Ophthalmic Procedures Research Articles

Comparing Different Decontamination Procedures in Harvesting Human Donor Cornea

ABSTRACTPurpose: To evaluate the effects of current hygiene standards for the enucleation of postmortem eyes by investigating the number of microorganisms during subsequent steps of decontamination and tissue processing.Materials and methods: This prospective, non-randomized cohort study includes 184 postmortem eyes of 92 human donors. Enucleation was performed, according to an ophthalmic surgical procedure. Two groups were generated as follows: right eyes were allocated to group A, left eyes were allocated to group B. In group A, a mucosal disinfectant was used accessorily. Conjunctival smears were taken to examine germ load in both groups before any intervention, in group A after mucosal disinfection, in both groups after transportation of the whole globes in transport fluid, and in both groups after a bath in 0.75% povidone iodine solution for at least 3 minutes just before preparation of the corneoscleral disc. Smears were sent to the local microbiologic laboratory in an aseptic package for testing.Results: All smears showed multiple contaminations (n = 184/184 eyes) before treatment with povidone iodine solution. Contamination was in both groups significantly prevented using the treatment strategy of an at least 3-minute bath in 0.75% povidone iodine solution (n = 1/184 eyes; p < 0.01) As a side effect, almost every eye of group A and none of group B showed brown iodine staining corresponding to corneal epithelial erosion.Conclusions: An aseptic setting for donor enucleation similar to a surgical procedure seems not to influence the outcome of germ colonization. The most effective step to decontaminate donor eyes is to use 0.75% povidone iodine solution for at least 3 minutes.

Update and review of Urrets-Zavalia syndrome.

For more than half a century, Urrets-Zavalia syndrome (fixed dilated pupil) has been described as a postoperative complication of ophthalmic surgery. Since first reported as a complication of penetrating keratoplasty for keratoconus in patients receiving atropine, the characteristic features of Urrets-Zavalia syndrome have been expanded. In previous literature, a total of 110 cases resulted in a fixed and dilated pupil. Increased intraocular pressure (IOP) in the immediate postoperative period, phakia, and air or gas in the anterior chamber appear to be the most important risk factors for Urrets-Zavalia syndrome following ophthalmic procedures. Mannitol, IOP control, the removal of air or gas in the anterior chamber, and iridectomy have all demonstrated utility in managing Urrets-Zavalia syndrome.

Stability of Reconstituted and Diluted Mitomycin C Solutions in Polypropylene Syringes and Glass Vials

Abstract: Mitomycin C (MMC) is widely used in treatment of non-muscle invasive bladder cancer at a 1 mg/mL concentration, by intravesical instillation. MMC is also used as an ophthalmic procedure in glaucoma care mostly with 0.2 mg/mL concentration. To accelerate syringes provision, it could be interesting to demonstrate the stability of the drug, in order to be able to prepare the chemotherapeutic drug several hours before the chemotherapy administration.: A stability indicating HPLC-UV method was developed and validated according to the ICH guidelines. Concentrations of the MMC stored at 25 °C and 60 % of relative humidity and protected from light in polypropylene syringes (1 mg/mL and 0.2 mg/mL) or glass vials (1 mg/mL) were evaluated for 96 h and compared to the initial observed concentrations.: MMC stability was demonstrated in syringes and glass vials at 1 mg/mL only for 8 h in water for injections and for 10 h at 0.2 mg/mL in 0.9 % sodium chloride solutions, because relative concentrations (95 % confidence interval of the mean of 3 samples) were systematically over 90 % of the initial concentrations. After 96 h the relative concentrations were found below 80 % as compared to initial concentrations, thus indicating instability of these solutions. Degradation products were observed and remained below 3 %.: This study confirms that MMC solutions for ophthalmic application at 0.2 mg/mL or vesical instillation at 1 mg/mL have to be formulated extemporaneously to maintain the desired concentration.

The risk of macular degeneration development in persons antenatally irradiated as a result of Chornobyl NPP accident

Assess the risk of macular degeneration development in persons exposed in utero as a result of Chornobyl NPP accident. The object of the study was the state of the macular area of the retina of 84 individuals exposed in utero as a result of the Chornobyl disaster. They were surveyed at the age of 14-30. The results of stan dardized ophthalmic examinations conducted between 2000 and 2016 were used. The control group consisted of 165 persons who have not undergone prenatal exposure and were examined at the same age as the core group. All patients were examined according to the formalized ophthalmic protocol procedure, examination included ophthal moscopy and fundus camera photography (VISUCAM lite Digital Camera, Zeiss). Statistical analysis of the survey results was carried out using the free trial version of «Open Epi 2.2.1» software package. It is shown that the prevalence of macular degeneration of the retina at the age of 14-30 for persons exposed in utero was 95.23 ± 32.03 in 1000 and compared with control age (17.86 ± 10.31 in 1000) was significant ly higher (χ2 = 7.827, p = 0.0026). In the under 30 age group of the antenatally exposed there already appear macular degenerations whose clinical picture resembles age related macular degeneration. It is proved that the prevalence of macular degeneration was significantly higher in the group of antenatally exposed as compared with non irradiated control at the same age.

