Segment Surgery Research Articles

Treatments, cost and healthcare utilization of patients with segmental bone defects

BackgroundTreatment of large segmental defects in skeletal long bones is challenging. Heterogeneity in patient presentation further increase the difficulty in designing and running randomized trials, hence the paucity of published data with large patient numbers. This study was designed to help understand patient presentation, costs and outcomes, using real world data sources. MethodsTwo data sources (Premier healthcare database (PHD) and IBM® MarketScan® Commercial Claims and Medicaid databases) were utilized, PHD for intraoperative and cost analyses, MarketScan for payer costs and longitudinal (2-year) outcomes. Patients were included in the analysis if they had diagnoses of osteomyelitis, non-union or open (acute) fractures, treated with bone graft and/or spacers, using either the Masquelet or external frames. Patient cohorts were defined by diagnosis at index (acute fracture, osteomyelitis, non-union) and descriptive statistics were conducted for patient variables (demographic, comorbidities) and outcomes. Risk of complications were estimated using logistic regression models. Hospital and payer costs for index and follow-up periods, were estimated using least means square estimators from generalized linear model outputs. All costs and payments were adjusted for inflation to 2019 consumer price-index. Results904 patients were identified in PHD (414 fractures, 388 osteomyelitis and 102 nonunion patients). Main comorbidities at time of initial surgery were hypertension (32.7%) followed by obesity (22.1%), diabetes with complications (20.9%) and chronic pulmonary disease (20.6%). Significant variability in surgical operating room time and length of stay were observed, with averages of 484.7 minutes and 11.7 days, respectively. Two-year postoperative infection rates ranged from 33.1% - 58.5%, the highest infection rates being reflective of ongoing infections in patients initially treated for osteomyelitis. Amputation rates ranged from 10.0% in patients with bone loss due to acute factures to 14.5% in patients with osteomyelitis. Osteomyelitis patients were also the costliest, with 12-months hospital costs averaging US$ 156.818 (95%CI: 112,970-217,685). ConclusionThis study identified high complication rates and costs of segmental bone repair surgery. All patients with segmental bone defects had high costs and risks but patients with osteomyelitis were at significant risk for increased cost and complications, including amputation. Medical innovation is particularly important for this high-risk patient group.

Anterior Segment Surgery Performed During the COVID-19 Pandemic.

Objectives:This study evaluated anterior segment surgeries performed during the coronavirus 2019 (COVID-19) pandemic. Prevention of virus transmission is a critical consideration for surgeons, and includes assessment of etiology, the referral region, demographic characteristics, and the surgery to be performed.Methods:The data of 144 patients who underwent anterior segment surgery between March 19, 2020 and June 1, 2020 were retrospectively reviewed. The patient demographic data and details of ophthalmological examination findings, the region patients were referred from, and the type of surgery performed were recorded and analyzed.Results:A total of 144 patients, 49 women (34%) and 95 men (66%), were included in this study. The mean age of the patients was 31.30±25.88 years (range: 1–86 years). The presenting complaint was in the right eye in 43.7% of the cases, in the left eye in 52.8%, and in both eyes in 3.5% of the cases. While 94.4% of the applications were from Istanbul, the remaining 5.6% were from outside the province. Though 43.7% of the cases were patients seen previously at the study hospital in Istanbul, 56.3% presented for the first time. This hospital was the first referral center in only 39.6% of the cases. Evaluation of etiology indicated that corneal perforation (18.1%) was the most common, followed by keratitis (13.2%). The most common surgical intervention applied was amnion membrane transplantation (19.4%), followed by perforation repair (16.7%).Conclusion:Ophthalmological surgeries continue to be performed during the ongoing COVID-19 pandemic, however, special algorithms must be used to reduce the risk of COVID-19 transmission and to ensure continuity of healthcare for ophthalmology patients.

The artificial iris - Analysis of various implantation techniques after ocular trauma.

