Artificial intelligence and ophthalmic surgery.

PURPOSE OF REVIEW: Artificial intelligence and deep learning have become important tools in extracting data from ophthalmic surgery to evaluate, teach, and aid the surgeon in all phases of surgical management. The purpose of this review is to highlight the ever-increasing intersection of computer vision, machine learning, and ophthalmic microsurgery. RECENT FINDINGS: Deep learning algorithms are being applied to help evaluate and teach surgical trainees. Artificial intelligence tools are improving real-time surgical instrument tracking, phase segmentation, as well as enhancing the safety of robotic-assisted vitreoretinal surgery. SUMMARY: Similar to strides appreciated in ophthalmic medical disease, artificial intelligence will continue to become an important part of surgical management of ocular conditions. Machine learning applications will help push the boundaries of what surgeons can accomplish to improve patient outcomes.

[Lege artis eye coverage performed during gynecological/urological laser surgery. Results of a survey of nursing experts]. / Lege artis durchgeführte Augenabdeckung während einer gynäkologischen/urologischen Laseroperation. Ergebnisse einer PflegeexpertInnenbefragung.

BACKGROUND: Intraoperative eye protection is generally important during surgery in patients under general anesthesia. There are, however, challenges that arise when a laser is used intraoperatively. In gynecological and urological diseases lasers are increasingly being used for treatment but a lege artis eye cover or protection has not yet been investigated in the international literature. OBJECTIVE: According to nursing experts, how is a lege artis eye coverage performed during gynecological and urological laser surgery? MATERIAL AND METHODS: In order to answer the research question, standardized expert interviews were carried out via telephone, direct face to face interviews and e­mails with experts from specialized clinics in Austria. The results of a nonsystematic literature search formed the basis for the interview guidelines. RESULTS: In this study 11 experts agreed to participate in a qualitative survey. The result of the interviews recommended the use of skin-friendly plasters in combination with a vitamin D eye ointment, special plasters/covers and/or laser safety goggles with a vitamin D eye ointment and NaCl dressings. In addition to the direct protection of the eye, a periodic intraoperative eyelid closure check must be performed. CONCLUSION: The findings from the expert interviews are to be understood as practice recommendations. Further research is needed in the future.

Effects of Discharge Education and Telephone Follow-up on Cataract Patients' Activities According to the Model of Living.

PURPOSE: Assess the impact of planned discharge education and telephone follow-up of patients who underwent cataract surgery on daily living activities. DESIGN: A controlled comparative study. METHODS: This study was carried out on patients who underwent cataract surgery (intervention group = 72, control group = 72). Discharge education designed according to the Model of Living was used in the intervention group. Phone follow up was performed for both groups after surgery and activities were assessed. FINDINGS: Significant differences were found between the two groups in applying eye drops, knowledge on using old eye glasses and protecting the operated eye, conditions requiring a physician call, conditions that may deteriorate the operated eye, personal hygiene, mobilization, and sleeping (P < .05). CONCLUSIONS: Using a Model of Living in discharge education of cataract patients and following up using a structured checklist was an effective intervention. This model can be efficiently used in postoperative education of day surgery patients.

Is oculofacial surgery complex or merely complicated?

PURPOSE OF REVIEW: There is confusion in all of healthcare, including oculofacial surgery, as to what is 'complex' and what is 'merely complicated'. Although in common usage, these terms tend to be interchangeable, the distinction is more than trivial. A different and somewhat unfamiliar toolset is needed to successfully navigate complex problems. This review will explore a methodology for the physician to understand what is complex in oculofacial surgery, the tools needed to optimize performance in a complex healthcare system and successfully manage patients with complex diseases. RECENT FINDINGS: A specific understanding of complexity science in oculofacial surgery is only in its nascent beginnings at this point. Nevertheless, recent advances in closely related fields can provide concrete applications. The practice of oculofacial surgery is optimized within a healthcare network of supporting professionals. Moreover, a newer understanding of the 'complex' nature of disease common to oculofacial surgery, such as neoplasia and inflammation, will direct the physician to recognize the most appropriate therapies. SUMMARY: Oculofacial surgery, like all of medicine, is a fluid mixture of problems that are complex and those that are merely complicated. As a different toolset is needed to deal with each, physicians need to recognize these differences and acquire those tools.

The Ophthalmology Surgical Competency Assessment Rubric (OSCAR) for anterior approach ptosis surgery.

