Cataract surgery using two 3D visualization systems: Complication rates, surgical duration & comparison with traditional microscopes.

PURPOSE: To compare the complication rates and surgical duration of cataract surgery using two 3D visualization systems and a traditional binocular microscope among experienced and inexperienced surgeons. METHODS: This retrospective case series included 571 eyes that received cataract surgery using either heads up cataract surgery, via a 3D head mounted system (N = 148-Group 1) or a 3D display screen (N = 338 eyes-Group 2), or traditional binocular microscope (N = 85 eyes-Group 3). The surgical records of consecutive patients who underwent cataract surgery by two groups of surgeons (experienced and inexperienced) were reviewed. Patients in all groups received either femtosecond laser assisted cataract surgery (FLACS) or traditional phacoemulsification. Complication rate, as well as duration of cataract surgery were evaluated between all three visualization approaches, between experienced and inexperienced surgeons. RESULTS: There was no statistically significant difference in duration of surgery between all 3 visualization approaches for both experienced and inexperienced surgeons (p < 0.05). Furthermore, the type of surgical technique (manual or FLACS) did not affect the surgical duration for both experienced and inexperienced surgeons (p < 0.05). No intraoperative complications were demonstrated in the current cohort. CONCLUSIONS: The implementation of heads up-3D visualization either through a screen or a head mounted platform for cataract surgery seems to offer similar safety and efficiency as the traditional binocular microscope, and both experienced and inexperienced surgeons demonstrate the same outcomes in terms of safety and efficiency.

Outcomes of toric IOL implantation guided by iris-registered femtosecond laser capsulotomy markings.

PURPOSE: To assess the accuracy and stability of iris-registered femtosecond laser-assisted anterior capsule axis markings (compensating cyclotorsion) along with refractive and visual outcomes after toric IOL implantation. METHODS: This prospective case series included eyes with visually significant cataracts and regular corneal astigmatism ranging from 1.25D to 4.0D, which received FLACS and toric IOL implantation, at The Eye Institute of West Florida, Largo, Florida, USA. Preoperative iris registration was used in conjunction with a femtosecond laser platform to create cyclotorsion corrected axis marks at the capsulotomy edge to facilitate toric IOL axial alignment. Patients were examined one, seven and thirty days after surgery to assess capsulotomy marks axis, toric IOL axis along with visual and refractive outcomes. RESULTS: Eighteen eyes of 13 patients aged 74.35 ± 8.65 years were included. Mean pre-op CDVA was 0.24 ± 0.16 LogMAR, while mean post-op UDVA was 0.09 ± 0.09 LogMAR. Mean pre-op corneal astigmatism was 1.85 ± 0.41 D, decreasing to 0.24 ± 0.41 D of refractive astigmatism postoperatively (p < 0.001). The capsular toric axis markings were visible in 100% of eyes throughout the follow-up; the mean difference between intended capsulotomy mark axis and measured capsulotomy mark axis was 1.6°, 1.7° and 1.3 o at the 1, 7 and 30 day intervals (p > 0.05), respectively. No capsule-related or any other type of complications was noted. CONCLUSIONS: Iris-registered femtosecond laser-assisted anterior capsule axis markings are safe and may be considered as an alternative option to the known axis marking techniques for toric IOL axial alignment at the time of cataract surgery.

Argentinian Flag Sign and Its Management during Femtosecond Laser-Assisted Cataract Surgery in a Case with Intumescent Cataracts.

We describe a case of radial extension and its management during femtosecond laser-assisted cataract surgery (FLACS) in a patient with intumescent cataracts. Radial extension was observed after injection of trypan blue into the anterior chamber. Management of the extension was achieved by separation of adhesions between the incomplete capsulotomy, along with manual completion at the areas of extensions. Careful observation during FLACS capsulotomy is advised in cases of intumescent cataracts due to the release of cortex into the anterior chamber which may interfere with the delivery of the laser treatment resulting in incomplete capsulotomy patterns. Furthermore, trypan blue staining is essential to identify possible incomplete capsulotomy patterns and extensions. The Argentinian flag sign may occur after femtosecond laser-assisted capsulotomy in cases of intumescent cataracts. Proper identification of incomplete capsulotomy patterns and radial extensions should be managed with careful manual completion of the capsulotomy.