Purpose:The aim of this study is to analyze the outcome of various techniques for a custom-made iris prosthesis implantation as part of reconstructive anterior segment surgery following traumatic aniridia.Methods:This retrospective interventional study was done for 6 eyes that received an artificial iris as secondary reconstructive measure for photophobia and unsatisfactory vision following initial globe repair. Different implantation techniques were employed. These included simple sulcus implantation, implantation of a composite (iris prosthesis with attached intraocular lens) implant, and combinations with phacoemulsification, vitrectomy, and penetrating keratoplasty.Results:In all cases, the artificial iris was implanted successfully. In the follow-up period (1–48 months), postoperative complications included rhegmatogenous retinal detachment, prolonged intraocular inflammation, and corneal transplant decompensation due to graft rejection. There was no case of secondary glaucoma. Complications could be managed successfully. All patients showed improved best-corrected visual acuity and were satisfied with functional and cosmetic results.Conclusion:This case series highlights the different implantation techniques for reconstruction of the anterior segment after ocular trauma. The versatility of the custom-made iris implant accounts for a wide range of applications and the foldable material reduces the need for large incisions in the already traumatized eye.

Minimally-invasive donor hepatectomy at the dawn of a decade: can we pick up the pace?

: Next year will mark two decades since the first minimally-invasive donor hepatectomy (MIDH) was performed in Paris to facilitate an adult-to-child live donor liver transplant (LDLT). Despite improvements and widespread proliferation of LDLT throughout the world, a concomitant broader application of the MIDH technique has not been wholly realized due to concerns over donor safety and the technical difficulties inherent to MIDH. On the contrary, during the same time period, minimally-invasive liver surgery (MILS) rapidly evolved into a standard approach for many benign and malignant forms of liver disease. To support this growth, numerous novel technologies such as advanced laparoscopy and robotic surgical systems, three-dimensional (3D) flexible videoscopy, real-time near-infrared fluorescence cholangiography with indocyanine green (ICG), and a variety of thermal energy devices and endovascular staplers have evolved and matured in the setting of MILS. A handful of select, high-volume liver transplant centers have incorporated these MILS advancements into their established segmental liver surgery and LDLT programs in order to develop the requisite technical sophistication to execute MIDH in an impactful manner. Two techniques, pure laparoscopic donor hepatectomy (PLDH) and robotic donor hepatectomy (DH), have emerged as the dominant modalities in MIDH surgery with each having their proponents and detractors. A few centers in Asia, France, the United States, and Saudi Arabia have recently reported series of sufficient volume and nuance to be instructive for the field in general. The intent of this review is to describe the experience to date in MIDH with a particular focus on lessons learned at these pioneering institutions who navigated through the learning curves in these demanding technical endeavors. The tricks, observations, and recommendations gleaned from this article should serve as a vital resource for those motivated surgeons embarking upon the challenging but rewarding field of MIDH surgery.

Anterior Segment Surgeries Under Topical Fresh Frozen Plasma Treatment in Ligneous Conjunctivitis.

To evaluate the efficacy of topical fresh frozen plasma (FFP) therapy on clinical symptoms, findings, and prognosis after anterior segment surgeries in patients with ligneous conjunctivitis (LC). Retrospective case note review. Eleven eyes of 7 cases whose remission was not achieved after medical treatment such as topical corticosteroids, cyclosporine A, and heparin were included in the study. The median age of admission was 19 (1-49) years, median duration of FFP treatment was 48 (15-79) months, median follow-up period was 62 (16-114) months, and median age at symptom onset was 12 (4-252) months. Diagnosis was made according to clinical presentations, plasminogen activities, and response to treatment. Topical FFP that was prepared in our clinic was used in all cases. Surgeries (membrane excision, eyelid surgery, deep anterior lamellar keratoplasty, and cataract surgery) were performed after at least 1 month of FFP treatment. Prosthetic contact lens was applied to one eye. During the follow-up period, recurrences requiring membrane excision and side effects from topical FFP were not observed. LC is a rare membranous conjunctivitis that proceeds with remissions and recurrences. When it was shown that the etiology of LC is plasminogen deficiency, FFP became the only treatment option targeting the etiology. In this study, we observed that the topical FFP is an effective treatment method that prevents recurrence and ensures regression of membranes and safer anterior segment surgeries in LC.

Assessing Effectiveness of Colonic and Gynecological Risk Reducing Surgery in Lynch Syndrome Individuals.