PURPOSE: The International Council of Ophthalmology (ICO) is currently developing a series of standardized, internationally validated, teaching tools for key ophthalmic surgical procedures called the Ophthalmology Surgical Competency Assessment Rubrics (OSCARs). This study aims to develop an OSCAR for anterior approach ptosis surgery. METHODS: An international panel of content experts, representing Australia, India, Iran, Italy, Turkey, UK, and the USA was established and worked to develop the rubric using a range of online collaboration tools. The team used the standardised OSCAR template as a baseline, developing explicit behavioural descriptors (the behaviour and performance expected for each step) that were reviewed and modified with successive models. Learners were scored a modified 4-point Dreyfus scale of skill acquisition (novice, beginner, advanced beginner, competent) with the removal of the expert domain. RESULTS: The final OSCAR ptosis tool was developed in alignment with the ICO-OSCAR standard. Seventeen agreed and weighted stems were produced. Domains such as communication and postoperative complications were removed from this rubric as they are evaluated in other spheres of residency training. Specific comments with regard to the parameters and wording were incorporated to formulate the final rubric, which was internationally agreed and demonstrated face and content validity. CONCLUSIONS: The OSCAR for anterior approach ptosis is skill and behaviour-based, has ICO agreed standards for assessment and provides learners with specific targets for improvement. Although the OSCAR ptosis tool has face and content validity, further development could better elucidate its precise role.

Coding Accuracy for Outpatient Ophthalmic Surgery: St. Joseph's Healthcare Hamilton.

Coding accuracy is an important factor in ensuring hospitals receive adequate reimbursement from the government for healthcare services rendered. A retrospective review of 100 charts, the purpose of this study was to determine the degree of coding accuracy from the surgeon perspective, for outpatient procedures performed for ophthalmic services at St. Joseph's Healthcare Hamilton from July to December 2016. Using ICD-10-CA, Canadian Classification of Health Interventions, Quality-Based Procedures criteria where applicable, and the 3M Coding and Reimbursement system, this paper reveals three primary sources of coding errors and presents recommendations to increase accuracy of reimbursement for the benefit of both the Ministry of Health and hospital organizations.

[How to understand the excessive lateral rectus muscle recession].

Surgical treatments of intermittent exotropia include symmetric bilateral lateral rectus recession, symmetric bilateral medial rectus resection, asymmetric monocular lateral rectus recession and/or medial rectus resection, in which lateral rectus recession is the most common method. The maximum amount of lateral rectus recession, however, is still controversial. Bilateral lateral rectus recession 7-8 mm for 35(Δ)-40(Δ) exotropia and unilateral lateral rectus recession and medial rectus resection for exotropia larger than 40(Δ) are suggested by most doctor usually. But some other doctors advocated augmented bilateral lateral rectus recession (9-14 mm ) for exotropia larger than 50(Δ) or augmented unilateral lateral rectus recession for moderate angle exotropia (30(Δ)-35(Δ)), which brought confusion in practical clinical work. In this paper, we'll focus on the amount of lateral rectus recession, and discuss several common issues related to augmented lateral rectus recession, in order to provide references for the majority of clinicians.

The efficacy of strabismus surgery in adults: a review for primary care physicians.

Many adult patients with strabismus are under the misconception that nothing can be done to correct the problem or that treatment is associated with a high degree of risk. Moreover, many optometrists, comprehensive ophthalmologists and primary care physicians are similarly misinformed. In fact, most adult patients with strabismus can be successfully treated, with ∼80% of patients achieving satisfactory alignment with one surgical procedure. In addition, adult strabismus surgery carries a relatively low risk, with serious complications being anecdotal and rare. The majority of adults will experience some improvement in binocular function after strabismus surgery even if the strabismus has been longstanding. Most commonly this takes the form of an expansion of binocular visual fields; however, some patients may also regain stereopsis. Consequently, strabismus surgery in adults is not merely cosmetic in most cases. There are many psychological and interpersonal benefits to adult strabismus surgery. These benefits are highlighted by the finding that the majority of adults with strabismus would trade a portion of their life expectancy to be rid of their ocular misalignment. Although adult strabismus surgery has been shown to be highly cost-effective, many adults with strabismus can be successfully managed by non-surgical means. If an adult with strabismus is under the impression, or was told, they cannot be treated, or that treatment is risky, they should consider a referral to an ophthalmologist specifically specialising in strabismus.

Development of the Veterans Healthcare Administration (VHA) Ophthalmic Surgical Outcome Database (OSOD) project and the role of ophthalmic nurse reviewers.

