Safety Of Cataract Surgery Research Articles

Cataract surgery in patients taking alpha-1 antagonists: know the risks, avoid the complications.

The growing use of alpha-1 receptor antagonists in the treatment of benign prostatic hyperplasia (BPH) has created a new problem in ophthalmic surgery, the so-called intraoperative floppy iris syndrome (IFIS). This consists of a billowing iris, insufficient pupillary dilation with progressive intraoperative miosis, and protrusion of iris tissue through the tunnel and side port incision that are made for access to the anterior chamber during surgery. IFIS presents particular difficulties in cataract surgery which is carried out through the pupil with manipulations in the immediate vicinity of the iris. The complications range from poor visibility of the operative field to iris damage with the surgical instruments and to rupture of the posterior capsule, with loss of lens material into the vitreous body. Selective literature review. Alpha-blockers have a direct effect on the alpha-receptors of the iris but also induce ultrastructural changes in the iridial stroma, leading to IFIS. The most important factor in avoiding complications of IFIS seems to be the ophthalmic surgeon's knowledge that the patient is taking an alpha-1 receptor antagonist. A thorough medical history and an optimized information flow among all physicians treating the patient-the urologist, the family physician, and the ophthalmic surgeon-are essential for safe cataract surgery.

Safety of cataract surgery under topical anesthesia with oral sedation without anesthetic monitoring.

The current study was conducted to determine whether topical anesthesia with oral sedation and without an anesthetist present in the operating room is a safe and cost-effective strategy for low-risk patients undergoing cataract surgery. This retrospective interventional case series included cases conducted between 2001 and 2003 at the Brandon Regional Health Centre in Brandon, Manitoba. Patients with visually significant cataracts were screened for study inclusion by using the following criteria: good general health, good dilation, moderate cataracts, cooperation with in-office tests and procedures, and understanding of cataract surgery. Oral sedation was provided by lorazepam, and an anesthetist was available to manage any medical adverse events. Topical anesthesia was achieved by means of tetracaine drops, lidocaine hydrochloride jelly, and intracameral lidocaine hydrochloride, as necessary. Main outcome measures were heart rate, systolic and diastolic blood pressure, oxygen saturation, intraoperative complications, and medical adverse events necessitating anesthetist intervention. A total of 538 eyes of 373 patients were included in the cataract surgery case series. No medical adverse events were reported in 454 cases (84.4%); 84 patients (15.6%) experienced adverse events, classified as mild in 13.5%, moderate in 1.1%, and severe in 0.9% (5 cases). The most common adverse event was mild pain, experienced in 69 procedures (12.8%). Moderate pain, necessitating use of intracameral 1% lidocaine, occurred in 3 procedures (0.6%). Topical anesthesia appears to be a safe alternative to injection anesthesia without many of the disadvantages of the latter and may be preferable in carefully selected patients.

Torsional mode phacoemulsification: Effective, safe cataract surgery technique of the future

Purpose:To compare various outcome measures using torsional mode and longitudinal mode in the phacoemulsification of cataract with different nuclear densities.Setting: Magrabi Eye Hospitals, Kingdom of Saudi Arabia.Design: A randomized comparative clinical study.Materials and Methods:This study includes 200 eyes of 156 patients (100 in the ultrasound longitudinal “US” group and 100 in the torsional group). All eyes received AcrySof® single piece intraocular lens (Alcon Surgical, Fort Worth, TX). The primary outcome measures were ultrasound time (UST), cumulative dissipated energy (CDE), and surgical complications. Postoperative outcome measures were the degree of corneal edema on the first postoperative day and final best corrected visual acuity (BCVA) and CCT (central corneal thickness).Results:The differences in UST and CDE between subgroups of nucleus hardness were statistically significant (P < 0.01). The UST and CDE consistently increased in eyes with higher grades of nucleus density. On day one, the mean BCVA was 0.61 ± 0.13 decimals in the ultrasound (US) group and 0.67 ± 0.11 decimals in the torsional group (significant P < 0.05). Corneal edema was significantly less in the torsional group (P < 0.05). At 30 days, the mean BCVA was 0.94 ± 0.22 decimals in the US group and 1.0 ± 0.12 decimals in the torsional group but this difference was not statistically different (P > 0.05).Conclusions:The torsional mode provides an effective and safe method for cataract removal with lower energy usage as compared to longitudinal traditional phacoemulsification. However, the final visual outcome was similar for both study groups.

