Preemptive pregabalin for postoperative analgesia during minimally invasive hysterectomy: a systematic review and meta-analysis of randomized controlled trials

We aimed to perform a systematic review and meta-analysis of all randomized placebo-controlled trials (RCTs) that examined the analgesic benefits of preemptive pregabalin among patients undergoing minimally invasive hysterectomy. Five major databases were systematically screened from inception until August 29, 2021 Relevant studies were evaluated for risk of bias. Endpoints were analyzed using the random-effects model and pooled as the mean difference or risk ratio with a 95% confidence interval. Four studies with seven treatment arms met the inclusion criteria. The total sample size was 304 patients: 193 and 111 patients were allocated to the pregabalin and placebo groups, respectively. Overall, the included studies revealed a low risk of bias. The summary results revealed that the mean postoperative pain scores at rest were significantly lower in the pregabalin group than in the control group at 0, 2, 4, 6, 12, and 24 hours. Moreover, the mean postoperative pain scores on movement/coughing were significantly lower in the pregabalin group than in the control group at 12 and 24 hours. The rate of patients who were opioid-free postoperatively was significantly higher in the pregabalin group than in the control group. There was no significant difference between the groups in terms of the mean postoperative time to first rescue analgesic and the rates of adverse events. Compared with placebo, preemptive pregabalin was largely safe, and was correlated with superior analgesic effects in terms of lower postoperative pain scores and higher opioid-sparing effects. Additional RCTs are needed to confirm these findings.

Evaluation of an accommodating intraocular lens

Introduction: Conventional intraocular lenses [IOLs] that focus light at a fixed distance provide excellent visual outcomes in most patients who have cataract extraction. However, most patients require reading glasses or bifocals for near vision, Steinert et al, [1999]. Replacing the natural lens with a multifocal intraocular lens that provides multiple focal distances for both near and distance vision offers an alternative to patients who need near vision correction after cataract surgery, Wolffsohn, et al. [2006]. The optical quality of the retinal image is worse than the retinal image produced with a monofocal IOL. The loss of image quality can affect visual performance and has led to an interest in alternative modalities for correcting near vision in pseudophakic patients, Steinert et al, [1999]. By using the new accommodating IOLs, ophthalmic surgeons will be able to provide a full range of visual focus in each eye of a patient to maintain binocular function while also avoiding visual disturbances that are experienced with monovision and multifocal IOLs, Doane [2004] . The Crystalens AT-45 [Eyeonics], is an accommodating, foldable, multi-piece plate shaped IOL. [Eyeonics Crystalens fact sheet]

Aim of the work: This research was designed to study the efficiency of the foldable accommodating IOL; Crystalens [AT-45] in the restoration of both distant and near visual acuity after phacoemulsification. Also, assessment of the IOL's possible displacement during accommodation and the accompanying modifications of the ciliary body and anterior chamber depth by using ultrasound biomicroscopy [UBM]

Patients and methods: This study comprised twenty five eyes of 25 patients [12 females and 13 males]. Patients had no preexisting ocular conditions other than cataract. All patients were subjected to phacoemulsification and Crystalens AT-45 [Eyeonics Inc.] implantation. All patients were above 45 years old and expressed a preference for spectacle independence. Postoperatively, measuring the monocular distant visual acuity [uncorrected and best corrected] and visual acuity for near [uncorrected, through a distance correction and best corrected with near add] were done. UBM was used to examine the anterior chamber depth and the shift of the IOL along the visual axis in response to ciliary muscle pharmacological stimulation

Results: The mean age was 52.23 +/- 5.3 years [Ranged from 45 to 65 years]. All surgeries were uneventful with no complications or adverse events. The mean preoperative decimal uncorrected visual acuity [UCVA] was 0.08 + 0.05. The mean preoperative best corrected visual acuity [BCVA] was 0.1 +/- 0.06. After 6 months follow up, the mean postoperative UCVA was 0.52 +/- 0.17; BCVA was 0.94 +/- 0.18. The mean uncorrected near visual acuity [UCNVA] was J5; distance corrected near visual acuity [DCNVA] was J5. The mean Add near correction was +/- 1.58 +/- 0.21 D. The mean postoperative anterior chamber depth was 4 mm +/- 0.55 and after pharmacological stimulation with 2% Pilocarpine, the mean depth was 3.5 +/- 0.35mm. The amplitude of accommodation was calculated by both an objective and subjective methods. The mean postoperative amplitude of accommodation was 0.91 +/- 0.27 D. Faint opacification was observed in 3 eyes at the first month postoperatively, and in 8 eyes at six months postoperatively

Conclusions: Accommodating IOL provides patients with excellent visual acuities both for distance and near. It should be considered to allow cataract patients to be spectacle independent. We have the clinical impression that the degree of pseudophakic accommodation provided with Crystalens is useful for patients' daily life. The accommodation range depends on the displacement of optic which is controlled by the range of ciliary body effect [contraction and anterior rotation]

Comparison of intravitrea injection of triamcinolone acetonide and bevacizumab as a primary treatment of diffuse diabetic macular edema

Introduction: Diabetic retinopathy is the leading cause of blindness in patients aged 20-74 years in the United States, Chew and Ferris [2001]. Diabetic macular edema [DME] is a manifestation of diabetic retinopathy that produces loss of central vision, Klein, et al., [1984]. Two different subtypes of DME are recognized. Focal macular edema, and diffuse macular edema, Ciardella, et al., [2004]. Intravitreal injection has been proposed as a new technique in the treatment, Jonas, et al., [2003]. Triamcinolone Acetonide [TA] is a synthetic glucocorticoid analog with marked anti-inflammatory action, used to take the advantage of its antiedematous effect, Jonas and Sofker [2001]. Anti-vascular endothelial growth factor [VEGF] therapy has probably been one of the most promising breakthroughs in medical retina treatment, Brwon, et al., [2006]. Bevacizumab, a full length monoclonal antibody binding all isoforms of VEGF, Michels, et al., [2005] and Moshfeghi, et al., [2006] . Bevacizumab is rapidly becoming one of the leading treatments for neovascular diseases,Fung, et al., [2006] and Jorge, et al., [2006]