Simple SummaryColorectal and endometrial cancers are the most important life-threating risk in Lynch syndrome subjects, with incidences at 75 years as high as 40–60%. However, surveillance has shown to be ineffective. Risk reducing surgeries are an option in Lynch Syndrome (LS) individuals to decrease incidence of this type of cancers. In this manuscript, we have analyzed the rates of colorectal and gynecological cancer in 976 LS individuals after a mean follow-up of 10.2 years (patients under regular surveillance or after a risk reducing surgery). We can confirm in the largest study published up to the present in a single-institution that risk reducing surgeries are effective in decreasing incidence of colorectal and gynecological cancer in all LS carriers. Moreover, is the first report showing a decrease in all-cause mortality cumulative incidence in females with Lynch syndrome that undergo gynecological risk reducing surgery.Background: Colorectal (CRC) and endometrial cancer (EC) are the most common types of cancer in Lynch syndrome (LS). Risk reducing surgeries (RRS) might impact cancer incidence and mortality. Our objectives were to evaluate cumulative incidences of CRC, gynecological cancer and all-cause mortality after RRS in LS individuals. Methods: Retrospective analysis of 976 LS carriers from a single-institution registry. Primary endpoints were cumulative incidence at 75 years of cancer (metachronous CRC in 425 individuals; EC and ovarian cancer (OC) in 531 individuals) and all-cause mortality cumulative incidence, comparing extended (ES) vs. segmental surgery (SS) in the CRC cohort and risk reducing gynecological surgery (RRGS) vs. surveillance in the gynecological cohort. Results: Cumulative incidence at 75 years of metachronous CRC was 12.5% vs. 44.7% (p = 0.04) and all-cause mortality cumulative incidence was 38.6% vs. 55.3% (p = 0.31), for ES and SS, respectively. Cumulative, incidence at 75 years was 11.2% vs. 46.3% for EC (p = 0.001) and 0% vs. 12.7% for OC (p N/A) and all-cause mortality cumulative incidence was 0% vs. 52.7% (p N/A), for RRGS vs. surveillance, respectively. Conclusions: RRS in LS reduces the incidence of metachronous CRC and gynecological neoplasms, also indicating a reduction in all-cause mortality cumulative incidence in females undergoing RRGS.

Clinical efficacy of intravenous anesthesia on breast segmental surgery and its effects on oxidative stress response and hemodynamics of patients.

This study was designed to investigate the clinical efficacy of intravenous anesthesia on breast segmental surgery and the effects on hemodynamics of patients. A total of 267 patients were collected as research subjects. These patients underwent breast segmental surgery in Chun'an First People's Hospital from March 2015 to September 2018. Among them, 137 patients undergoing intravenous anesthesia were the research group, and 130 patients undergoing inhalation anesthesia were the control group. The following parameters were recorded: Clinical efficacy, postoperative adverse conditions, hemodynamic indicators including systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR). Visual analogue scale (VAS) was used to observe the analgesic effect of the two groups, the mental state of patients in the two groups was observed by mini-mental state examination (MMSE) scoring method, and systemic evaluation was made by oxidative stress (OS) reaction indicators. The MMSE scores of the two groups decreased one day after surgery, but the score in the research group was higher than that in the control group (P<0.05). The levels of SBP and DBP at T1 and T2 in the control group were significantly higher than those in the research group (P<0.05). HR of research group at T1 and T2 was lower than that at T0 and that at corresponding time of control group (P<0.05). The incidence rate of postoperative adverse reactions in the research group was significantly lower than that in the control group (P<0.05). In conclusion, intravenous anesthesia for breast segmental surgery can reduce the occurrence of adverse reactions after surgery, with complete sedation and analgesia. Patients were able to wake up quickly and stably after surgery, and their cognitive function and OS recovered rapidly. However, due to the great impact on hemodynamics during surgery, attention should be paid to maintain hemodynamic stability during surgery to avoid hypotension and bradycardia.

Pre-bent Buccal Distractor Made from a 3D Model for Maxillary Anterior Segmental Distraction Osteogenesis for Precious Fit and Decreasing Surgical Time.

Maxillary anterior segmental distraction osteogenesis surgery involves a distraction segment that is made at the anterior part of the maxilla. Although bending and fitting the distractor during surgery is a complex procedure, we present here a usefulness of the pre-bent distractor made with a 3D model for precise fixing and reducing the operative time.

