Ophthalmic Surgical Procedures Research Articles

Cosmetic blepharoplasty and dry eye disease: a review of the incidence, clinical manifestations, mechanisms and prevention.

Dry eye disease is a multifactorial disease of the ocular surface and can be caused by a variety of iatrogenic interventions, especially ophthalmic surgical procedures. This article reviews the incidence, clinical manifestations, mechanisms and prevention of dry eye disease caused or worsened by cosmetic blepharoplasty, and focus on how to reduce and prevent the occurrence of postoperative dry eye disease and provide the basis for the selection of operation methods and the rational drug during the perioperative period.

Postural Changes and the Trans–Lamina Cribrosa Pressure Difference: A Pilot Study in Neurosurgical Patients without Glaucoma

To evaluate the effect of changes in position in the trans-lamina cribrosa pressure difference (TLCPD) by simultaneously measuring and comparing intracranial pressure (ICP) with intraocular pressure (IOP) in seated and supine positions. Prospective cohort study. Patients admitted to the neurosurgery unit at Toronto Western Hospital with an external ventricular drain placed for ICP monitoring. Exclusion criteria were any ophthalmic surgical procedures within the preceding 6 months, history of glaucoma, and corneal abnormalities affecting IOP measurement. Intraocular pressure and ICP were recorded simultaneously in both the supine and seated positions with the order of positions randomized. Measurements were made 10 minutes after assuming each position. The TLCPD (IOP minus ICP) was calculated for the sitting and supine positions. The paired t test was used to assess significance of differences. The TLCPD. Twenty patients were included in the study. The average age was 54±17 years. Results were similar for left and right eyes. Data are shown for right eyes only. Mean sitting and supine IOPs were 15.3±3.5 mmHg and 15.9±3.7 mmHg, respectively (P= 0.32). Mean sitting and supine ICPs were 12.5±6.8 mmHg and 12.8±5.1 mmHg, respectively (P= 0.66). Mean TLCPD was 3.1±6.0 mmHg in the sitting position and 3.1±7.0 mmHg in the supine position (P= 1.00). Supine TLCPD increased in 10 patients (50%), decreased in 8 patients (40%), and was unchanged in 2 patients (10%). In this pilot study of 20 neurosurgical patients without glaucoma, posture-induced TLCPD changes were variable.

Surgical Confusions in Ophthalmology: Description, Analysis, and Prevention of Errors from 2006 through 2017

To characterize surgical confusions in ophthalmology to determine their incidence, root causes, and impact on patients and physicians. Retrospective cohort study of errors in ophthalmic surgical procedures between January 1, 2006, and December 31,2017. One hundred forty-three cases involving surgical confusions. Cases were identified by the Ophthalmic Mutual Insurance Company from closed case files and by the New York State Health Department from the New York Patient Occurrence Reporting and Tracking program that identified the surgical confusions. Incidence and impact by intended surgery, error type, and root cause as well as preventability by the Universal Protocol. Of the 143 cases of surgical confusions identified, 92 cases (64.3%) were deemed preventable by the Universal Protocol. Approximately two thirds, 95 cases (66.4%), were cases of incorrect implants being used during cataract surgery (cataract extraction and intraocular lens implantation), of which 33 cases (34.7%) were not preventable by the Universal Protocol. Wrong eye blocks or anesthesia accounted for 20 cases (14.0%), incorrect eye procedures accounted for 10 cases (7.00%), incorrect refractive surgery measurements accounted for 6 cases (4.20%), incorrect patient or procedure accounted for 5 cases (3.50%), incorrect intraocular gas concentration accounted for 4 cases (2.80%), and incorrect medication in surgery accounted for 3 cases (2.10%). The most common root cause of confusion was an inadequately performed time out, which was responsible for nearly one third of all surgical confusions, 46 cases (32.2%). Incorrect lens orders or calculations before surgery (so-called upstream errors) were the second most common cause of surgical confusion, involving 31 cases (21.7%). The average legal indemnity for incorrect implant during cataract surgery was $57 514 (United States dollars). The average indemnity for incorrect refractive surgery measurement was $123 125, that for incorrect eye procedure was $50 000, and that for incorrect gas concentration was $220 844. Most surgical confusions could have been prevented by following the Universal Protocol properly. However, upstream errors, originating in the clinic or office before surgery, and ineffective communication during time outs suggest a need for modification of the Universal Protocol.