Aim of the work: The aim of this study is to compare the short term effect of single intravitreal injection of Triamcinolone Acetonide [as a corticosteroid] and Bevacizumab [as an anti-VEGF] for treatment of diffusediabetic macular edema

Patients and methods: 30 eyes of 30 diabetic patients were enrolled in this prospective study. All patients were type 2 diabetics on oral hypoglycemic drugs with 8 years or more duration since the diagnosis of their diabetes mellitus . All of them had diffuse macular edema with central macular thickness of more than 300 microm. Patients were divided into two groups. Group I assigned for intravitreal injection of 4mg [0.1ml] Triamcinolone Acetonide and Group II assigned for intravitreal injection of 1.25mg [0.05 ml] Bevacizumab. All patients were examined before entry into the study then first day post injection then weekly for the first month then at the end of second and three months. In each visit patients were examined as routine ophthalmic examination with best corrected visual acuity and stereoscopic fundus examination. Optical coherence tomography was done before injection then after the first and third months

Results: In group I, the pre-injection [baseline] mean best corrected visual acuity was 6/60 +/- [0.12] and increased to be 6/18 [0.3] after one month and at the end of third month. While in group II, the pre-injection [baseline] mean best corrected visual acuity was 6/60 [0.09] and increased to be 6/24 [0.25] after one month and 6/36 [0.17] at the end of third month. In group I, the pre-injection [baseline] mean central macular thickness was 523.2 +/- 87.1 microm. and decreased to be 287.64 +/- 91.15 microm after one month and 256.14 +/- 93.57 microm at the end of third month. While in group II, the pre-injection [baseline] mean central macular thickness was 527.7 +/- 91.8 microm and decreased to be 377.6 +/- 103microm after one month and 382.5 +/- 130.4 microm at the end of third month. No complications were noticed in both groups including increased intraocular pressure, vitreous hemorrhage and infection

Conclusion: One single intravitreal injection of Triamcinolone Acetonide may offer better effect than Bevacizumab in the short term management of diffuse diabetic macular edema especially with regard to changes in visual acuity and central macular thickness

High vacuum phacoemulsification technique in cataract surgery

Phacoemulsification offers the advantage of cataract removal through a small wound which decreases the surgical complications and enhances rehabilitation. In phacoemulsification corneal endotlielial loss was correlated to duration of ultrasound power used. The longer the duration, the greater is the loss . Increasing the power carries the risk of increasing the insult. While decreasing the power causes less effective cutting power and more stress on capsule and zonules. Vacuum is one of the tools that can be used in phacoemulsification. It can be used as a holding power at probe port for efficient cutting. It also, aspirates soft materials and therefore reduces the need for ultrasound power. To evaluate the use of high vacuum while performing phacoemulsification and to correlate the ultrasonic power needed in relation to the vacuum level. Forty patients with 40 cataractous eyes were enrolled in this study. Their ages ranged between 53 to 65 years with a mean of 59 +/- 6.5 years. Patients were divided into two groups each containing 20 patients [eyes]. Group I underwent phacoemulsification cataract extraction with posterior chamber [PC] foldable acrylic lens using the highest possible vacuum and accordingly lowest possible ultrasound power. Group II underwent traditional phacoemulsification cataract extraction with posterior chamber [PC] foldable acrylic lens. In both groups phacoemulsification was performed in-situ using stop and chop technique. The viscoelastic substance that had been used was sodium hyalurinate [Healon]. Central corneal ultrasound pachymetry was done for all patients preoperatively. Postoperatively; patients were examined weekly in the first postoperative month then after second and third month where central corneal pachymetry was done in each visit. These pachymetric values were used as a sensitive indicator of corneal endothelial physiology. The ultrasound powers and times used in emulsification were recorded during surgeries to correlate them to the vacuum. Postoperatively; the corneal thickness had been increased in all patients due to corneal edema. This corneal edema continued to improve during the 3 months follow up period. The corneal edema postoperatively was less in group I than in group II. With the high vacuum; the ultrasound power needed was less that that needed with traditional vacuum levels. The ultrasound energy [Power x Time] was inversely proportional to the vacuum used. From our study we can conclude that using the highest possible vacuum while doing phacoemulsification is a good tool that allows the use of lower ultrasound power. This lower ultrasonic power is safer for the corneal endothelium. Thus; the final visual outcome of the phacoemulsification cataract surgery can be refined

Frontalis sling using expanded poly tetra fluoro ethylene [EPTFE] material through an open approach

Purpose: To evaluate the proposed material [EPTFE] and approach as a suitable alternative for the correction of poor levator function ptosis

Method: Twenty-one eyes with unilateral and bilateral poor levator function ptosis were subjected to the proposed frontalis sling procedure using an open approach with internal fixation using EPTFE material. Follow up ranged 1 year to 3 years

Result: All cases showed functional improvement with an average increase of 2.7 mm in palpebral fissure measurements. Regression of results was documented up to 3 months postoperative, after which lid height seemed to stabilize. No cases of slippage, extrusion or granuloma formation were encountered

Conclusion: EPTFE material, internally fixated through an open approach is a reliable and effective alternative to other materials used with conventional closed frontalis sling approach