Pars plana vitrectomy combined with penetrating keratoplasty and transscleral-sutured intraocular lens implantation in complex eyes: a case series

BackgroundThe aim of this study was to evaluate the clinical outcomes of pars plana vitrectomy (PPV) combined with penetrating keratoplasty (PKP) and transscleral-sutured intraocular lens (IOL) implantation (IOL-suture) in complex eyes.MethodsIn this prospective, consecutive interventional case series, patients who underwent PKP combined with PPV and IOL implantation from July 2014 to March 2018 at Yokohama Minami Kyosai Hospital were enrolled. The postoperative best corrected visual acuity (BCVA) (converted to logarithm of the minimal angle of resolution [logMAR] units), intraocular pressure (IOP, mmHg), endothelial cell density (ECD, cells/mm2), graft survival, complications, astigmatism, and spherical equivalent (dioptres [D]) were evaluated.ResultsThis study included 11 eyes of 11 patients (three females and eight males; mean age, 61.8 ± 13.9 years) with an injury (n = 6) or bullous keratopathy (n = 5). The BCVA significantly improved from 1.50 ± 0.66 logMAR preoperatively to 0.78 ± 0.59 logMAR (p < 0.001) postoperatively. The baseline ECD significantly decreased from 2396 ± 238 cells/mm2 preoperatively to 1132 ± 323 cells/mm2 (p < 0.001) postoperatively. Despite two rejection episodes, graft survival rates were 100%. The mean follow-up period was 38.0 ± 20.5 months. Two patients required combined glaucoma surgery, and three patients underwent subsequent glaucoma surgery. Postoperative astigmatism and spherical equivalent were 3.9 ± 3.2 D and 0.29 ± 2.18 D, respectively.ConclusionThe combination of PKP, PPV, and IOL-suture implantation could be a safe and effective approach for eyes requiring anterior segment surgery; however, these eyes are associated with a higher incidence of glaucoma surgery.

Intraoperative Optical Coherence Tomography Imaging in Corneal Surgery: A Literature Review and Proposal of Novel Applications.

Intraoperative optical coherence tomography (iOCT) is widely used in ophthalmic surgeries for cross-sectional imaging of ocular tissues. The greatest advantage of iOCT is its adjunct diagnostic efficacy, which facilitates to decision-making during surgery. Since the development of microscopic-integrated iOCT (MIOCT), it has been widely used mainly for vitreoretinal and anterior segment surgeries. In corneal transplantation, MIOCT allows surgeons to visualise structure underneath the turbid and distorted cornea, which are impossible to visualise with a usual microscope. Real-time visualisation of hard-to-see area reduces the operation time and leads to favorable surgical outcomes. The use of MIOCT is advantageous for a variety of corneal surgical procedures. Here, we have reviewed articles focusing on the utility of iOCT and MIOCT in penetrating keratoplasty, deep anterior lamellar keratoplasty, Descemet stripping automated endothelial keratoplasty, and Descemet membrane endothelial keratoplasty. The applications of MIOCT to corneal surgery in terms of surgical education for trainees, emergency surgery, and novel surgery are also discussed, with our cases performed using RESCAN® 700.

Effect of microalbuminuria on corneal endothelium in patients with diabetes without retinopathy

BackgroundThe aim of this study was to investigate the effect of microalbuminuria on corneal endothelium in patients with diabetes without retinopathy.MethodsThis cross‐sectional study comprised 100 patients with type 2 diabetes mellitus (DM) without diabetic retinopathy and 92 control subjects without diabetes. Forty‐five patients had microalbuminuria and 55 subjects were microalbuminuria negative. Endothelial measurements were obtained using specular microscopy. Endothelial cell density, average area, co‐efficient of variation, maximum area, minimum area, hexagonality and corneal thickness were compared between the groups on the basis of microalbuminuria, DM duration and medication, HbA1c, body mass index, serum lipid and protein profiles, hypertension and hyperlipidaemia diagnosis.ResultsThere were no significant differences in age, gender, endothelial cell density, average area, co‐efficients of variation, maximum area, minimum area, hexagonality or corneal thickness among the microalbuminuria positive, microalbuminuria negative and control groups (p > 0.05). However, microalbuminuria positive patients had lower high‐density lipoprotein levels than the microalbuminuria negative patients (p = 0.042). DM and control groups showed similar endothelial measurements (p > 0.05). Patients with a HbA1c > 7 per cent (53 mmol/mol) had lower hexagonality value (p = 0.039) than in the subjects with a HbA1c ≤ 7 per cent. No significant differences were found in endothelial parameters when groups were compared based on DM duration, medication and co‐morbidities.ConclusionsMicroalbuminuria positive and negative patients with DM without retinopathy seem to have similar corneal endothelial measurements with controls. However, patients with a HbA1c > 7 per cent should be monitored for deterioration in corneal endothelial cell morphology even without diabetic retinopathy, which might be critical prior to anterior segment surgery.