Mini-Rhexis For White Intumescent Cataracts

PURPOSE:To compare the intraoperative safety of two techniques of capsulorhexis for intumescent white cataracts: traditional one-stage continuous curvilinear capsulorhexis and two-stage continuous curvilinear capsulorhexis.METHODS:This prospective comparative randomized study included two groups: the 1-CCC group (11 patients) received traditional one-stage continuous curvilinear capsulorhexis with 5–6 mm diameter, and the 2-CCC (13 patients) group received a deliberately small continuous curvilinear capsulorhexis that was secondarily enlarged, or a two-stage continuous curvilinear capsulorhexis. Patients were stratified according to cataract subset, which was characterized echographically. Six patients were considered as type 1, fifteen as type 2 and three as type 3. Type 1 included intumescent white cataracts with cortex liquefaction and extensive internal acoustic reflections, type 2 included white cataracts with voluminous nuclei, a small amount of whitish solid cortex, and minimal internal acoustic reflections, and type 3 included white cataracts with fibrous anterior capsules and few internal echo spikes.RESULTS:With the one-stage technique, 46.15% of patients had leakage of the liquefied cortex; in addition, the surgeon perceived high intracapsular pressure in 61.53% of cases. Anterior capsule tears occurred in 23.07% of cases, discontinuity of capsulorhexis in 30.79% of cases and no posterior capsular rupture occurred. With the two-stage technique, leakage of the liquefied cortex occurred in 45.45% of cases; additionally, the surgeon perceived high intracapsular pressure in 36.36% of cases. No anterior capsule tears, discontinuity of capsulorhexis or posterior capsular rupture occurred. Considering each cataract subset, there was a higher incidence of leakage for type 2 as compared to types 1 and 3.CONCLUSIONS:Two-stage continuous curvilinear capsulorhexis helps prevent unexpected radial tears of the initial capsulotomy from high intracapsular pressure, sudden radialization of the CCC and other intraoperative complications due to high intracapsular pressure, thus providing a safe cataract surgery in cases of white cataracts. These findings were supported by ultrasonography.

Safety of cataract surgery under topical anesthesia with oral sedation without anesthetic monitoring

Purpose: The current study was conducted to determine whether topical anesthesia with oral sedation and without an anesthetist present in the operating room is a safe and cost-effective strategy for low-risk patients undergoing cataract surgery.Methods: This retrospective interventional case series included cases conducted between 2001 and 2003 at the Brandon Regional Health Centre in Brandon, Manitoba. Patients with visually significant cataracts were screened for study inclusion by using the following criteria: good general health, good dilation, moderate cataracts, cooperation with in-office tests and procedures, and understanding of cataract surgery. Oral sedation was provided by lorazepam, and an anesthetist was available to manage any medical adverse events. Topical anesthesia was achieved by means of tetracaine drops, lidocaine hydrochloride jelly, and intracameral lidocaine hydrochloride, as necessary. Main outcome measures were heart rate, systolic and diastolic blood pressure, oxygen saturation, intraoperative complications, and medical adverse events necessitating anesthetist intervention.Results: A total of 538 eyes of 373 patients were included in the cataract surgery case series. No medical adverse events were reported in 454 cases (84.4%); 84 patients (15.6%) experienced adverse events, classified as mild in 13.5%, moderate in 1.1%, and severe in 0.9% (5 cases).The most common adverse event was mild pain, experienced in 69 procedures (12.8%). Moderate pain, necessitating use of intracameral 1% lidocaine, occurred in 3 procedures (0.6%).Interpretation: Topical anesthesia appears to be a safe alternative to injection anesthesia without many of the disadvantages of the latter and may be preferable in carefully selected patients.

Achievement of Less Invasive Cataract Surgery

Phacoemulsification and aspiration (PEA) has become the most popular type of cataract surgery. The safety of cataract surgery has been dramatically improved due to the development of surgical techniques and associated instruments. However, corneal endothelial damage still represents a serious complication, as excessive damage can lead to irreversible bullous keratopathy. Collision of lens fragments to corneal endothelium by turbulent flow causes physical breakdown of the endothelial cells. We report a case in which corneal endothelial damage occurred by the collision of lens fragments during phacoemulsification and aspiration. The outcome prompted us to perform safer operations with new surgical instruments.

Safety of cataract surgery under topical anesthesia with oral sedation without anesthetic monitoring

Safety of cataract surgery under topical anesthesia with oral sedation without anesthetic monitoring

Randomised controlled single-blind study of conventional versus depot mydriatic drug delivery prior to cataract surgery

BackgroundA prerequisite for safe cataract surgery is an adequately dilated pupil. The authors conducted a trial to assess the efficacy (in terms of pupil diameter) of a depot method of pre-operative pupil dilatation, as compared with repeated instillations of drops (which is time-consuming for the nursing staff and uncomfortable for the patient).MethodsA prospective randomised masked trial was conducted comprising 130 patients with no significant ocular history undergoing elective clear corneal phacoemulsification. 65 patients had mydriatic drops (Tropicamide 1%, Phenylephrine 2.5%, Diclofenac sodium 0.1%) instilled prior to surgery, 65 had a wick soaked in the same drop mixture placed in the inferior fornix. Horizontal pupil diameters were recorded on a millimetre scale immediately prior to surgery.ResultsThere was no significant difference in pupil size between the two groups (p = 0.255, Student's t-test).ConclusionThere was no significant difference between the mydriasis obtained with the depot system compared with conventional drop application. Use of a depot mydriatic delivery system appears to be a safe and efficient method of drug delivery.Trial RegistrationInternational Standard Randomised Controlled Trial Number Register ISRCTN78047760

Patient safety in cataract surgery

Patient safety in cataract surgery

Improving patient safety in cataract surgery

Patient safety is an international concern in every hospital speciality as well as in general practice.1 Medical errors are estimated to occur in 10% of admissions.2 The trend is to try to improve systems, rather than blame individual healthcare workers. Recent patient safety initiatives in the United Kingdom include the formation of the National Patient Safety Agency (NPSA) (www.npsa.nhs.uk). Clinicians are encouraged to report incidents, adverse events, and near misses either through local NHS Trust risk management systems, or directly to the NPSA (www.npsa.nhs.uk/health/reporting/reportanincident), in efforts to learn from these incidents. The Royal College of Ophthalmologists is to be congratulated as one of a small number of medical Royal Colleges to have provided a menu of suggested patient safety incidents to report.