Role of dexmedetomidine for sedation in a patient with schizophrenia for strabismus surgery.

Patients with schizophrenia are generally less suitable candidates for regional anaesthesia. Post-operative delirium is commonly seen in patients with schizophrenia after general anaesthesia. Dexmedetomidine is an alpha-2 adrenoreceptor agonist with sedative, analgesic and anxiolytic properties with minimal respiratory depression.[1,2] It provides conscious sedation and has been safely used for ophthalmic procedures including strabismus surgery.[3] The use of dexmedetomidine is associated with lesser incidence of post-operative delirium in comparison to propofol and midazolam.

Relocation consequences on an ophthalmology consultation service from an inpatient to outpatient facility.

ImportanceThis study shows that relocation of an academic ophthalmology residency program from an inpatient to an outpatient setting in western New York does not affect the consult volume but affects management patterns and follow-up rates.ObjectiveTo investigate the effects on the ophthalmology consultation service of an academic program with relocation from a Regional Level-1 Trauma center to an outpatient facility.DesignConsultation notes from 3 years before and 3 years after the University at Buffalo’s (UB) Department of Ophthalmology relocation from a Regional Level-1 Trauma center (Erie County Medical Center) to an outpatient facility (Ross Eye Institute) were obtained from hospital electronic medical records and analyzed.SettingHospitalized care and institutional practice.ParticipantsAll inpatient or Emergency Room Ophthalmology consultation patients from the Department of Ophthalmology at UB from 2004 to 2010 (1,379 patients).ExposuresNone, this was a retrospective chart review.Main outcome measuresPatient demographics, reason for consult, diagnoses, and ophthalmic procedures performed by the UB Department of Ophthalmology before and after its relocation.ResultsRelocation to the outpatient facility did not affect consult volume (P=0.15). The number of consults focusing on ophthalmic conditions, as a percentage of the yearly total, rose 460% (P=0.0001), while systemic condition consults with ocular manifestations fell 83% (P=0.0001). Consults for ocular trauma decreased 65% (P=0.0034). Consults ending with a diagnosis of “normal exam” fell, as a percentage of the yearly total (56%, P=0.0023), while diagnoses of new ocular conditions rose 17% (P=0.00065). The percentage of consults for Medicaid patients fell 12% (P=0.0001), while those for privately insured patients rose 15% (P=0.0001). The number of ophthalmic procedures did not change, but postconsult patient follow-up fell from 23% at the Erie County Medical Center clinic to 2% after the move to Ross Eye Institute, a ≥97% decrease.Conclusion and relevanceRelocation of UB’s academic Ophthalmology program from an inpatient department to an outpatient facility had no effect on its consultation patient or procedure volume, but it significantly affected the nature of consult diagnoses and decreased outpatient follow-up by >90% at the latter location. Many hospitals are creating separate outpatient facilities that may experience similar obstacles.

Ocular safety comparison of non-steroidal anti-inflammatory eye drops used in pseudophakic cystoid macular edema prevention

Non-steroidal anti-inflammatory drug (NSAID) eye drops are widely used to treat ocular inflammatory conditions related to ophthalmic surgical procedures, such as pseudophakic cystoid macular edema, and they have been used for off-label treatments. The most commonly used NSAIDs are diclofenac and ketorolac and the new molecules bromfenac and nepafenac have also been used. We used primary human keratocytes in cell culture in combination with a novel technology that evaluates dynamic real-time cytotoxicity through impedance analysis. This study also included classic cell viability tests (WST-1® and AlamarBlue®), wound healing assay, Hen’s Egg Test and an ex vivo histopathological assay. NSAIDs were shown to have important cytotoxicities and to retard the healing response. Furthermore, the new eye drops containing bromfenac and nepafenac were more cytotoxic than the more classical eye drops. Nevertheless, no immuno-histochemical changes or acute irritation processes were observed after the administration of any eye drops tested. Due to cytotoxicity and the total absence of discomfort and observable injuries after the administration of these drugs, significant corneal alterations, such as corneal melts, can develop without any previous warning signs of toxicity.