Comparative Assessment of Ergonomic Experience with Heads-Up Display and Conventional Surgical Microscope in the Operating Room.

PURPOSE: Musculoskeletal pain issues are prevalent in ophthalmic surgeons and can impact surgeon well-being and productivity. Heads-up displays (HUD) can improve upon conventional microscopes by reducing ergonomic stress. This study compared ergonomic outcomes between HUD and a conventional optical microscope in the operating room, as reported by ophthalmic surgeons in the US. METHODS: An online questionnaire was distributed to a sample of surgeons who had experience operating with HUD. The questionnaire captured surgeon-specific variables, the validated Nordic Musculoskeletal Questionnaire, and custom questions to compare HUD and conventional microscope. A multivariable model was built to identify variables that were likely to predict improvement in pain-related issues. RESULTS: Analysis was conducted on 64 surgeons (37 posterior-segment, 25 anterior-segment, and two mixed) with a mean 14.9 years of practice and 2.3 years using HUD. Most surgeons agreed or strongly agreed that HUD reduced the severity (64%) and frequency (63%) of pain and discomfort, improved posture (73%), and improved overall comfort (77%). Of respondents who experienced headaches, or pain and discomfort during operation, 12 (44%) reported their headaches improved and 45 (82%) reported feeling less pain and discomfort since they started using HUD. The multivariable model indicated the odds of reporting an improvement in pain since introducing the HUD in the operating room were 5.12-times greater for those who used HUD in >50% of their cases (P=0.029). CONCLUSION: This study indicates that heads-up display may be an important tool for wellness in the operating room as it can benefit ophthalmic surgeons across several ergonomic measures.

Heads-up Cataract Surgery: Complication Rates, Surgical Duration, and Comparison With Traditional Microscopes.

PURPOSE: To compare the complication rates and surgical duration between a three-dimensional visualization system (heads-up surgery) and traditional binocular microscope in cataract surgery. METHODS: This retrospective case series included 2,320 eyes that received cataract surgery using either a three-dimensional display system (n = 1,673 eyes) (3D group) or a traditional binocular microscope (n = 647 eyes) (traditional group). The medical records of consecutive patients who underwent cataract surgery by a single surgeon in The Eye Institute of West Florida from August 2016 to July 2017 using either a three-dimensional display system or the traditional binocular microscope for visualization were reviewed. Patients in both groups received either femto-second laser-assisted cataract surgery (FLACS) or traditional phacoemulsification. Complication rate (posterior capsular rapture and vitreous prolapse) and duration of cataract surgery were evaluated. RESULTS: The 3D group had 12 (0.72%) complications and the traditional group had 5 (0.77%) complications (P > .05). Mean surgical time was 6.48 ± 1.15 minutes for the 3D group and 6.52 ± 1.38 minutes for the traditional group (P > .05). There was no statistically significant difference in complication rate and duration of surgery between the two groups (P > .05). CONCLUSIONS: The implementation of heads-up three-dimensional visualization for cataract surgery seems to offer similar safety and efficiency as the traditional binocular microscope. [J Refract Surg. 2019;35(5):318-322.].

The Effect of NSAID Pretreatment on Aqueous Humor Prostaglandin E2 Concentration in Eyes Undergoing Femtosecond Laser-Assisted Capsulotomy.