Current Concepts and Challenges in Ocular Surface Reconstruction Using Cultivated Mucosal Epithelial Transplantation

Ocular surface disorders wherein corneal stem cells are deficient result in total conjunctivalization leading to severe visual dysfunction and blindness. Treatment of these diseases requires reconstruction of the ocular surface using epithelial transplantation to provide a smooth refractive corneal surface and biologic and physical barriers against a variety of destructive factors. Recently, regenerative medicine focusing on tissue-engineered techniques has been developed and established as a new clinical field. In particular, cultivated mucosal epithelial transplantation using well-differentiated, stratified epithelial sheets on amniotic membrane allows a rapid re-epithelial cover over the entire corneal surface, resulting in early reduction of inflammation and cicatrization. This surgical approach dramatically improves the prognosis of severe ocular surface diseases, especially severely inflamed corneal stem cell deficiency. This new approach not only provides early epithelialization but also allows reconstruction of the corneal surface using autologous cultivated epithelium including the cornea and oral mucosa from a small number of cell sources after amplification. Tissue-engineered strategies using autologous corneal or oral mucosal epithelial sheet transplantation avoid the risk of rejection and complications associated with immunosuppressive treatments. In addition to new cellular transplantation, combined automated lamellar therapeutic keratoplasty provides better refractive stromal interference and contributes to performance and safety of cataract surgery in severe corneal opacity cases. Although long-term prognosis and cell biologic behavior of tissue-engineered epithelium after transplantation should be carefully monitored, these recent surgical treatments have opened a new field for ocular surface reconstruction.

Patient safety in cataract surgery

The recent focus on healthcare errors and safety suggest that practitioners and policy makers might appraise their cataract surgical care from a patient safety perspective. This paper reviews patient safety issues relevant to cataract care. Causation and consequences of incidents in cataract surgery, with implications for policy, are discussed. Models of accident causation from other domains were drawn on and empirically applied to cataract care. Consultation was undertaken with experts in cataract surgery, patient safety, and in risk management. Feedback on patient safety was included from presentations made to staff and patients and from personal insights. Ophthalmology teams should embrace steps to improve patient safety. The role of incident reporting is advanced, including the provision of a prompt menu of cataract patient safety incidents as suggested by the Royal College of Ophthalmologists. Strict attention to detail, risk assessment, and careful consideration of the patient pathway is needed to enhance cataract care. Clinical errors, near misses and complications happen, and may provide an opportunity for learning to reduce the risk of similar events in the future. Investment in staffing and training, appropriate equipment, and development of a safety culture with patient involvement are key elements of safe cataract surgical care. Patients and the public expect that safe cataract care should be commissioned for them. Critical patient safety incidents, including incidents that have led to permanent harm, require careful analysis of underlying systems and/or root causes.

Lidocaine versus ropivacaine for topical anesthesia in cataract surgery

Purpose: To assess the anesthetic efficacy and safety of topical ropivacaine versus topical lidocaine in cataract surgery. Setting: Institute of Ophthalmology, University of Modena and Reggio Emilia, Modena, Italy. Methods: This prospective controlled randomized double-blind study comprised 64 patients scheduled for planned routine cataract extraction. Patients were randomized into 2 groups; 1 received topical ropivacaine 1% and the other, topical lidocaine 4%. The duration of surgery, intraoperative and early postoperative complications, and the need for supplemental intracameral anesthesia were recorded. Intraoperative and postoperative subjective pain was quantified by patients using a scale from 1 to 10. An endothelial cell count was performed preoperatively and 2 months after surgery. Results: The mean endothelial cell density decreased from 2334 cells/mm 2 ± 496 (SD) to 2016 ± 674 cells/mm 2 in the ropivacaine group and from 2519 ± 404 cells/mm 2 to 1847 ± 607 cells/mm 2 in the lidocaine group. The difference in cell density between groups was not significant before ( P = .154) or after surgery ( P = .329); however, the difference in mean cell loss between groups was statistically significant ( P = .031). The duration of surgery and intraoperative complications were the same in both groups. Four patients in the ropivacaine group and 5 in the lidocaine group required supplemental anesthesia ( P > .05). The mean subjective analog pain score was slightly higher in the lidocaine group ( P > .05). The day after surgery, 12 eyes in the ropivacaine group and 6 in the lidocaine group had transient corneal edema ( P = .150). Conclusions: Topical ropivacaine performed at least as well as topical lidocaine in efficacy and safety in cataract surgery. It provided sufficient and long-lasting analgesia without the need for supplemental intracameral anesthesia in most cases.