Postoperative Endophthalmitis: Incidence, Causes and Comparison Between Medical and Surgical Treatment in a United Kingdom Region in the Last 10 Years

PurposeTo investigate the incidence, procedures performed, isolated causative microorganisms if found and final visual outcome of Endophthalmitis in a UK tertiary referral centreMethodsA retrospective audit of all cases treated as postoperative endopthalmitis in the last 10 years has been performed. Details of each case (preceding ophthalmic procedure, isolated microorganisms, management plan and visual acuity before and after treatment) were recordedResultsSixty patients have been diagnosed with post‐operative Endophthalmitis over the audit period. Full data were available for 44 patients. Twenty‐four patients (54.54%) had intravitreal injections procedures (IVI) of Anti‐VEGF 4 weeks or less before day of presentation, eighteen patients (40.91%) had endophthalmitis following cataract surgery and 2 patients after trabeculectomy (4.55%). Incidence rates were calculated for cataract surgery and IVI in the last 5 years and were 0.024% and 0.048% respectively. All cases received intravitreal injections of antibiotics. Microorganisms were detected in 8 patients. There were 7 culture positive cases with coagulase negative staphylococcus aureus (6 cases after cataract operation, 1 after IVI) and one case with Staphylococcus Legdunens (after IVI). Eighteen patients presented with visual acuity of CF or worse. Eleven of them have been treated with vitrectomy (1st group) while the other seven have not (2nd group). Ten patients from the first group could achieve better visual acuity that that at the time of presentation, while only three patients of the second group showed improvement (p value = 0.04, Fisher Exact test)ConclusionsThe incidence of endophthalmitis in this audit is comparable to larger studies. Vitrectomy may be recommended for postoperative endophthalmitis patients with visual acuity of CF or worse.

Ophthalmic Procedures for Treatment of Advanced Ocular Surface Diseases.

Dry eye disease and other ocular surface diseases are complex multifactorial disorders often characterized by ocular surface inflammatory changes, instability of the tear film, and functional vision impairment. Recent research has led to new concepts regarding diagnosis and management, and therapeutic interventions now include ocular lubricants, secretagogues, topical and systemic anti-inflammatory and immunosuppressive agents, tear preservation, and, for advanced cases, a variety of surgical approaches. This review considers contemporary procedures for treatment of advanced ocular surface diseases, including thermal and electrocautery of the lacrimal puncta, lid surgeries such as tarsorrhaphy, and multiple procedures to protect the exposed or compromised ocular surface.

A cross‐sectional survey of optometrists and optometric practices in Ghana

PurposeThe study was conducted to profile optometrists and optometric practices in Ghana.MethodsAn online survey was conducted among 146 optometrists, who were registered with the Ghana Optometric Association (GOA). It included questions on their demographics, equipment, ophthalmic procedures routinely conducted and the barriers to providing a full scope of optometric services.ResultsNinety registered optometrists (62 per cent) responded, their mean age being 28.97 ± 3.36 years. There were more males (68.9 per cent) than females and most had the Doctor of Optometry (OD) degree, the profession's highest degree in Ghana. There were more practitioners in urban centres (71.1 per cent) and most practices had basic optometric instruments, such as direct ophthalmoscopes, slitlamp biomicroscopes and retinoscopes. Many optometrists routinely conducted direct ophthalmoscopy (100 per cent), slitlamp biomicroscopy (87.5 per cent) and contact tonometry (55.7 per cent); however, few provided contact lens (10.2 per cent) and low vision (9.1 per cent) assessments, with 76 per cent stating that it was due to the unavailability of low vision devices, poor sources of contact lenses (27 per cent) and perceived insufficient training (11.2 per cent). Many practitioners (97 per cent) reported the use of diagnostic pharmaceutical agents and therapeutic pharmaceutical agents (96.6 per cent). Most practitioners (52.9 per cent) preferred conferences for the delivery of continuous professional development over publications (26.4 per cent) and internet resources (12.6 per cent).ConclusionThe data elicited in this study provide a basis for addressing the country's unmet eye‐care needs and can be used to determine training and support guidelines for the profession.

Measuring localized viscoelasticity of the vitreous body using intraocular microprobes.