PURPOSE: To assess aqueous humor concentration of prostaglandin E2 (PGE2) after capsulotomy creation using a femtosecond laser (FLAC) in patients pretreated with short-term topical ketorolac versus patients without pretreatment. METHODS: This prospective study comprised consecutive patients scheduled to undergo cataract surgery using a femtosecond laser platform to perform only capsulotomies. An identical protocol for preoperative mydriasis was used for all the eyes included in the study, while aqueous humor was extracted from the anterior chamber of all patients immediately after the initial side port incision. ELISA was performed to quantify aqueous humor PGE2. The patients were divided into 2 groups; in group 1, the patients received short-term topical ketorolac preoperatively, while the patients in group 2 did not receive NSAID pretreatment. RESULTS: Twenty eyes of 20 patients were included in the study (10 eyes in each group). Mean concentration of aqueous humor PGE2 after FLAC was 392.16 ± 162.00 pg/ml and 622.63 ± 331.84 pg/ml for groups 1 and 2, respectively. A statistically significant difference in aqueous humor PGE2 concentration between the two groups (p < 0.05) was demonstrated, with the eyes that received ketorolac pretreatment demonstrating a lower concentration of PGE2. CONCLUSION: Short-term topical use of ketorolac prior to FLAC seems to prevent excessive release of PGE2 in the anterior chamber of the eyes that received NSAID pretreatment when compared to the eyes that did not receive NSAIDs preoperatively.

Crystalline lens endocapsular fragmentation using an elastic loop filament.

PURPOSE: To describe a novel mechanical endocapsular fragmentation technique of the crystalline lens during cataract surgery using a loop elastic-thin filament. METHODS: An alternative method to mechanically fragment the crystalline lens utilizing a nitinol loop is described. This device achieves lens sectioning in multiple pieces, decreasing ultrasonic energy expenditure during cataract surgery. RESULTS: Endocapsular fragmentation of crystalline lens was achieved using a nitinol loop filament, without the use of ultrasound energy. CONCLUSION: This surgical technique demonstrates that a micro loop filament may be used as an alternative surgical approach for energy-free mechanical endocapsular nucleus disassembly and fragmentation.

Cyclorotation during femtosecond laser-assisted cataract surgery measured using iris registration.

PURPOSE: To assess ocular cyclorotation of eyes having femtosecond laser-assisted cataract surgery using iris registration. SETTING: Eye Institute of West Florida, Largo, Florida, USA. DESIGN: Retrospective cases series. METHODS: Charts of patients who had femtosecond laser-assisted cataract surgery with preoperative and intraoperative iris registration in 1 or 2 eyes between November 2015 and March 2016 were reviewed. Cyclorotation was assessed via iris-registration acquired preoperatively using the Cassini topographer (patient in upright position) and intraoperatively using the iris registration option of the Lensar laser system (patient in supine position) acquired immediately before the laser treatment. RESULTS: The study comprised 241 patients (337 eyes). The mean age of the 107 men and 134 women was 68.0 years ± 9.0 (SD) (range 37 to 90 years). The mean absolute value of cyclorotation was 5.81 ± 4.20 degrees (range 0 to 17 degrees), which was statistically significant when comparing the preoperative axis with the intraoperative axis deviation (P < .0001). Overall, incyclorotation (67.4%) was more common than excyclorotation (30.9%). In patients having bilateral femtosecond laser-assisted cataract surgery, bilateral incyclorotation (47.37%) was the most common occurrence. CONCLUSIONS: During femtosecond laser-assisted cataract surgery, clinically significant cyclotorsion that might influence astigmatism correction outcomes can occur in patients having cataract extraction. Iris registration was useful in accounting for cyclorotation during this procedure when corneal or intraocular lens-based forms of astigmatic corrections will be used.

Dysfunctional tear syndrome: dry eye disease and associated tear film disorders - new strategies for diagnosis and treatment.

