Anterior Chamber Depth Change Following Cataract Surgery in Pseudoexfoliation Syndrome; a Preliminary Study.

PURPOSE: To assess the pseudophakic anterior chamber depth (PP-ACD) or effective lens position (ELP) change after cataract surgery in patients with pseudoexfoliation syndrome (PEX). METHODS: Consecutive eyes with PEX and cataract underwent standard phacoemulsification and were implanted with single-piece acrylic posterior chamber intraocular lenses (IOLs). Eyes with severe PEX and with axial length (AL) greater than 24 mm or less than 22 mm were not included. Eyes with capsular complication or unstable bags that needed capsular tension ring insertion were excluded. The SRK-II formula was applied to calculate IOL power for postoperative emmetropia. PP-ACD or ELP was measured using anterior segment optical coherence tomography. Data obtained at one and six months post operation were evaluated during analysis. RESULTS: Twenty-six eyes of 26 subjects (mean age: 72 years; range: 60-84 years) were studied. PP-ACD was deepened (mean change: 0.08 mm) and a concurrent hyperopic shift (0.3 D) was observed postoperatively between month 1 and month 6 (P values ≤0.002). PP-ACD and postoperative refraction changes were correlated with age and AL (P values < 0.025), respectively. Increased hyperopic shift and PP-ACD deepening in eyes with posterior capsule opacification (PCO) was noted postoperatively at six months, but the difference was not statistically significant (P values = 0.15 and 0.2, respectively). CONCLUSION: After cataract surgery in eyes with PEX syndrome, a significant backward movement of the IOL occurs postoperatively in the first six months, which is associated with a concurrent small hyperopic shift.

Idiopathic granulomatous lobular mastitis - report of 43 cases from iran; introducing a preliminary clinical practice guideline.

BACKGROUND: We aimed to report a large series of idiopathic granulomatous lobular mastitis (IGLM) from Iran and sketch preliminary clinical practice guidelines (CPG) for approaching an inflammatory breast mass. PATIENTS AND METHODS: In a retrospective records review, 43 consecutive IGLM cases were studied. Data on baseline, clinical, imaging, and pathologic characteristics were collected. RESULTS: The mean age of the women was 33.5 years. All but 1 were married and had given birth. 16% had a cancer-like presentation. Inflammatory signs, architectural distortion, and a nodular pattern were the most common findings clinically, mammographically and ultrasonographically, respectively. 29.5% of the pathological reports indicated necrosis which was more common in younger subjects (p = 0.016); microabscesses were associated with a shorter lactation course (p = 0.006). Corticosteroids had been used as the initial treatment modality in 51%, immunosuppressive agents had not been administered, and a 16% relapse rate was recorded. We recognized the need for a multidisciplinary approach covering radiology, oncology, and surgery to best handle diagnostic and therapeutic issues and manage relevant infections as well as the major differential diagnosis, i.e. malignancy. CONCLUSION: We hypothesized that a shorter lactation period may cause more milk stasis and extravasation and be contributory to IGLM. CPGs are needed to incorporate the needed multidisciplinary approach and to standardize IGLM care. We present one such guideline.

An algorithm for glaucoma screening in clinical settings and its preliminary performance profile.

PURPOSE: To devise and evaluate a screening algorithm for glaucoma in clinical settings. METHODS: Screening included examination of the optic disc for vertical cupping (≥0.4) and asymmetry (≥0.15), Goldmann applanation tonometry (≥21 mmHg, adjusted or unadjusted for central corneal thickness), and automated perimetry. In the diagnostic step, retinal nerve fiber layer imaging was performed using scanning laser polarimetry. Performance of the screening protocol was assessed in an eye hospital-based program in which 124 non-physician personnel aged 40 years or above were examined. A single ophthalmologist carried out the examinations and in equivocal cases, a glaucoma subspecialist's opinion was sought. RESULTS: Glaucoma was diagnosed in six cases (prevalence 4.8%; 95% confidence interval, 0.01-0.09) of whom five were new. The likelihood of making a definite diagnosis of glaucoma for those who were screened positively was 8.5 times higher than the estimated baseline risk for the reference population; the positive predictive value of the screening protocol was 30%. Screening excluded 80% of the initial population. CONCLUSION: Application of a formal screening protocol (such as our algorithm or its equivalent) in clinical settings can be helpful in detecting new cases of glaucoma. Preliminary performance assessment of the algorithm showed its applicability and effectiveness in detecting glaucoma among subjects without any visual complaint.

Pain and Its Determinants in Photorefractive Keratectomy.

PURPOSE: To assess the determinants of early postoperative pain in photorefractive keratectomy. DESIGN: A prospective cross-sectional study. METHODS: One hundred and four myopic-astigmatic patients undergoing bilateral standard photorefractive keratectomy were evaluated for early postoperative pain severity. On day 1 postoperatively, the level of pain experienced was reported by the patient on a visual analog scale of 0 to 10. At the preoperative interview, data were collected on clinical, demographic, and social characteristics to find potential pain determinants. RESULTS: The median reported pain level was 3. About 20% of subjects reported a pain score of 6 or higher, and 2.9% (6 eyes of 4 patients) reported the highest pain score. The presence of external eye inflammatory signs was associated with higher levels of pain (P < 0.001). Patients with a higher body mass index reported more severe pain (P = 0.006). An inverse association was found between pain and harmful lifestyle choices (P = 0.008). Demographic characteristics, history of contact lens wear, history of major operation, past experience of severe pain, knowledge about the operation's adverse effects, preoperative insomnia, preoperative anxiety, operative factors, and refractive indices were not related to the severity of pain experienced (all P > 0.05). CONCLUSIONS: The association of pain with ocular surface inflammation suggests that inflammatory processes have a role in early postoperative pain, supporting the use of anti-inflammatory agents for pain management. Prescription of weight-adjusted dosages of analgesics is recommended on the basis of the association between severity of postoperative pain and body mass index.

