Monitored anesthesia care by registered respiratory therapists during cataract surgery: an update.

OBJECTIVE: To reevaluate the safety and practicality of registered respiratory therapists (RRTs) providing monitored anesthesia care during cataract surgery. DESIGN: Prospective observational cohort study. PARTICIPANTS: A total of 15,440 consecutive patients undergoing phacoemulsification cataract surgery with intraocular lens insertion using topical anesthesia +/- intravenous (IV) sedation at 2 surgical centers. METHODS: Registered respiratory therapists, specially trained as anesthesia assistants, provided monitored anesthesia care during all stages of surgery, with an anesthesiologist immediately available for consultation as required. MAIN OUTCOME MEASURES: The primary outcome measure was the rate of serious perioperative medical complications relating to the surgery and anesthesia. The secondary outcome measure was the rate (total and by stage of surgery) of anesthesiologist intervention, defined as consultation by the RRT to the attending anesthesiologist for any reason irrespective of the ultimate level of patient care rendered. Patient age and American Society of Anesthesiology (ASA) Physical Status (PS) score were also analyzed as potential predictors of the need for anesthesiologist intervention. RESULTS: There were no serious perioperative medical complications leading to death, endotracheal intubation, or postoperative hospitalization. A total of 395 cases (2.6%) required anesthesia intervention, with 257 (1.7%) occurring preoperatively, 140 (0.91%) occurring intraoperatively, and 5 occurring (0.03%) postoperatively. Seven cases required interventions at 2 different stages of surgery. Mean patient age in the anesthesiology intervention group (73.2 years) was greater than in the non-intervention group (71.2 years) (P = 0.0002), whereas patient age of > or =75 years correlated with a greater need for intervention (3.0%) than <75 years (2.2%) (P = 0.001). The mean ASA PS score was higher for cases requiring anesthesiology intervention (2.6) than for those not requiring intervention (2.2) (P<0.0001), and the intervention rate was significantly greater for cases with ASA ratings > or =3 (5.9%) compared with < or =2 (1.3%) (P<0.0001). CONCLUSIONS: We have demonstrated that allowing RRTs to provide monitored anesthesia care during cataract surgery with an anesthesiologist available as required seems to be both safe (no serious medical complications in 15,440 cases) and practical (anesthesiology intervention rate of 2.6%).

ASCRS White Paper: clinical review of intraoperative floppy-iris syndrome.

Intraoperative floppy-iris syndrome (IFIS) is associated with the use of systemic alpha(1)-antagonists, and tamsulosin in particular. The incidence and severity of IFIS are variable; however, the syndrome is associated with a higher rate of cataract surgical complications, especially when the condition is not recognized or anticipated. Questioning cataract patients preoperatively about current or previous use of alpha(1)-antagonists is therefore important. Intraoperative floppy-iris syndrome surgical management strategies include pharmacologic measures, the use of high-viscosity ophthalmic viscosurgical devices, and mechanical dilating devices. However, sphincterotomies and pupil stretching are ineffective. Whether used alone or in combination, these small-pupil techniques improve the surgical success rate in these cases. Stopping the alpha(1)-antagonist preoperatively is of questionable value.

Clinical experience with intraoperative floppy-iris syndrome. Results of the 2008 ASCRS member survey.

According to an online survey, most members of the American Society of Cataract and Refractive Surgery believe that tamsulosin makes cataract surgery more difficult (95%) and increases the risks of surgery (77%). Commonly reported complications of intraoperative floppy-iris syndrome (IFIS) were significant iris trauma and posterior capsule rupture, with 52% and 23% of respondents, respectively, reporting these complications at a higher rate than in non-IFIS eyes. There was no single preferred surgical method for managing IFIS; 33% of respondents routinely used multiple strategies. Of respondents with sufficient experience, 90% believe that IFIS is more likely with tamsulosin than with nonspecific alpha1-antagonists. Ninety-one percent believe that physicians prescribing alpha1-antagonists should become better educated about IFIS, and 59% would recommend a pretreatment ophthalmic evaluation for patients with cataracts or decreased vision. If they themselves had mildly symptomatic cataracts, 64% of respondents would avoid taking tamsulosin or would have their cataract removed first.

Second instrument tip breaks during phacoemulsification.

