic suspension 0.1% (Nevanac^®; Alcon Research Ltd) in the prevention of macular edema following cataract surgery in diabetic retinopathy patients.

Methods

This was a multicenter, randomized, double-masked, vehicle-controlled study of 263 adult diabetic patients with nonproliferative diabetic retinopathy requiring cataract surgery. Patients were randomized (1:1) to instill nepafenac or vehicle three times daily beginning 1 day prior to surgery through day 90. Efficacy included the percentage of patients who developed macular edema (≥30% increase in central subfield macular thickness from baseline) and the percentage of patients with decreases of more than five letters in best-corrected visual acuity from day 7 to 90.

Results

A significantly lower percentage of patients in the nepafenac group developed macular edema relative to patients in the vehicle group (3.2% versus 16.7%; P < 0.001). A significantly lower percentage of patients in the nepafenac group had best-corrected visual acuity decreases of more than five letters relative to patients in the vehicle group on day 30 (P < 0.001), day 60 (P = 0.002), and day 90 (P = 0.006). The mean central subfield macular thickness and mean percent change from baseline in macular volume were also significantly lower in the nepafenac group versus the vehicle group at days 14 through 90 (P ≤ 0.005). No safety issues or trends were identified when dosing was increased to 90 days that negatively impacted the favorable benefit/risk profile of nepafenac.

Conclusion

Nepafenac demonstrated statistically significant and clinically relevant advantages compared with vehicle in preventing macular edema and maintaining visual acuity in diabetic patients following cataract surgery. These advantages were seen at multiple time points over the course of the 90-day therapy period. There was no clinically relevant increase in risk from 90 days dosing compared with 14 days. Therefore, with a similar safety profile and benefit in preventing macular edema and maintaining vision, the risk/benefit to the diabetic patient undergoing cataract surgery appears to be positive.

Botulinum toxin injections for blepharospasm prior to ocular surgeries

PURPOSE

The aim of this study was to show the efficiency of preoperative botulinum toxin A (Botox A) in patients with benign essential blepharospasm who were to undergo ocular surgery with local anesthesia.

MATERIALS AND METHODS

Twenty-eight benign essential blepharospasm patients who were administered unilateral Botox A prior to ocular surgery between January 2004 and May 2011 were included in this study. Eleven cases had pterygiums, ten had cataracts, and four had glaucomas, while the remaining three had aphakia. All cases' severity of spasm (stage 0-4) and eyelid closing forces (stage 1-4) were evaluated according to the Jankovic scale prior to the injection, at 3 days, 14 days, 1 month, and 3 months after Botox A injection.

RESULTS

Of the patients enrolled in the study, 16 were female and 12 were male, with an average age of 55.52 ± 1.53 years (52-65). Average onset of the Botox injection's effect was 2.8 ± 0.9 (2-5) days. Its effect lingered for about 11.5 ± 3.6 (8-22) weeks. The severity of spasm and eyelid closing forces of all the patients enrolled were compared prior to the injection at 3 and 14 days and the first and third months after the injection. There were statistically significant differences between prior to the injection and 3 days (P = 0.001), 14 days (P < 0.001) and 1 month after the injection (P < 0.001). There was no statistically significant difference between prior to the injection and 3 months after the injection (P = 0.513). Fourteen days following the injection, the surgeries were successfully performed.

CONCLUSION

Botox A administered prior to ocular surgery will control both blepharospasm and lower the risks that can be encountered before and during surgery, thus increasing the comfort of the patient and the surgeon.

Evaluation of tensile strength of tissue adhesives and sutures for clear corneal incisions using porcine and bovine eyes, with a novel standardized testing platform

BACKGROUND

Tissue adhesives for ophthalmologic applications were proposed almost 50 years ago, yet to date no adequate tissue glues have been identified that combine strong sealing properties with adequate safety and absence of postsurgical side effects. In recent years, cataract surgeries and Descemet's stripping with endothelial keratoplasty procedures have significantly increased the number of clear corneal incisions performed. One of the obstacles to discovery and development of novel tissue adhesives has been the result of nonstandardized testing of potential tissue glues.

METHODS

We developed an instrument capable of controlling intraocular pressure in explanted porcine and bovine eyes in order to evaluate sealants, adhesives, and surgical closure methods used in ophthalmic surgery in a controlled, repeatable, and validated fashion. We herein developed and validated our instrument by testing the adhesive properties of cyanoacrylate glue in both porcine and bovine explant eyes.

RESULTS

The instrument applied and maintained intraocular pressure through a broad range of physiological intraocular pressures. Cyanoacrylate-based glues showed significantly enhanced sealing properties of clear corneal incisions compared with sutured wounds.

CONCLUSION

This study shows the feasibility of our instrument for reliable and standardized testing of tissue adhesive for ophthalmological surgery.