INTRAOPERATIVE OPTICAL COHERENCE TOMOGRAPHY (OCT) GUIDANCE OF VITREORETINAL SURGERY

Background: Multiple studies have described the utility of intraoperative spectral-domain OCT (SD-OCT) with two dimensional (2D) B-scan imaging in the management of numerous vitreoretinal disorders including macular holes, vitreomacular traction disorders, epiretinal membranes and retinal detachment. Some of these studies also described post-processing of the 2D B-scans to obtain 3D images. With the advancement of intraoperative OCT technology, live volumetric (4D, i.e. 3D over time) visualization of different anterior and posterior segment surgeries has been described in recent studies using intraoperative swept-source microscope-integrated OCT (SS-MIOCT). Our study aims to explore the potential utility of SS-MIOCT during vitrectomy for complications of proliferative diabetic retinopathy. Aim of the work: To evaluate the use of live volumetric (4D) intraoperative swept-source microscope-integrated OCT (SS-MIOCT) in vitrectomy for proliferative diabetic retinopathy (PDR) complications.Patient and Methods: In this prospective study, we analyzed a subgroup of cases with PDR complications that required vitrectomy and that were imaged by the research SS-MIOCT system. In near real time, images were displayed in stereo heads-up display facilitating intraoperative surgeon feedback. Postoperative review included scoring image quality, identifying different diabetic retinopathy (DR)-associated pathologies and reviewing the intraoperatively documented surgeon feedback.Results: Twenty eyes were included. Indications for vitrectomy were tractional retinal detachment (TRD, 16 eyes), combined tractional-rhegmatogenous retinal detachment (2 eyes) and vitreous hemorrhage (2 eyes). Useful, good quality 2D (B-scans) and 4D images were obtained in 16/20 eyes (80%). In these eyes, multiple DR pathologies could be imaged. SS-MIOCT provided surgical guidance, e.g. in identifying dissection planes under fibrovascular membranes, and in determining residual membranes and traction that would benefit from additional peeling. In 4/20 eyes (20%) acceptable images were captured, but they were not useful due to high TRD elevation which was challenging for imaging.Conclusion: SS-MIOCT can provide important guidance during surgery for PDR complications through intraoperative identification of different pathologies and facilitation of intraoperative decision making.

Cataract surgery and dry eye syndrome. Visual outcomes. Patient's satisfaction

Cataract surgery and dry eye syndrome. Visual outcomes. Patient's satisfaction. Matias S. Haffar Hospital Oftalmologico Santa Lucia, Argentina Abstract Visual Evoked Potential (VEP) measures the electrical activity in the entire vision system. When light enters the eye it is converted to electrical energy at the retina and travels through the optic nerve to the visual cortex which processes vision. The Diopsys VEP test measures the strength and speed of the retinal signal all the way to the visual cortex. VEP technology uniquely helps determine the communication between the eye and the brain. Electroretinography (ERG) measures retinal function. When light enters the eye it is converted into electrical energy by cones and rods, visual cells. ERG tests record the activity of the visual cells and thereby reflecting cell health and integrity. These two modalities are useful in diagnosing cellular pathology such as Age Related Maculopathy(AMD), glaucoma,Diabetic Macula Edema(DME) ,amblyopia,brain injury, stroke and other vision related issues. VEP is especially useful in Enfant and Pediatric exams to diagnose pathology. Biography: Matias S. Haffar, is an ophthalmologist who was born in Buenos Aires. Since the year 2006 he has been performing his activity uninterruptedly at the Hospital Santa Lucia in Buenos Aires, Argentina. He works as an instructor of surgeons in the Hospital Ocular Surgery Service, performing cataract, refractive, glaucoma, ocular surface and emergency surgeries.He also works as head of the anterior segment surgery service in the Centro de Investigacion y Tratamiento Ocular (CITO). He had worked as a teacher at the University of El Salvador in the advanced course of Ophthalmology, andnow he teaches in theadvanced course at the Universidad de Buenos Aires office (UBA) in Hospital Santa Lucia. . 29th International Conference on Insights in Ophthalmology; Webinars- June 17-18, 2020 Abstract Citation: Matias S. Haffar, Cataract surgery and dry eye syndrome. Visual outcomes. Patient's satisfaction., 29th International Conference on Insights in Ophthalmology; Webinars- June 17-18, 2020 (https://ophthalmology.insightconferences.com/ocm/2020/matias-haffar-hospital-santa-luc-a-buenos-aires-france )