Surgical casuistic in dogs at a Veterinary Hospital - Piauí State Federal University

The objective of this report was to record surgical procedures performed in 241 dogs in a teaching veterinary hospital. There were 40 elective surgical procedures (16.6%) and 201 therapeutic surgical procedures (83.4%). The most frequent procedure was ovariohysterectomy (OH), 65% (26/40) and 24.38% (49/201), respectively, for elective and therapeutic surgical procedures. Among therapeutic surgical procedures were registered fracture reduction (16.91%, 34/201), mastectomies (13.93%, 28/201), drainage of the otohematoma (12.94%; 26/201) and ophthalmic surgical procedures (5.47%, 11/201). The high percentage of therapeutic surgical procedures conducted demonstrates the complexity of the cases attended daily in a teaching veterinary hospital.

The Management of Childhood Intracranial Tumours and the Role of the Ophthalmologist

ABSTRACTObjective: This study looked at a single paediatric neuro-oncology centre’s experience of childhood intracranial tumours seen in the ophthalmology clinic over an approximately five-year period. This was used to analyse the role of the ophthalmologist in their long term follow up.Methods: A database was compiled of all children discussed at the neuro-oncology multi-disciplinary team (MDT) meeting between January 2012 and April 2017. All children who had an intracranial tumour determined by histology or suspected on neuro-imaging, who had also been seen in the ophthalmology clinic, were included. A retrospective case review was performed to create a record for each child.Results: The database contained 129 children of which 82 (64%) were boys and 47 (36%) were girls. Of these 89 (69%) had a histological diagnosis and 40 (31%) had a tumour suspected on neuroimaging. The most common tumour locations were the posterior fossa (n = 54, 42%), diencephalon (n = 20, 16%) and the visual pathways (n = 17, 13%). Papilloedema at first presentation was only found in 39 (30%) children. The most common other neuro-ophthalmic manifestations were non-paralytic strabismus (n=33), sixth nerve palsy (n=19) and seventh nerve palsy (n=12). Non-paralytic strabismus was a presenting symptom in only one case. There were 13 ophthalmic surgical procedures required for these children, the most common being strabismus surgery.Conclusion: We report the types and locations of paediatric intracranial tumours seen in the ophthalmology clinic as well as their neuro-ophthalmic manifestations. Only 30% presented with papilloedema and approximately 10% required an ophthalmic surgical procedure.

Commentary: Role of alpha-2 agonists in regional ophthalmic anaesthesia.