Dysfunctional tear syndrome (DTS) is a common and complex condition affecting the ocular surface. The health and normal functioning of the ocular surface is dependent on a stable and sufficient tear film. Clinician awareness of conditions affecting the ocular surface has increased in recent years because of expanded research and the publication of diagnosis and treatment guidelines pertaining to disorders resulting in DTS, including the Delphi panel treatment recommendations for DTS (2006), the International Dry Eye Workshop (DEWS) (2007), the Meibomian Gland Dysfunction (MGD) Workshop (2011), and the updated Preferred Practice Pattern guidelines from the American Academy of Ophthalmology pertaining to dry eye and blepharitis (2013). Since the publication of the existing guidelines, new diagnostic techniques and treatment options that provide an opportunity for better management of patients have become available. Clinicians are now able to access a wealth of information that can help them obtain a differential diagnosis and treatment approach for patients presenting with DTS. This review provides a practical and directed approach to the diagnosis and treatment of patients with DTS, emphasizing treatment that is tailored to the specific disease subtype as well as the severity of the condition.

Review of Top 10 Prescribed Drugs and Their Interaction with Dental Treatment.

The proportion of people over age 60 is growing faster than any other group. Many patients take several medications to manage multiple chronic medical conditions. Poor oral health is common and dental visits by patients over the age of 65 are increasing. The dentist must recognize that these medications may interact with dental treatment. This article reviews the top 10 prescribed drugs as listed in the IMS Institute national prescription audit in January 2015 and reviews the interactions between these medications and dental treatment. The medications reviewed include levothyroxine, acetaminophen/hydrocodone, lisinopril, metoprolol, atorvastatin, amlodipine, metformin, omeprazole, simvastatin, and albuterol.

Use of recombinant factor VII for tooth extractions in a patient with severe congenital factor VII deficiency: a case report.

BACKGROUND AND OVERVIEW: Patients with factor VII deficiency have an increased risk of prolonged perioperative hemorrhage. In this article, the authors present a case of severe factor VII deficiency in a patient who required tooth extraction. CASE DESCRIPTION: A 44-year-old woman with severe congenital factor VII deficiency sought care for a symptomatic, carious, and nonrestorable maxillary right second molar that required extraction. The authors obtained hematologic consultation, and the patient underwent the extraction under general anesthesia in the inpatient setting. Perioperative management included performing relevant laboratory studies, preoperative recombinant factor VII infusion, and postoperative intravenous aminocaproic acid administration. No hemorrhagic complications occurred throughout the perioperative course. CONCLUSIONS AND PRACTICAL IMPLICATIONS: The degree of factor VII deficiency correlates poorly with bleeding risk. Perioperative management is variable, requiring preoperative consultation with a hematologist.

Incidental treatment of maxillary dysesthesia with maxillary sinus lift procedure--a case report.

A 54-year-old woman presented with an 8-month history of dysesthesia to the left palate with referred pain to the left infraorbital distribution after extraction of the left maxillary first and second premolars. The clinical and radiologic examination revealed an alveolar crestal bone dehiscence suggestive of an occult oral antral communication (OAC) that had spontaneously healed. Stimulation of the mucosa at this bony dehiscence consistently reproduced the dysesthesia. A sinus lift procedure was performed in this region for implant site development and also resulted in resolution of the dysesthesia. This case represents an instance in which surgical alteration of a trigger zone of neuropathic pain can result in its resolution.

Thyroid crisis in the maxillofacial trauma patient.

Thyroid crisis, also known as thyroid storm, is a rare complication of thyrotoxicosis that results in a hypermetabolic and hyperadrenergic state. This condition requires prompt recognition and treatment because the mortality from thyroid crisis approaches 30%. Thyrotoxicosis alone will usually not progress to thyroid crisis. Thyroid crisis will typically be precipitated by some concomitant event such as infection, iodine-containing contrast agents, medications such as amiodarone, pregnancy, or surgery. Trauma is a rare precipitator of thyroid crisis. Several published studies have reported thyroid crisis resulting from blunt or penetrating neck trauma. Significant systemic trauma, such as motor vehicle accidents, has also been reported to precipitate thyroid crisis. It is very unusual for minor trauma to precipitate thyroid crisis. In the present study, we report the case of a patient who had incurred relatively minor maxillofacial trauma and developed thyroid crisis 2 weeks after the initial trauma.

Composite three-layer closure of oral antral communication with 10 months follow-up-a case study.