Risk Factors for Glaucoma Drainage Device Failure and Complication in the Pediatric Population

Report factors associated with failure and complication in a cohort of children who have undergone glaucoma drainage device (GDD) implantation. Retrospective case series. Consecutive pediatric GDD eyes that met criteria between May 1997 and July2019. Entries were included for analysis if age <18 years at the time of GDD implantation. Failure was defined as an intraocular pressure (IOP) greater than 21 mmHg or IOP reduction <20% or IOP <5 mmHg at 2 consecutive follow-up visits >3 months after implantation, reoperation for glaucoma, or loss of light perception vision. Complications were defined as postoperative events due to the GDD that required additional examination under anesthesia or additional surgery. Survival analyses of surgical failures and complications. Over a mean follow-up period of 5.4 years, 58 (38%) of 150 first-time GDD implants failed. Glaucoma associated with acquired conditions had decreased risk for failure when compared with glaucoma secondary to nonacquired systemic diseases (hazard ratio [HR], 12; P= 0.0063), nonacquired ocular anomalies (HR, 12; P= 0.0054), and primary congenital glaucoma (HR, 5.4; P= 0.041). There was an increased risk of failure for first-time tubes in younger patients with a 23% reduction of failure with each 3-year increase in age (HR, 0.77; P= 0.034). A total of 38 (25.3%) of the first-time GDD implantations had a complication. Higher preoperative IOP (5 mmHg increase; HR, 1.2; P= 0.038) and younger age (<3 years; HR, 2.1; P=0.024; < 2 years, HR, 1.9; P= 0.046) increased the risk of complication. There were 22 second-time GDD implants in the study, of which 11 failed (50%), and increased risk for failure was associated with younger age at the time of implantation (<1 year; HR, 27; P= 0.0053) and concurrent glaucoma-related procedures with or without non-glaucoma anterior segment surgery at the time of implantation (HR, 13; P= 0.0085). Although GDD implantation in children is relatively safe and effective, these data should be interpreted in the context of children's relative longevity. These findings offer an outcome metric to which future novel glaucoma procedures in children can be compared.

Peri-Operative Intracameral Antibiotics: The Perfect Storm?

In our University journal club we discussed a large, retrospective study of cataract surgery endophthalmitis rates before and after instituting the use of an intracameral fluoroquinolone antibiotic. We identified several factors involved in the use of off-label, compounded moxifloxacin in intraocular surgery. The introduction of phacoemulsification for cataract surgery led to the potential for smaller incisions. Intraocular lens technology improved to allow for foldable lenses, obviating the requirement to enlarge the incision. This allowed for clear corneal incisions, which unfortunately allow bidirectional passage of liquid. Preservatives were introduced into multi-dose ophthalmic products in the mid 20th century to retard microbial growth. However, more recently, chronic use of benzalkonium chloride has led to concerns about concerns about conjunctival toxicity, especially in patients with ocular surface disease. In the formulation of ocular moxifloxacin, developers were able to develop a "self-preserved", multi-dose product. Other concerns with eyedrops include varying levels of adherence and performance, and the expansion of compounding pharmacies from a named-patient basis to widespread national delivery, with concerns for lower quality. Integrating these factors, use of intracameral moxifloxacin as a prophylactic during cataract and other anterior segment surgery has become a standard of care in much of the U.S. We are concerned that the current position is on a narrow ledge-the standard of care for millions of surgeries each year based upon off-label, compounting use of a single product. We discuss possible ramifications and solutions to this public health issue.