Transition to phacoemulsification at the farabi eye hospital, iran.

PURPOSE: To provide objective evidence on the transition of cataract surgical care at Farabi Eye Hospital, Iran. MATERIALS AND METHODS: Two separate years, 2003 and 2006, were selected for evaluation. One thousand nine hundred fifty-seven surgical records of age-related cataract cases were randomly selected and reviewed. Three hundred fifty-three patients (405 eyes) in 2006 and 125 patients (153 eyes) in 2003 were selected randomly for a follow-up examination. The two phases were compared in terms of surgical routines, patient characteristics and outcomes for statistical differences. P <0.05 was considered statistically significant. RESULTS: The phacoemulsification rate increased from 25% to greater than 90% between 2003 and 2006, rates of corneal incisions and use of foldable intraocular lenses tripled, administration of general anesthesia dropped from 80% to 12%, the outpatient admission rate rose from 5.2% to 71%, 4% vs. 66% of the operations were performed by a senior phacoemulsification surgeon and the number of advanced surgeons changed from 6% to 38% (all P-values < 0.001). In 2006, more patients at the two extremes of age, more patients with poor systemic conditions and myopes underwent surgery (all P-values < 0.05); the cataract surgery volume increased by 49% and post-operative visual acuity improved (P = 0.03) while patient satisfaction was unchanged. CONCLUSION: We objectively documented the transition in cataract surgery technique to phacoemulsification at the Farabi Eye Hospital in the mid-2000s. This was accompanied by significant expansion of the spectrum of cataract surgery candidates and remarkable attainment of surgical skill.

Sheep practice eye for ophthalmic surgery training in skills laboratory.

UNLABELLED: Pig eyes are not available for surgical practice in the Middle East and Central Asia. We reviewed the literature to select an alternative animal practice eye based on biometry, availability, expense, and the ethical issue of animal sacrifice. Twenty enucleated sheep eyes were studied with an ultrasonography immersion technique, and a variety of techniques for globe harvesting were tested and compared. The sheep eye was judged to be the best practical choice for ophthalmic surgery practice and the "bone shattering" exenteration maneuver, the most efficient harvesting method. Several anterior segment procedures were performed in the sheep eyes. Introduction of this sheep model would be instrumental in the development of ophthalmology skills laboratories and surgical training in Middle Eastern and Central Asian regions. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Globe-fixation system for animal eye practice.

UNLABELLED: We designed a globe-fixation system for use with animal eyes for surgical skills training. The system core is a cup with an adjustable aperture. Vacuum is exerted through the cup to capture the globe at the preequatorial region. The cup rides over a hollow base, sliding on its opening spurs. A ballast is screwed to the end of the thread of the cup to create tactile feedback and create a tendency to return to the primary position. The system provides optimum versatility for the practice of anterior segment procedures, namely stability, rotation, a tendency to return to the primary position, globe pressure adjustability, and a modifiable orbit size. FINANCIAL DISCLOSURE: Disclosures are found in the footnotes.

Conceptualizing a quality plan for healthcare. A philosophical reflection on the relevance of the health profession to society.

Today, health systems around the world are under pressure to create greater value for patients and society; increasing access, improving client orientation and responsiveness, reducing medical errors and safety, restraining utilization via managed care, and implementing priority allocation of resources for high-burden health problems are examples of strategies towards this end. The quality paradigm by virtue of its strategic consumer focus and its methods for achieving operational excellence has proved an effective approach for creating higher value in many sectors. If applied in a deliberate and holistic manner, the quality paradigm can bring about a more cost-effective organization of the health systems. In this article, we apply quality concepts to healthcare in a conceptual format; we characterize the health system's customers and outputs with their quality dimensions. The product of this effort is a blueprint for a customer-driven health system which identifies six types of customers, nine types of outputs and the associated operations. As a preliminary step, a new analysis and definition of health and disease is provided. Rethinking the structure of health system in this manner and the related conceptual model can guide medical research, health sciences education, and health services policy, and help the practitioner to integrate all modern trends in healthcare delivery.

Introduction of a quality improvement program in a children's hospital in Tehran: design, implementation, evaluation and lessons learned.

BACKGROUND AND OBJECTIVE: Reports addressing continuous quality improvement (CQI) methods in developing countries are scant and there are questions about the applicability of quality improvement methods in such settings. The structure and output of a formal quality improvement program implemented in a teaching hospital affiliated with the Tehran University of Medical Sciences is presented. OBJECTIVE METHOD: During a nine-month period, a multi-stage quality improvement program was implemented. It comprised: (i) training workshops; (ii) a steering committee; (iii) weekly consultation and facilitation of improvement projects; and (iv) a day-long demonstration and recognition meeting. Four cycles of workshops were held in which 132 employees were trained in the basics of CQI. RESULTS: Thirty improvement projects were initiated. Twenty-five of the projects were completed. In an evaluation survey more than 70% of respondents assessed a 'positive impact' on organizational culture, work efficiency and quality of services. More than 90% believed that the changes were sustained, and more than 60% reported that they have implemented additional improvement projects. CONCLUSION: Our quality improvement package supported rapid implementation of multiple projects. The underlying 'change structure' comprised the improvement teams, top management and the university's quality improvement office; it integrated project management, support and facilitation functions by the respective participant. Organization-wide change was more limited than anticipated. To institutionalize the program and ensure sustainability, a local structure for change should be organized, management coaching should be sustained, local facilitators should be developed, incentives should be established and physician involvement should be emphasized.