BACKGROUND: Second instrument tip breaks during phacoemulsification are complications that are anecdotally recalled, yet little information exists on why and how often they occur, whether they are consistently tracked, and how they are managed. They may be an underreported, but potentially serious, complication of phacoemulsification. METHODS: We surveyed 114 cataract surgeons in Ontario to determine reported rates of second instrument tip breaks, their management, and presumed etiology. We reviewed 4 Toronto cataract centres for incident reports, instrument sterilization processes, and purchase histories. Using scanning electron microscopy (SEM), we compared the characteristics of a broken Sweeney tip to new and used second instruments. RESULTS: Of the 35 surgeons responding to the survey, 34% had experienced a second instrument tip break during their careers. Approximately 73% (16 cases) of the 22 cases reported were managed successfully during the procedure by the primary surgeon, 14% (3 cases) required imaging by computerized tomography or x-ray, and another 14% (3 cases) required pars plana vitrectomy for tip retrieval. Purchase histories revealed that 1 Sweeney hook was exchanged monthly, equivalent to 100 to 150 surgeries. SEM of new and used second instruments revealed signs of metal fatigue on both new and used second instruments. INTERPRETATION: Although both physicians and hospitals lack a method for ensuring quality control of second instruments, approximately one third of cataract surgeons encounter second instrument tip breaks during the course of their careers. Although most cases are managed intraoperatively, consistent hospital tracking records and standardized instrument inspection by institutions and surgeons are needed to determine how these complications occur and to establish protocols for complication reporting and management.

Should ophthalmologists receive communication skills training in breaking bad news?

BACKGROUND: Effective communication is essential in the delivery of health care. The purpose of the present study was to determine whether formal communication skills training in breaking bad news should be incorporated into the training of ophthalmologists. METHODS: An online survey was offered to every member of the Canadian Ophthalmological Society (COS) with a registered email address. Survey questions focused on 2 specific scenarios: (S1) disclosing permanent vision loss to a patient and (S2) revoking a patient's driver's licence. Main outcome measures were the respondents' opinions on the need for and benefit of including communication skills in the training of ophthalmologists and, if considered necessary, its optimal format and point in their training. RESULTS: The response rate was 28% (225/800). The vast majority of respondents believed that it is important for ophthalmologists to be able to communicate effectively when breaking bad news (S1: 99%, mean Likert score 4.81; S2: 97%, 4.73); that communication skills training would be beneficial in breaking bad news for both future ophthalmologists (S1: 88%, 4.28; S2: 87%, 4.24) and patients (S1: 92%, 4.26; S2: 87%, 4.24); and that it should be included in the training of ophthalmologists (S1: 87%, 4.27; S2: 83%, 4.15). Residency was the preferred point in training (95% for both scenarios), but there was no consensus on what type of training format(s) to use. INTERPRETATION: Survey respondents strongly support the inclusion during ophthalmology residency of formal communication skills training in breaking bad news. This would be a logical choice of content for ophthalmology residency programs striving to meet the mandated "interpersonal and communication skills" core competency requirements.

Intraoperative complication rates in cataract surgery performed by ophthalmology resident trainees compared to staff surgeons in a Canadian academic center.

PURPOSE: To compare the intraoperative complication rates in cataract surgery performed by resident trainees and staff ophthalmologists. SETTING: Kensington Eye Institute, University of Toronto, Toronto, Canada. DESIGN: Prospective case series. METHODS: This study included 8738 consecutive cases of primary phacoemulsification cataract surgery performed by staff surgeons and resident trainees from January to December 2016. There were no exclusion criteria. Data collected included the level of resident training, case complexity, degree of resident involvement, and intraoperative complications. Primary outcome measures included intraoperative complication rates and level of complexity of cataract surgeries performed by resident trainees and staff surgeons. RESULTS: Resident trainees were involved in 44% of surgeries. Of those, 82% were completed in their entirety by a resident and 18% were performed by both the staff surgeon and resident. Staff surgeons performed 56% of all surgeries without resident involvement. Sixty-seven percent of surgeries were simple and 33% were complex, with small pupil or intraoperative floppy-iris syndrome being the most common reason for complex cases. For simple cases, there was no difference in the overall complication rates (1.7% and 2.0%; P = .52), posterior capsule rupture rates (0.9% and 0.8%; P = .76), or vitreous loss rates (0.4% and 0.2%; P = .08) between staff and residents, respectively. CONCLUSION: There were no differences in complication rates between the two groups.

Primary piggyback implantation of 3 intraocular lenses in nanophthalmos.

We present a patient with bilateral nanophthalmos who had uneventful cataract extraction in the right eye with primary implantation of 3 intraocular lenses (IOLs) of 2 different materials: a 30 diopter (D) acrylic IOL and a 9 D silicone IOL in the capsular bag and a 30 D silicone IOL in the ciliary sulcus. Subsequently, cataract extraction was done in the left eye with bag-sulcus implantation of two 30 D silicone IOLs. The use of 3 IOLs in 1 eye was necessary because the highest available power of acrylic and silicone IOLs at our institution was 30 D. The only short-term complications were temporary corneal edema and partial displacement of the sulcus IOL anterior to the iris in the right eye and bilateral posterior capsule opacification. The late complication of interlenticular opacification was not present 1 year after piggyback IOL implantation.