Regional anaesthesia is the most common mode of anaesthesia used in ophthalmic surgical procedures. Among regional blocks, peribulbar anaesthesia is the safest and most commonly employed. However, in procedures with prolonged operating time, such as vitreoretinal surgeries, repeated need for block supplementation and patient anxiety, are a challenge. Adjuvants to peribulbar anaesthetics, namely, hyaluronidase and adrenaline along with preoperative anxiolytics/sedatives have been tried to overcome these challenges.[1] Alpha-2 agonists are drugs which bind selectively to alpha-2 adrenergic receptors in the central, peripheral and autonomic nervous system as well as in vital organs and blood vessels. They produce dose-dependent analgesia, anxiolysis and sedation without causing respiratory depression by acting on the G protein-coupled alpha-2 receptors.[2] Two main alpha-2 agonists that are commercially available include clonidine and dexmedetomidine. Although neither of them is completely selective for alpha-2 receptors, dexmedetomidine is 8-10 times more selective towards these receptors compared to clonidine. Dexmedetomidine has a higher avidity and affinity for alpha-2 receptors, shorter elimination half-life and higher clinical efficacy with a lesser side-effect profile compared to clonidine.[3] The study by Gujral et al. adds credence to the anxiolytic effect of dexmedetomidine which is coupled with hemodynamic safety in patients receiving peribulbar block for vitreoretinal surgery.[4] Clonidine was the first alpha-2 agonist to be used as an adjuvant by Mjahed et al. who found that its addition to peribulbar block decreased intraocular pressure, enhanced anaesthesia, akinesia and intraoperative sedation.[5] However, use of clonidine was associated with hemodynamic side-effects such as bradycardia, arterial and orthostatic hypotension, rebound hypertension and syncope. The long half-life of clonidine meant that the hemodynamic instability was not only seen intra-operatively but also for up to 8 hours in the post-operative period.[6] Dexmedetomidine, a newer alpha-2 agonist, has shown potential with a better safety profile due to its higher selectivity and shorter half-life. Two recent studies have evaluated its efficacy and side-effect profile when used as an adjunct to peribulbar block during vitreoretinal surgery.[78] Ahmed et al.[7] used 20 μg of dexmedetomidine along with lidocaine, bupivacaine and hyaluronidase. They found faster onset of anaesthesia, akinesia, increased duration of anaesthesia and increased patient sedation in comparison to a control group using normal saline. EL-Shmaa et al.[8] compared two doses of dexmedetomidine, 15 and 30 μg, as adjuvants to routine peribulbar anaesthetic agents. They also found similar results in terms of onset and duration of anaesthesia in the dexmedetomidine groups compared with the control group. The two doses did not differ significantly in terms of their efficacy or side-effect profile. The current study in contrast did not find any difference in the time of onset of anaesthesia between the study and the control groups; however, the patient and surgeon comfort were significantly better with dexmedetomidine. This study is also unique in keeping the systemic stability as its primary outcome measure.[4] No significant systemic side-effects have been reported with either of the studies while using this drug in vitreoretinal surgeries. There is increasing evidence that supports the use of dexmedetomidine as an adjunct to regional blocks for ophthalmic anaesthesia. This drug seems to be especially useful in cases with prolonged operating times such as complex vitreoretinal surgeries and for apprehensive patients. However, use of dexmedetomidine in patients with heart block, heart failure, renal/hepatic insufficiency, uncontrolled diabetes, obesity and/or chronic obstructive pulmonary disease is contraindicated. Meticulous pre-operative evaluation by the anaesthesia team is thus essential before subjecting a patient to peribulbar block with dexmedetimidine as an additive. Establishment of standard pre-anaesthetic evaluation and intra-operative monitoring protocols are needed before this drug gains popularity as an adjunct for regional anaesthesia in ophthalmic surgery. Hence, further studies on the requirement of systemic monitoring during surgery and long-term safety profile of these agents are warranted.

Nonsurgical treatment of diplopia.

As the population ages, the number of patients presenting to ophthalmologists with complaints of double vision is increasing. Diplopia is known to occur for optical, neuroophthalmological, strabismological and even iatrogenic reasons following various ophthalmic surgical procedures. The mainstays of the nonsurgical treatment of diplopia including no treatment, partial or total occlusion, press-on or ground in prisms and vergence exercises (to increase fusional vergence amplitudes) have been utilized for some time. Although a review of the literature demonstrates that very little has been published on this topic in recent years, subtle treatment variations have evolved. The ability to successfully manage patients' diplopia symptoms remains important to decrease the risk of patient injuries, as well as maximize their independence and quality of life. These concerns are especially important as patients age.