Vitrectomy is a standard ophthalmic procedure to remove the vitreous body from the eye. The biomechanics of the vitreous affects its duration (by changing the removal rate) and the mechanical forces transmitted via the vitreous on the surrounding tissues during the procedure. Biomechanical characterization of the vitreous is essential for optimizing the design and control of instruments that operate within the vitreous for improved precision, safety, and efficacy. The measurements are carried out using a magnetic microprobe inserted into the vitreous, a method known as magnetic microrheology. The location of the probe is tracked by a microscope/camera while magnetic forces are exerted wirelessly by applied magnetic fields. In this work, in vitro artificial vitreous, ex vivo human vitreous and ex vivo porcine vitreous were characterized. In addition, in vivo rabbit measurements were performed using a suturelessly injected probe. Measurements indicate that viscoelasticity parameters of the ex vivo human vitreous are an order of magnitude different from those of the ex vivo porcine vitreous. The in vivo intra-operative measurements show typical viscoelastic behavior of the vitreous with a lower compliance than the ex vivo measurements. The results of the magnetic microrheology measurements were validated with those obtained by a standard atomic force microscopy (AFM) method and in vitro artificial vitreous. This method allows minimally-invasive characterization of localized mechanical properties of the vitreous in vitro, ex vivo, and in vivo. A better understanding of the characteristics of the vitreous can lead to improvements in treatments concerning vitreal manipulation such as vitrectomy.

Ophthalmic regional blocks: management, challenges, and solutions.

In the past decade ophthalmic anesthesia has witnessed a major transformation. The sun has set on the landscape of ophthalmic procedures performed under general anesthesia at in-hospital settings. In its place a new dawn has ushered in the panorama of eye surgeries conducted under regional and topical anesthesia at specialty eye care centers. The impact of the burgeoning geriatric population is that an increasing number of elderly patients will present for eye surgery. In order to accommodate increased patient volumes and simultaneously satisfy administrative initiatives directed at economic frugality, administrators will seek assistance from anesthesia providers in adopting measures that enhance operating room efficiency. The performance of eye blocks in a holding suite meets many of these objectives. Unfortunately, most practicing anesthesiologists resist performing ophthalmic regional blocks because they lack formal training. In future, anesthesiologists will need to block eyes and manage common medical conditions because economic pressures will eliminate routine preoperative testing. This review addresses a variety of topical issues in ophthalmic anesthesia with special emphasis on cannula and needle-based blocks and the new-generation antithrombotic agents. In a constantly evolving arena, the sub-Tenon’s block has gained popularity while the deep angulated intraconal (retrobulbar) block has been largely superseded by the shallower extraconal (peribulbar) approach. Improvements in surgical technique have also impacted anesthetic practice. For example, phacoemulsification techniques facilitate the conduct of cataract surgery under topical anesthesia, and suture-free vitrectomy ports may cause venous air embolism during air/fluid exchange. Hyaluronidase is a useful adjuvant because it promotes local anesthetic diffusion and hastens block onset time but it is allergenic. Ultrasound-guided eye blocks afford real-time visualization of needle position and local anesthetic spread. An advantage of sonic guidance is that it may eliminate the hazard of globe perforation by identifying abnormal anatomy, such as staphyloma.

Anesthetic management of pediatric patients with Sturge-Weber syndrome: our experience and a review of the literature.

Sturge-Weber syndrome (SWS) is a rare sporadic congenital neurocutaneous syndrome which is characterized by vascular malformation involving the brain, face and eye. The anesthetic management is complicated by its localized as well as systemic manifestations, associated anomalies and difficult airway due to the presence of angiomas of the oral cavity and airway. We retrospective analyzed the perioperative anesthetic management of children with SWS undergoing ophthalmic surgery and reviewed the literature. Medical records and anesthetic charts of all the children with SWS who had undergone an ophthalmic procedure under general anesthesia during the past 6 years were reviewed. Information related to the demographic profile, preoperative evaluation, anesthetic techniques, and perioperative complications were collected and analyzed. Forty children with SWS received general anesthesia for an ophthalmic procedure within the 6-year period. The median age of the children was 3 years. 30 (92.5%) children had facial port-wine staining, 10 (25%) had facial hypertrophy, 15 (37.5%) had a history of convulsion and 4 (10%) children had mental retardation. Inhalational induction was performed in 34 (85%) children (sevoflurane 82.8%). A laryngeal mask airway (LMA) and endotracheal tube were used in 32 (80%) and 5 (12.5%) cases, respectively. One patient had difficult mask ventilation and difficult LMA insertion. There was no significant problem in any of the other children. Preoperative evaluation with airway assessment should be performed with the knowledge of local and systemic manifestation of the syndrome. Proconvulsant and anticonvulsant properties of the anesthetics, as well as drug interactions of antiepileptic medications should be considered when planning anesthesia. Avoiding a rise in intracranial and intraocular pressures, vigilant intraoperative monitoring and postoperative care are the key for conducting safe anesthesia in these children. For ophthalmic procedures, LMAs can be used for airway maintenance with minimal complications in children with SWS.