Prophylaxis of postoperative endophthalmitis after cataract surgery: results of the 2007 ASCRS member survey.

An online survey of members of the American Society of Cataract and Refractive Surgery indicated a strong preference for preoperative and postoperative topical antibiotic prophylaxis, with most surgeons favoring latest generation topical fluoroquinolones. A significant percentage of surgeons reported being concerned about the risks of homemade intracameral antibiotic preparations, and there was a strong desire to have a commercially available antibiotic approved for intracameral injection. This is reflected in the fact that 77% of respondents were still not injecting intracameral antibiotics, but 82% would likely do so if a reasonably priced commercial preparation were available.

Thermal effect of microburst and hyperpulse settings during sleeveless bimanual phacoemulsification with advanced power modulations.

PURPOSE: To assess wound temperature during bimanual sleeveless phacoemulsification using customizable power modulations such as hyperpulse and microburst technology. SETTING: In vitro laboratory. METHODS: The Millennium Microsurgical System (Bausch & Lomb) with custom control software (CCS) was used to perform phacoemulsification in 5 porcine eyes with MicroFlow needles (Bausch & Lomb) and with power varied from 20% to 80% in 10% increments. Pulse modes were set for fixed microburst (4 ms on, 4 ms off; and 6 ms on, 12 or 24 ms off) and for hyperpulse (30% duty cycle with 8 or 75 pulses per second [pps]), with and without aspiration-line occlusion. Wound temperatures were measured 3 times per second. RESULTS: Using 80% total power, the wound temperature during 3 minutes of occlusion did not exceed 39.0 degrees C. The maximum temperature with fixed microbursts of 4 ms on, 4 ms off was 29.0 degrees C without occlusion and 37.8 degrees C with occlusion (duration 3 minutes). At 6 ms on, 12 ms off, the maximum temperatures were 28.1 degrees C and 38.7 degrees C, respectively. At 6 ms on, 24 ms off, peak temperatures were 24 degrees C and 23.6 degrees C, respectively. The hyperpulse mode of 30% duty cycle and 8 pps produced maximum temperatures of 25.5 degrees C nonoccluded and 33.4 degrees C occluded. With 30% duty cycle, 75 pps, temperatures were 28 degrees C and 38.0 degrees C, respectively. For all power below 80%, temperatures were lower. CONCLUSIONS: Customizable power modulation with microburst and hyperpulse technology further reduced wound temperatures during bimanual sleeveless phacoemulsification. This enhances the safety and effectiveness of phacoemulsification through a sleeveless needle and a small stab incision.

Hydro-chop technique for soft lenses.

Chopping techniques were initially developed to expend the least amount of phacoemulsification power inside the eye to remove a lens and to improve efficiency. Soft nuclei are not generally conducive to traditional chopping techniques and have required alternate, energy-consuming techniques, such as sculpting, to be removed. We describe a modified chopping technique that can be used to mechanically cleave soft nuclei into distinct fragments before phaco power is required, reducing total power and energy expended in the eye.

Phacoemulsification in anterior megalophthalmos.

This case outlines the phacoemulsification technique used to overcome the challenge of the hyperdeep anterior chamber, weak zonules, abnormal anterior capsule, and large capsular bag. Key steps included trypan blue staining of the anterior capsule, a large capsulorhexis, prolapse of the nucleus into the anterior chamber with phacoemulsification anterior to the capsulorhexis, and a posterior chamber-placed iris-clip intraocular lens. Successful visual rehabilitation is achievable in these anatomically challenging eyes.

Surgical correction of presbyopia.

UNLABELLED: Presbyopia is the most common refractive disorder for people older than 40 years. It is characterized by a gradual and progressive decrease in accommodative amplitude. Many surgical procedures for the correction of presbyopia exist, with additional procedures on the horizon. This review describes the prevalent theories of presbyopia and discusses the available surgical options for correction. FINANCIAL DISCLOSURE: Proprietary or commercial disclosures are listed after the references.

Cataract surgery and nonsteroidal antiinflammatory drugs.

Nonsteroidal antiinflammatory drugs (NSAIDs) have become an important adjunctive tool for surgeons performing routine and complicated cataract surgery. These medications have been found to reduce pain, prevent intraoperative miosis, modulate postoperative inflammation, and reduce the incidence of cystoid macular edema (CME). Whether used alone, synergistically with steroids, or for specific high-risk eyes prone to the development of CME, the effectiveness of these medications is compelling. This review describes the potential preoperative, intraoperative, and postoperative uses of NSAIDs, including the potency, indications and treatment paradigms and adverse effects and contraindications. A thorough understanding of these issues will help surgeons maximize the therapeutic benefits of these agents and improve surgical outcomes. FINANCIAL DISCLOSURE: Proprietary or commercial disclosures are listed after the references.