Comparison of intraocular pressure, tear production and cardiorespiratory variables before and after induction of anaesthesia with either propofol or ketofol in dogs premedicated with midazolam

The objective of the present study was to compare the effects of propofol and ketofol on intraocular pressure, tear production and cardiorespiratory variables in dogs premedicated with midazolam. Six castrated adult mixed-breed dogs were used in a cross-over design with a one-week interval. Twenty minutes after premedication with midazolam (0.2 mg/kg), animals were assigned randomly to two groups and received either propofol (6 mg/kg) or ketofol (3 mg/kg; 1 : 1 mg/ml ratio) treatments intravenously. Intraocular pressure, tear production, heart rate, respiratory rate, rectal temperature and direct mean arterial blood pressure were measured at base (before induction), and at 5, 10, 15, 20 and 30 min after induction of anaesthesia. Blood gas samples were obtained at base (before induction), and at 5, 15 and 30 min after administration of treatments. Intraocular pressure showed significantly higher values at 5 min after induction in ketofol compared with propofol (16.1 ± 4.5 mm Hg vs 8.2 ± 1.2 mm Hg, respectively). There were no significant changes in tear production in either group. Significantly higher heart rate and mean arterial blood pressure were detected in ketofol at several time points. Respiratory depression occurred in both groups with no significant differences between them. In conclusion, although ketofol improved heart rate and mean arterial blood pressure and did not elicit more pronounced respiratory depression than propofol, it resulted in significantly higher values of intraocular pressure at 5 min after administration in dogs. Despite the small number of dogs in this study, our results indicate that ketofol should not be recommended for ophthalmic surgical procedures in dogs. Appropriate oxygenation should be provided when propofol is used for ophthalmic surgeries.

ANESTHESIA OF AQUARIUM-HOUSED WALRUS ( ODOBENUS ROSMARUS): A CASE SERIES.

Walruses are a challenging species to anesthetize as a result of their large mass, limited access for drug delivery, unique physiology, and small number of reports describing anesthetic procedures. Three aquarium-housed walruses ( Odobenus rosmarus) ranging in age from 3 to 11 yr old (344-1,000 kg) were anesthetized for dental or ophthalmic surgical procedures, with one animal anesthetized twice and one anesthetized three times. Preanesthetic medication was with intramuscular midazolam (0.1-0.2 mg/kg) and meperidine (2-3 mg/kg). A catheter was placed in the extradural intravertebral vein, and anesthesia was induced with propofol to effect. Orotracheal intubation was performed and anesthesia maintained with isoflurane in oxygen using a circle breathing system connected to a ventilator. Intermittent positive pressure ventilation was used in all procedures. For the ophthalmic surgery, the neuromuscular blocking agent, cisatracurium, was given intravenously to provide a central eye and optimal surgical conditions. The neuromuscular block was antagonized with edrophonium. Total anesthesia times ranged from 1.5 to 6 hr. Midazolam and meperidine were antagonized with flumazenil and naltrexone, respectively, in five of six cases. Nonsteroidal anti-inflammatory agents were provided for analgesia. Recoveries were calm and uneventful. The described anesthetic protocols and case management were successful under the conditions encountered.

Intraoperative Optical Coherence Tomography (MI-OCT) for the Treatment of Corneal Dystrophies

The surgical treatment of corneal dystrophies develops rapidly as the use of lamellar corneal grafting techniques continue. While penetrating keratoplasty was the gold standard for treating a variety of dystrophies a few years ago, the affected layers of the cornea can, nowadays, be selectively replaced or ablated using laser technology. Of particular importance for these methods is optical coherence tomography, which has recently been integrated into surgical microscopes (MI-OCT). Literature overview from PubMed and Google.scholar.de supplemented with own imaging data. The MI-OCT enables the intraoperative real-time monitoring of different ophthalmic surgical procedures, such as deep anterior lamellar keratoplasty, Descemet's membrane endothelial keratoplasty, as well as minimally-invasive procedures, such as phototherapeutic keratectomy. In addition, it enables an evaluation of the cornea, but also of structures of the anterior chamber, in situations in which the cornea, for example, is clouded by an edema. Microscope-integrated, intraoperative optical coherence tomography (MI-OCT) represents a useful supplement to the normal surgical microscope. It is superior to the sole surgical microscope, especially in already severely clouded corneas, and represents a sensible supplement, especially for novel lamellar transplantation procedures. Prospective randomized trials are necessary to increase safety and efficacy when using MI-OCT for different indications.