High-speed photorefractive keratectomy with femtosecond ultraviolet pulses.

Femtosecond near-infrared lasers are widely used for a number of ophthalmic procedures, with flap cutting in the laser-assisted in situ keratomileusis (LASIK) surgery being the most frequent one. At the same time, lasers of this type, equipped with harmonic generators, have been shown to deliver enough ultraviolet (UV) power for the second stage of the LASIK procedure, the stromal ablation. However, the speed of the ablation reported so far was well below the currently accepted standards. Our purpose was to perform high-speed photorefractive keratectomy (PRK) with femtosecond UV pulses in rabbits and to evaluate its predictability, reproducibility and healing response. The laser source delivered femtosecond 206 nm pulses with a repetition rate of 50 kHz and an average power of 400 mW. Transepithelial PRK was performed using two different ablation protocols, to a total depth of 110 and 150 μm. The surface temperature was monitored during ablation; haze dynamics and histological samples were evaluated to assess outcomes of the PRK procedure. For comparison, analogous excimer ablation was performed. Increase of the ablation speed up to 1.6 s/diopter for a 6 mm optical zone using femtosecond UV pulses did not significantly impact the healing process.

When Should We Perform Incisional Glaucoma Surgery?

Deciding when to perform glaucoma surgery can be challenging despite evidence in the literature supporting its safety and efficacy. In addition to clinical examination, visual field testing, and optic nerve imaging, other patient factors such as age, family history, and ocular comorbidities influence the decision-making process and are especially helpful in patients with borderline intraocular pressure and/or equivocal progression. The potential for a complicated postoperative course and lack of immediate visual benefit makes glaucoma surgery less straightforward than other ophthalmic procedures. The decision to operate is ultimately based on a discussion between each individual patient and the glaucoma surgeon, with careful consideration of disease severity, risk for progression, and quality of life.

Clinical Management of Malignant Glaucoma.

Malignant glaucoma remains one of the most challenging complications of ocular surgery. Although it has been reported to occur spontaneously or after any ophthalmic procedure, it is most commonly encountered after glaucoma surgery in eyes with prior chronic angle closure. The clinical diagnosis is made in the setting of a patent peripheral iridotomy and axial flattening of the anterior chamber. Intraocular pressure is usually elevated, but it may be normal in some cases. Although the exact etiology of this condition is not fully understood, several mechanisms have been proposed and it is thought to result from posterior misdirection of aqueous humor into or behind the vitreous. This review discusses pathophysiology, differential diagnosis, imaging modalities, and current treatment strategies for this rare form of secondary glaucoma.

The influence of the bispectral index in hospital time of patients undergoing ophthalmic procedures

The influence of the bispectral index in hospital time of patients undergoing ophthalmic procedures

Comprehensive monitored anesthesia care during day care ophthalmic surgery

Today elderly patients with complex health-related issues undergoing successfully a day care ophthalmic procedure are a common scenario. How can these high risk patients safely undergo an eye surgery and be back at home on the same day? This is possible, only when a well-planned, scientifically drawn protocol is in place at an institution. This plan of action takes into consideration every possible detail about the patient and also his or her special requirements if not demands. The anesthesiologist commands these well-set actions and guides the other health care staff to streamline the day care program, thereby sparing the busy ophthalmologist to attend to his clinical and surgical workload.

Regional anesthesia of the eye, orbit, and periocular skin

Advances in ophthalmic surgery, together with achieving greater patient safety, have changed the requirements of regional anaesthesia of the eye, orbit, and periocular skin. Patient comfort, safety, and low complication rates are essentials of regional anesthesia, which includes invasive procedures that generate intraoperative and postoperative analgesia, as well as akinesia. We present the currently used local anesthesia (topical and subcutaneous infiltration of local anesthetics) and regional anesthetic techniques in ophthalmic procedures, describing the techniques, advantages, disadvantages, and complications in ophthalmic regional blocks, as well as some educational measures to implement them to reduce the risk of ocular complications. Currently, there is no absolutely safe ophthalmic regional block, and the anesthetic modality should be assessed on a patient and surgeon basis.Local anesthesia is the reversible loss of sensation in certain area of the body to minimize pain and obtain patient comfort. It can be achieved through topical application or injection of anesthetic agents that block the nerve impulses to that tissue.

Has the time come for "medication tourism"?

Has the time come for "medication tourism"?