PURPOSE: We propose a 3-layer composite closure technique for an oral antral communication (OAC) while avoiding secondary donor site morbidity. PATIENTS AND METHODS: A patient had developed a 1-cm OAC after extraction of right maxillary first molar. The patient subsequently developed acute maxillary sinusitis. The patient was taken to the operating room, and a Caldwell-Luc procedure was performed. The bony window from the Caldwell-Luc was "press fit" over the bony OAC defect. Soft tissue closure was then achieved with a buccal fat pad flap and a buccal mucosal advancement flap. The patient was examined on postoperative day 5 and 1, 2, 3, 6, and 10 months postoperatively. RESULTS: The acute sinusitis had resolved. The soft tissue closure was successful. The bone graft remained intact, prevented sinus pneumatization, and restored continuity to the floor of the maxillary sinus. CONCLUSIONS: The presented technique for 3-layer closure of OACs allows for the stability of a double-layer closure of OAC with the added benefit of bone grafting from single operative site, achieving stable oral antral closure, bone grafting, and the avoidance of secondary donor site morbidity.

Risk of airway embarrassment during root canal therapy.

BACKGROUND: Root canal therapy (RCT) is a commonly performed dental procedure that has a good success rate. Complications of RCT usually are minor, but severe complications can occur. CASE DESCRIPTION: A 59-year-old Hispanic man with no history of coagulopathy started to hemorrhage profusely from the mesiolingual canal of the right mandibular first molar (tooth no. 30) during RCT. The general dentist practitioner briefly controlled the hemorrhaging by packing a gutta-percha point into the mesiolingual canal. Shortly afterward, the patient developed an expanding hematoma in the submandibular space. The authors extracted tooth no. 30, raised buccal and lingual flaps, and evacuated the hematoma. PRACTICAL IMPLICATIONS: It is possible for clinicians to encounter significant hemorrhaging and airway compromising swelling when performing root canal therapy. Clinicians must recognize and understand how to manage such complications when they occur.

Surgical anatomy of the nasal cavity and paranasal sinuses.

The oral cavity and its bony components (maxilla and mandible), along with the nose and its related sinuses, constitute most of the face. Because of their proximity, disease in one may affect the other, whereas trauma of the midface will involve bones common to the oral cavity, nose, and paranasal sinuses. The two serve important life-supporting functions, being the portals for nutrition and respiration. The paranasal sinuses are pneumatic cavities lined by mucous membrane and communicate directly with the nasal cavity. This article presents a brief but relevant view of the surgical anatomy of the nasal cavity and paranasal sinuses.

Prospective multicenter trial assessing effectiveness, refractive predictability and safety of a new aberration free, bi-aspheric intraocular lens.

PURPOSE: To determine the effectiveness and safety of the Softec HD IOL; and to present refractive outcomes for lenses manufactured at an IOL power tolerance of 0.11 D. METHODS: Three-hundred and ninety adult patients requiring removal of a cataractous lens with implantation of a monofocal IOL in at least one eye were eligible for study participation across eight US investigative sites. Patients were enrolled unilaterally. After routine surgery, subjects were examined for adverse events (AEs), best corrected visual acuity (BCVA) and manifest refraction correction at 12 months postoperatively. RESULTS: Three-hundred and sixty-six (95%) of patients completed the 12-month postoperative visit. The percent of patients achieving best corrected Snellen acuity 20/40 or better was 98.9%, and 81.1% of patients achieved best corrected Snellen acuity 20/25 or better. Of those patients (80%) implanted with a lens available in 0.25 D increments (manufactured at a tolerance of 0.11 D) 40.9%, 69.8% and 93.8% of patients were within ±0.25 D, ±0.50 D and ±1.0 D of predicted target refraction respectively. Overall incidence of cumulative and persistent IOL Grid AEs was 2.2% with no AE meeting or exceeding the FDA Grid of Historical Controls. CONCLUSIONS: The Softec HD IOL is a safe and effective lens. The high manufacturing tolerance of the lens appears to enhance refractive outcomes.