Microscope-integrated Intraoperative Optical Coherence Tomography for Anterior Segment Surgical Maneuvers.

PurposeTo evaluate the potential value of microscope-integrated optical coherence tomography (MI-OCT) in anterior segment surgical maneuvers.MethodsTwenty-four ophthalmology residents, who were randomly and evenly divided into two groups, performed four anterior segment surgical maneuvers (corneal tunnel, scleral tunnel, simple corneal suture, and corneal laceration repair) on porcine eyes with (group B) or without (group A) real-time MI-OCT feedback. All residents performed the maneuvers again without MI-OCT.ResultsCompared with group A, group B (with MI-OCT) showed better accuracy in the length/depth of the corneal tunnel and the length of the scleral tunnel. However, both groups showed similar performances in the depth of both the simple corneal suture and the corneal laceration suture. When both groups performed the maneuvers again without MI-OCT, group B still showed better results than group A for the length of both the corneal and scleral tunnels.ConclusionsPrimary results suggest that real-time MI-OCT images are valuable for some anterior segment surgical maneuvers and could be helpful in surgical training.Translational RelevanceMI-OCT systems can be valuable in improving accuracy and decision making during anterior segment surgery and will be useful in surgical training.

Is a Final Splint Necessary in Bimaxillary Orthognathic Surgery?

For bimaxillary orthognathic surgery, a splint is commonly used to achieve the final occlusion and is then maintained through initial skeletal healing. The purpose of this study is to document how often a final splint is used to achieve the planned intraoperative occlusion, and how often is the final splint retained after surgery to maintain the occlusion during the initial skeletal healing phase.The investigators developed a retrospective case series. The study variables were demographic and operative. The outcome variables were the use of a final splint to achieve the desired intraoperative occlusion; the frequency and clinical indication for maintaining the final splint during the 5-weeks of initial skeletal healing; and the occlusion achieved after initial healing (5 weeks) compared to that planned from model surgery. Descriptive statistics were reported.The study sample was composed of 41 consecutive subjects. The mean age at operation was 26.9 ± 11.8 years and 51% of the subjects were male. Twenty-five subjects required segmental maxillary surgery. The final splint was used in 39% of subjects to achieve final occlusion and maintained postoperatively in only 10%. No subjects developed transverse relapse during the initial healing phase (5-weeks). All subjects with planned immediate mid-arch open-bites (n = 8) showed vertical improvement or closure during the initial healing when the splint was not maintained.The use of a final occlusal splint and then maintenance of the splint through initial skeletal healing is not required in the majority of bimaxillary orthognathic surgery cases to achieve the planned occlusion.

One stage or two? A cohort analysis of anterior-posterior spinal fusions for severe pediatric scoliosis.

Retrospective case-series study of prospectively collected data. We sought to identify the differences in outcomes between one-stage (single surgical episode) and two-stage (separate day) anterior and posterior spinal fusion and segmental spinal instrumentation surgeries in severe non-idiopathic and idiopathic scoliosis cases. Patients with severe pediatric spine deformity may require combined anterior and posterior fusion procedures. Given their increased complexity and morbidity, surgeons may consider staging these procedures on separate days. A retrospective cohort study was performed on a prospective Pediatric Spine Database. Patients 21years of age or under with pediatric scoliosis who underwent primary anterior and posterior spinal deformity correction surgery either through a one-stage or planned two-stage sequence with greater than 2-year follow-up were included. Differences in demographics, comorbidities, surgical details, perioperative morbidity, complications, and outcomes were assessed based on scoliosis etiology. Multivariate models were utilized to control for confounders. There were 70 non-idiopathic (14 two-stage vs. 56 one-stage) and 65 idiopathic scoliosis (8 two-stage vs. 57 one-stage) patients. Mean follow-up was 90.1 ± 54.7months. In non-idiopathic scoliosis patients, two-stage surgery was independently associated with a 140-min increased surgical time (95% confidence interval: 52-229min, p = 0.002) and an 8.2-day (95% confidence interval: 2.3-14.1days, p = 0.007) increased hospital length of stay. In idiopathic scoliosis patients, two-stage surgery was independently associated with a 2108ml increase in crystalloid use (95% confidence interval: 834-3381ml p = 0.002) and a 5.3-day increased hospital length of stay (95% confidence interval: 4.0-6.5days, p < 0.001). There were no significant differences in blood loss, transfusions, complications, or post-operative curves on multivariate analysis between one-stage and two-stage surgery cohorts in either non-idiopathic or idiopathic scoliosis patient groups. Two-stage surgery was associated with increased crystalloid use in idiopathic scoliosis patients and longer operative times in non-idiopathic scoliosis patients, and longer hospital length of stay in both populations, without significant difference in complications or deformity correction. In the appropriate patient, one-stage anterior-posterior scoliosis surgery may be preferable to two-stage surgery. Level III Retrospective Comparative Study.