Oral anticoagulation : Current overview and perioperative management in ophthalmic surgery

Antithrombotic treatment with oral anticoagulants and antiplatelet agents can increase the risk for perioperative bleeding. In contrast to other surgical fields, the optimal perioperative management in ophthalmic surgery has not yet been exactly defined and, thus, is not standardized. In this contribution, we provide an overview of currently available oral anticoagulants and discuss potential strategies for the management of these agents in different ophthalmic surgical procedures.

Inhibition of Mitochondrial Fission Preserves Photoreceptors after Retinal Detachment

Photoreceptor degeneration is a leading cause of visual impairment worldwide. Separation of neurosensory retina from the underlying retinal pigment epithelium is a prominent feature preceding photoreceptor degeneration in a variety of retinal diseases. Although ophthalmic surgical procedures have been well developed to restore retinal structures, postoperative patients usually experience progressive photoreceptor degeneration and irreversible vision loss that is incurable at present. Previous studies point to a critical role of mitochondria-mediated apoptotic pathway in photoreceptor degeneration, but the upstream triggers remain largely unexplored. In this study, we show that after experimental retinal detachment induction, photoreceptors activate dynamin-related protein 1 (Drp1)-dependent mitochondrial fission pathway and subsequent apoptotic cascades. Mechanistically, endogenous reactive oxygen species (ROS) are necessary for Drp1 activation invivo, and exogenous ROS insult is sufficient to activate Drp1-dependent mitochondrial fission in cultured photoreceptors. Accordingly, inhibition of Drp1 activity effectively preserves mitochondrial integrity and rescues photoreceptors. Collectively, our data delineate an ROS-Drp1-mitochondria axis that promotes photoreceptor degeneration in retinal diseased models.

Prion Deposition in the Retina of Sporadic Cruetzfeldt‐Jakob Disease

IntroductionHuman spongiform encephalopathies, also known as prion diseases, are a rare group of infectious, heritable, and acquired diseases leading to rapid cognitive decline. Prion diseases are considered a serious public health threat due to the high level of infectivity and delayed presentation. Up to 50% of patients with prion disease develop visual symptoms during their clinical course, possibly secondary to abnormal prion protein (PrPSc) accumulation within the eye or within the visual pathway in the brain. Few studies, however, have investigated the presence and deposition pattern of PrPSc within the eye of patients with sporadic Creutzfeldt‐Jakob disease (sCJD). Knowing the presence or levels of PrPSc in the eye is important to assess the potential risk of transmission from common ophthalmic surgical procedures (cornea transplantations and cataract extractions). Additionally, the current gold standard of diagnosis for prion disease remains brain autopsy. If PrPSc expression is present consistently in the eye, ocular imaging modalities with PrPSc‐binding compounds may potentially enable earlier diagnosis. Here, we investigate the expression of PrPSc within retinas of confirmed prion disease cases collected from post‐mortem enucleations.MethodsFrom December 2015 to May 2017, 28 eyes were collected from 14 autopsies of clinically suspected prion disease and 6 of non‐prion disease at a single institution. sCJD was confirmed in all cases by brain autopsy and genetic analysis of the PRNP gene. Immunohistochemistry was performed with antibodies against PrP and PrP deposition within the retina was evaluated and compared with normal controls. Subjects included both male and female patients with ages ranging from 51–80 years old. The clinical disease course ranged from 2–24 months.ResultsIn twelve of the fourteen prion disease cases, PrPSc deposits were observed in the retina by immunohistochemistry. PrPScwas limited to the outer and inner plexiform layers of the retina and was most prominent in the outer plexiform layer, with the majority of cases exhibiting a coarse, 5–10 um well‐aligned ovoid deposits. Controls showed no PrPSc staining in any retinal layers. In the sclera, cornea, lens, and optic nerve, no deposits were observed.ConclusionPrPSc deposits were present in a majority of retinas of patients with confirmed prion disease, primarily within the outer plexiform layer, and these deposits can be detected immunohistochemically. Our findings confirm previous isolated reports of retinal PrPSc deposition in the largest series of documented prion cases to date. We suggest that the retina potentially serves as a diagnostic target in clinically suspected prion disease. Additionally, retinal involvement may contribute to visual symptoms commonly associated with prion disease.This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