Ex vivo corneal epithelial wound healing following exposure to ophthalmic nonsteroidal anti-inflammatory drugs

Purpose:

Ketorolac 0.45% is a new formulation of topical ketorolac in which preservative (benzalkonium chloride, BAK) was removed and carboxymethylcellulose (CMC) was added to improve tolerability and reduce dosing frequency. This study compared the effects of ketorolac 0.45% on corneal wound healing to prior ketorolac formulations (0.4% and 0.5%), bromfenac 0.09%, and nepafenac 0.1%.

Methods:

Two parallel-group comparisons were performed in series. A 5-mm central epithelial wound was made in fresh porcine corneas. After 24 hours in minimum essential medium (MEM), corneas were incubated for 10 minutes with study drugs, Triton X-100 1% (positive control), or MEM (negative control), followed by 24 hours in MEM. The remaining wound area was stained, photographed, and quantified (pixels). Study 1 compared ketorolac 0.45% to ketorolac 0.4% and ketorolac 0.5%. Study 2 compared ketorolac 0.45% to bromfenac 0.09% and nepafenac 0.1%.

Results:

The mean (±SD) original wound area was 200,506 ± 4,363 pixels, which was reduced to 59,509 ± 4850 at 48 hours after exposure to Triton X-100 1%. In study 1, the mean remaining wound areas at 48 hours in pixels were 2969 ± 1633 with MEM, 586 ± 299 with ketorolac 0.45% (significantly reduced, P < 0.05 vs all other treatments), 10,228 ± 7541 with ketorolac 0.4%, and 50,674 ± 33,409 with ketorolac 0.5% (significantly enlarged, P < 0.05 vs MEM). In study 2, the mean remaining wound areas at 48 hours were 565 ± 1263 with MEM, 322 ± 229 with ketorolac 0.45% (significantly reduced, P < 0.01 vs bromfenac 0.09% and nepafenac 0.1%), 29,093 ± 14,295 with bromfenac 0.09% (significantly enlarged, P <0.01 vs MEM) and 47,322 ± 13,736 with nepafenac 0.1% (significantly enlarged, P < 0.01 vs MEM and vs bromfenac 0.09%).

Conclusion:

Corneas treated with ketorolac 0.45% healed as rapidly as those treated with MEM, likely secondary to addition of CMC and removal of BAK. In the ex vivo corneal organ culture model, ketorolac 0.45% had statistically less impact on corneal re-epithelialization than prior ketorolac formulations (0.4% and 0.5%), bromfenac 0.09%, and nepafenac 0.01%.

A novel lidocaine hydrochloride ophthalmic gel for topical ocular anesthesia

Topical anesthetics play an important role in the practice of ophthalmology, both for procedures in the office and in the operating room. The need for safe, long-acting topical ocular anesthetic agents is ongoing, and has been highlighted by the increase of intravitreal administration of pharmacologic agents. Current practices for ocular anesthesia include subconjunctival injection of 2% aqueous lidocaine, topical 2% lidocaine drops and topical 0.5% tetracaine. Tetracaine is not yet FDA approved, and is associated with corneal epithelial toxicity and delayed epithelial healing after multiple administrations. Lidocaine jelly (2%) preparations have been reported to be beneficial in several systemic procedures, including those of the upper airway, dental, urogenital, and gastrointestinal. It has been theorized, and recent studies support the idea, that gel formulations of lidocaine may enhance anesthetic effect, and therefore be superior to anesthetic solutions for topical cataract surgery. The viscous nature of gel formulations is thought to lengthen contact time, resulting in better anesthesia at lower drug concentrations. Furthermore, several studies suggest that lidocaine is bactericidal and bacteriostatic, and may have a supplementary role in preventing and treating surgical site infections. Akten™, lidocaine 3.5% gel (Akorn, Buffalo Grove, IIlinois) was FDA approved for all ophthalmic procedures in October 2008. This gel is a preservative-free, lidocaine-based anesthetic gel consisting of 35 mg/mL of lidocaine hydrochloride. We describe the properties, including chemical structure, indications, evidence of support, use, adverse effects, and precautions, which we believe enable Akten to provide superior anesthesia, while minimizing side effects.

Perioperative visual loss in ocular and nonocular surgery

Incidence estimates for perioperative vision loss (POVL) after nonocular surgery range from 0.013% for all surgeries up to 0.2% following spine surgery. The most common neuro-ophthalmologic causes of POVL are the ischemic optic neuropathies (ION), either anterior (AION) or posterior (PION). We identified 111 case reports of AION following nonocular surgery in the literature, with most occurring after cardiac surgery, and 165 case reports of PION following nonocular surgery, with most occurring after spine surgery or radical neck dissection. There were an additional 526 cases of ION that did not specify if the diagnosis was AION or PION. We also identified 933 case reports of central retinal artery occlusion (CRAO), 33 cases of pituitary apoplexy, and 245 cases of cortical blindness following nonocular surgery. The incidence of POVL following ocular surgery appears to be much lower than that seen following nonocular surgery. We identified five cases in the literature of direct optic nerve trauma, 47 cases of AION, and five cases of PION following ocular surgery. The specific pathogenesis and risk factors underlying these neuro-ophthalmic complications remain unknown, and physicians should be alert to the potential for loss of vision in the postoperative period.