A New Two-Step Anesthesia for 23- or 25-Gauge Vitrectomy Surgery: A Prospective, Randomized Clinical Trial

Objective: To investigate the safety and efficacy of topical anesthesia combined with subconjunctival anesthesia (termed two-step anesthesia) for 23- or 25-gauge pars plana vitrectomy or other posterior segment surgery. Methods: Patients (n = 90) requiring 23-/25-gauge vitrectomy or other posterior segment surgery were randomized into 3 groups. Group 1 received peribulbar anesthesia, group 2 received retrobulbar anesthesia and group 3 received two-step anesthesia. A 5-point visual analog pain scale (VAPS) was used to measure self-report of patient pain. Complications were recorded for subsequent analysis. Results: VAPS scores for overall intraoperative pain ranged from 0 to 3 (1.07 ± 1.07) in group 1, from 0 to 2 (0.69 ± 0.93) in group 2 and from 0 to 3 (1.06 ± 0.98) in group 3. Assessment of surgeon discomfort score ranged from 0 to 2 (0.31 ± 0.66) in group 1, from 0 to 3 (0.38 ± 0.82) in group 2 and from 0 to 2 (0.47 ± 0.62) in group 3. Both scores reveal no significant difference among the 3 groups. While there were no complications noted in group 1, there was an ocular perforation in group 2. Additionally, there were no complications in group 3 related to the anesthetic technique. Conclusions: Results suggest that two-step anesthesia is a safe and effective anesthetic approach for selected patients undergoing 23- or 25-gauge pars plana vitrectomy or other posterior segment surgeries. It may offer a viable alternative to peribulbar anesthesia and retrobulbar anesthesia for carefully selected 23- or 25-gauge cannular-access ocular surgeries.

Shifting Paradigm: From General Anesthesia to Local Anesthesia in Posterior Segment Surgeries

Purpose: To evaluate the methods of anesthesia in posterior segment surgeries.Study Design: Cross sectional survey.Place and Duration of Study: Akhtar Saeed Medical College, from April 2017 to May 2019.Material and Methods: Two hundred and three patients who underwent posterior segment surgeries wereselected. Average surgery time was 45 minutes under local anesthesia (LA). All patients whose surgery was performed in general anesthesia (GA), had at least 6 hours hospital stay andfour hours nothing by mouth before and after procedure. Patient age, gender, indication for surgery, type of surgery performed and type of anesthesia were noted. Datawas analyzed by using SPSS 25.Results: Total 203 patients were included in study, 122 (60.1%) male and 81 (39.9%) females. Generalanesthesia (GA) was used in 18.2% surgeries and local anesthesia (LA) was opted in 81.8%. Mean age ofpatients who underwent GA was 30.62 years and 51.71 years for LA. Three major indications for LA were retinalattachment surgery 64 (38.6%), vitreous hemorrhage 20 (12%) and endophthalmitis in 12 (7.2%) patients.Indications for surgery under GA were surgery for retinal detachment in 23 (62.2%), endophthalmitis 6 (16.2%)and removal of silicon oil 2 (5.4%). PPV was done in 64.5% patients under LA and 9.8% in GA but all combinedprocedures (PPV and scleral buckling) were done under GA.Conclusion: The local anesthesia is favorable for posterior segment ocular surgeries in term of less hospitalstay, no need of NPO, fast recovery and cost effectiveness