The Ophthalmology Surgical Competency Assessment Rubric (OSCAR) for anterior approach ptosis surgery

ABSTRACTPurpose: The International Council of Ophthalmology (ICO) is currently developing a series of standardized, internationally validated, teaching tools for key ophthalmic surgical procedures called the Ophthalmology Surgical Competency Assessment Rubrics (OSCARs). This study aims to develop an OSCAR for anterior approach ptosis surgery.Methods: An international panel of content experts, representing Australia, India, Iran, Italy, Turkey, UK, and the USA was established and worked to develop the rubric using a range of online collaboration tools. The team used the standardised OSCAR template as a baseline, developing explicit behavioural descriptors (the behaviour and performance expected for each step) that were reviewed and modified with successive models. Learners were scored a modified 4-point Dreyfus scale of skill acquisition (novice, beginner, advanced beginner, competent) with the removal of the expert domain.Results: The final OSCAR ptosis tool was developed in alignment with the ICO-OSCAR standard. Seventeen agreed and weighted stems were produced. Domains such as communication and postoperative complications were removed from this rubric as they are evaluated in other spheres of residency training. Specific comments with regard to the parameters and wording were incorporated to formulate the final rubric, which was internationally agreed and demonstrated face and content validity.Conclusions: The OSCAR for anterior approach ptosis is skill and behaviour-based, has ICO agreed standards for assessment and provides learners with specific targets for improvement. Although the OSCAR ptosis tool has face and content validity, further development could better elucidate its precise role.

The incidence of hyperthermia during cochlear implant surgery in children.

Inadvertent hyperthermia during anaesthesia is a rare but life-threatening complication. We have encountered several cases of severe hyperthermia in paediatric patients undergoing anaesthesia for cochlear implantation. This study aimed to describe the clinical characteristics of children who developed hyperthermia while undergoing cochlear implantation, and to explore possible mechanisms and predisposing factors. The anaesthetic charts of all patients aged under 18 years who underwent cochlear implantation, or mastoid or ophthalmic surgery, between 1 January 2006 and 31 December 2009, at Soroka Medical Center in Beer Sheva, Israel, were reviewed. Patients undergoing mastoid and ophthalmic surgical procedures were used as controls. A larger percentage of patients who underwent cochlear implant surgery (10 per cent) developed hyperthermia compared to controls (0.7 per cent, p < 0.05). In five of the seven cases, hyperthermia appeared in combination with tachycardia and hypercapnia, adhering to the clinical triad of malignant hyperthermia. Patients undergoing cochlear implantation are susceptible to developing intra-operative hyperthermia. This article describes the hyperthermic events that occur during paediatric cochlear implantation, and attempts to identify potential triggers of hyperthermia.

Three-Dimensional Head-Mounted Display System for Ophthalmic Surgical Procedures.

Three-Dimensional Head-Mounted Display System for Ophthalmic Surgical Procedures.

Surgical options for the correction of presbyopia

Presbyopia is an age-related eye condition, and its most prominent sign is the reduction in the amplitude of accommodation, resulting in the disability to modify the focus from far to near of the eyes.Surgical therapy of presbyopia still remain great challenge for refractive surgeons.Surgical strategies of presbyopia include extraocular (corneal or scleral) and intraocular procedures, such as excimer laser surgery, conductive keratoplasty, INTRACOR, corneal inlays, multiple types of multi-focal or accommodating intraocular lens, laser-assisted presbyopia reversal, scleral expansion bands, etc.Each procedure owns its unique advantages and disadvantages.This review attempted to address the surgical options available and likely to be available in the near future and discuss the key problems in presbyopia procedures. Key words: Presbyopia; Refraction, ocular; Ophthalmic surgical procedures