Monitored anesthesia care provided by registered respiratory care practitioners during cataract surgery: a report of 1957 cases.

OBJECTIVE: To evaluate the safety and feasibility of having monitored anesthesia care during cataract surgery provided by registered respiratory care practitioners (RRCPs). DESIGN: Retrospective case series. PARTICIPANTS: One thousand nine hundred fifty-seven consecutive patients undergoing cataract surgery at one surgical center between November 2001 and October 2003. METHODS: Phacoemulsification cataract surgery with intraocular lens insertion was performed using topical anesthesia, with or without IV sedatives. An RRCP, trained to function as an anesthesia assistant, provided monitored anesthesia care during all stages of surgery, with an anesthesiologist immediately available for consultation or assistance as required. MAIN OUTCOME MEASURES: The number of serious medical complications resulting from the anesthesia or surgery was measured. The rate of anesthesiologist intervention required at each stage of surgery--preoperative, intraoperative, and postoperative--was determined, along with the reasons for the interventions. Age, American Society of Anesthesiologists (ASA) risk class (a rating of preoperative physical status), and number of IV sedative agents given were analyzed as potential predictors of the need for anesthesiologist intervention. RESULTS: Among the 1957 cataract surgeries, there were no adverse medical events that resulted in death, hospitalization, or tracheal intubation. Two cases were aborted intraoperatively for medical reasons. A total of 78 cases (4.0%) required anesthesiologist intervention, with 34 (1.7%) requiring preoperative intervention, 43 (2.2%) requiring intraoperative intervention, and 3 (0.2%) requiring postoperative intervention; 4 cases required 2 separate interventions. The mean age of the intervention group (73.9 years) was statistically greater than that of the nonintervention group (71.0) (P = 0.02). A higher ASA rating (>2) correlated with an increased need for anesthesiologist intervention in terms of the total intervention rate (P<0.0001) and the intraoperative rate alone (P<0.0001). The use of more IV sedative agents (2 or 3 vs. 0 or 1) was marginally associated with a higher total intervention rate (P = 0.053) but not with a higher intraoperative intervention rate (P = 0.68). CONCLUSION: With the inherent safety of cataract surgery and the relatively low need for anesthesiologist intervention, we believe it is justified to allow RRCPs, trained as anesthesia assistants, to provide monitored anesthesia care during cataract surgery so long as anesthesiologist support is directly available when required. Potential benefits include cost savings in health care and decreased demand for anesthesiology services. To validate formally the preservation of patient safety from such a change in practice, however, a larger sample size would be required due to the inherently low rate of cataract surgery complications.

A survey for the need of translational aids among Canadian ophthalmologists.

OBJECTIVE: To conduct a needs assessment survey of Canadian ophthalmologists to determine whether there is a requirement for translational aids in ophthalmology, and if so, the content, format, and languages to include. DESIGN: Anonymous voluntary online needs assessment questionnaire. PARTICIPANTS: A total of 139 ophthalmologists completed the online needs assessment questionnaire. METHODS: An anonymous voluntary online survey in English and French was distributed to 700 active members (practicing Canadian ophthalmologists) of the Canadian Ophthalmological Society. Data were collected regarding the potential utility of translational aids, as well as the contents and languages that should be included if such aids were to be created. Level of support for translational aids, as well as the contents and languages of potential translational aids, was assessed. RESULTS: The survey response rate was 19.9% (139/700). The majority of the respondents (130/139, 93.5%) have encountered difficulty in communicating with patients because of language barrier, and 88.5% (123/139) would benefit from having a list of ophthalmologic terms translated into several of Canada's most popular languages. The top 10 languages that the respondents indicated would be most beneficial are (in descending order): Chinese, Hindi, Spanish, Punjabi, Italian, Portuguese, Arabic, Greek, Cree, and Vietnamese. The survey responses provided a comprehensive list of the most useful ophthalmologic symptoms, instructions to patients, and diagnoses to be translated. Most respondents (120/139, 86.3%) believed that having basic information pamphlets on specific ocular conditions translated into several languages would benefit their practice; the top 3 conditions were cataract, glaucoma, and age-related macular degeneration. Producing the translational aids in both paper and electronic format was found to be the most favoured (89/139, 64.0%). CONCLUSIONS: Canadian ophthalmologists believe they would benefit from translational aids. The results of this survey provide a framework for the creation of such aids.