Fibrin glue inhibits migration of ocular surface epithelial cells

PurposeFibrin glue has been used successfully in numerous ophthalmic surgical procedures. Recently, fibrin glue has been used in limbal stem cell transplantation to reduce both operative time and to negate the need for sutures. The aim of this study was to determine the effects of fibrin glue on epithelial cell migration in vitro.MethodsCorneoscleral rims were split to retain the epithelial layer, Bowman's layer, and anterior stroma. Rims were cut into eight equal-sized pieces and were placed directly on culture plates or affixed with fibrin glue. Rims were maintained in culture for 25 days and epithelial cell growth was monitored. Cells were photographed to measure area or growth and immunofluorescence staining of explants for fibrin was performed.ResultsExplants that were glued demonstrated significantly delayed epithelial cell growth and migration as compared with explants without glue. By day 16, all fibrin glue had dissolved and coincided with onset of cell growth from glued explants. Cell growth commenced between days 3 and 4 for control explants without glue and around days 14-16 for explants with fibrin glue.ConclusionsFibrin glue delays epithelial cell migration by acting as a physical barrier and can potentially interfere with explant-derived limbal epithelial cell migration on to the corneal surface. We propose that glue should be used to attach the conjunctival frill of the limbal explant but care should be taken to ensure that the glue does not wrap around the explant if used to secure the explant as well. Strategic use of glue, to attach the recessed conjunctiva, can be advantageous in delaying conjunctival cell migration and reducing the need for sequential sector conjunctival epitheliectomy.

Rebound tonometry over an air-filled anterior chamber in the supine child after intraocular surgery

Intracameral air is a critical component of multiple ophthalmic surgical procedures and is frequently used in pediatric intraocular surgery. Among other benefits, it helps to facilitate postoperative examination in uncooperative children by allowing quick confirmation of a formed anterior chamber. The purpose of this study was to evaluate the usefulness and accuracy of a position-independent rebound tonometer (Icare PRO) in measuring intraocular pressure (IOP) intraoperatively in pediatric eyes with intracameral air compared to a commonly used handheld applanation tonometer (Tono-Pen XL). In this prospective study of sequential children undergoing intraocular surgery, IOP was measured immediately following general anesthesia induction using both Icare PRO rebound tonometry and Tono-Pen XL tonometry, with instrument order randomized, in the supine child's eye(s). At completion of surgery after standard placement of intracameral air IOP was again measured using both instruments. A total of 42 eyes of 30 children were included. Surgeries included glaucoma (25), cataract-related (16), and both (1). Mean preoperative IOP by Tono-Pen XL was 23.52±9.76mm Hg; by Icare PRO, 20.94±10.01mm Hg (P=0.0012). Mean IOP over intracameral air at surgery conclusion by Tono-Pen XL (n=41) was 12.66±4.90; by Icare PRO (n=42), 12.96±5.10mm Hg (P=0.46). One eye had postoperative IOP unrecordable by Tono-Pen XL but 7.9mm Hg by Icare PRO. Bland-Altman analysis, which included only paired measurements, showed a preoperative mean difference in IOP (ΔIOPT-I) of 2.58mm Hg (95% CI, -6.86 to 12.02); postoperative mean ΔIOPT-I of -0.42mm Hg [95% CI, -7.57 to 6.73]. Position-independent rebound tonometry (Icare PRO) accurately measured IOP in supine children's eyes postoperatively in the presence of intracameral air.

Robotic Systems in Ophthalmology

The use of robotic systems has developed extensively in various surgical subspecialties. This article attempts to provide an overview of the applications of these systems in the field of ophthalmology. The robotic surgical platforms available for ophthalmic use are discussed with their inherent advantages and disadvantages, including the da Vinci and the IRISS (Intraocular Robotic Interventional and Surgical System). The potential for complete automation of ophthalmic surgical procedures in the recent future makes the field of robotics an exciting development.