Currently, ophthalmic surgical cases are not included in the Veterans Administration Surgical Quality Improvement Project data collection. Furthermore, there is no comprehensive protocol in the health system for prospectively measuring outcomes for eye surgery in terms of safety and quality. There are 400,000 operative cases in the system per year. Of those, 48,000 (12%) are ophthalmic surgical cases, with 85% (41,000) of those being cataract cases. The Ophthalmic Surgical Outcome Database Pilot Project was developed to incorporate ophthalmology into VASQIP, thus evaluating risk factors and improving cataract surgical outcomes. Nurse reviewers facilitate the monitoring and measuring of these outcomes. Since its inception in 1778, the Veterans Administration (VA) Health System has provided comprehensive healthcare to millions of deserving veterans throughout the U.S. and its territories. Historically, the quality of healthcare provided by the VA has been the main focus of discussion because it did not meet a standard of care comparable to that of the private sector. Information regarding quality of healthcare services and outcomes data had been unavailable until 1986, when Congress mandated the VA to compare its surgical outcomes to those of the private sector (PL-99-166). 1 Risk adjustment of VA surgical outcomes began in 1987 with the Continuous Improvement in Cardiac Surgery Program (CICSP) in which cardiac surgical outcomes were reported and evaluated. 2 Between 1991 and 1993, the National VA Surgical Risk Study (NVASRS) initiated a validated risk-adjustment model for predicting surgical outcomes and comparative assessment of the quality of surgical care in 44 VA medical centers. 3 The success of NVASRS encouraged the VA to establish an ongoing program for monitoring and improving the quality of surgical care, thus developing the National Surgical Quality Improvement Program (NSQIP) in 1994. 4 According to a prospective study conducted between 1991-1997 in 123 VA medical centers by Khuri et al., the 30-day mortality and morbidity rates for major surgeries had decreased by 9% and 30%, respectively. 5 Recently renamed the VA Surgical Quality Improvement Program (VASQIP) in 2010, the quality of surgical outcomes has continued to improve among all documented surgical specialties. Ophthalmic surgery is presumed to have a very low mortality rate and therefore has not been included in the VASQIP database.

The 2021 European Group on Graves' orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves' orbitopathy.

Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease (GD). Choice of treatment should be based on the assessment of clinical activity and severity of GO. Early referral to specialized centers is fundamental for most patients with GO. Risk factors include smoking, thyroid dysfunction, high serum level of thyrotropin receptor antibodies, radioactive iodine (RAI) treatment, and hypercholesterolemia. In mild and active GO, control of risk factors, local treatments, and selenium (selenium-deficient areas) are usually sufficient; if RAI treatment is selected to manage GD, low-dose oral prednisone prophylaxis is needed, especially if risk factors coexist. For both active moderate-to-severe and sight-threatening GO, antithyroid drugs are preferred when managing Graves' hyperthyroidism. In moderate-to-severe and active GO i.v. glucocorticoids are more effective and better tolerated than oral glucocorticoids. Based on current evidence and efficacy/safety profile, costs and reimbursement, drug availability, long-term effectiveness, and patient choice after extensive counseling, a combination of i.v. methylprednisolone and mycophenolate sodium is recommended as first-line treatment. A cumulative dose of 4.5 g of i.v. methylprednisolone in 12 weekly infusions is the optimal regimen. Alternatively, higher cumulative doses not exceeding 8 g can be used as monotherapy in most severe cases and constant/inconstant diplopia. Second-line treatments for moderate-to-severe and active GO include (a) the second course of i.v. methylprednisolone (7.5 g) subsequent to careful ophthalmic and biochemical evaluation, (b) oral prednisone/prednisolone combined with either cyclosporine or azathioprine; (c) orbital radiotherapy combined with oral or i.v. glucocorticoids, (d) teprotumumab; (e) rituximab and (f) tocilizumab. Sight-threatening GO is treated with several high single doses of i.v. methylprednisolone per week and, if unresponsive, with urgent orbital decompression. Rehabilitative surgery (orbital decompression, squint, and eyelid surgery) is indicated for inactive residual GO manifestations.

Strabismus in Graves' orbitopathy.

Strabismus is a disabling aspect of thyroid orbitopathy. Whilst horizontal deviations can be corrected relatively simply, the propensity for inferior rectus involvement makes vertical deviations common. Because the deviations are usually incomitant, prisms have a limited role in management, and surgery is frequently indicated after stability has been documented for at least 6 months. Careful pre-operative discussion of the goals and limitations of strabismus surgery is of paramount importance since a degree of limitation remains postoperatively, even after two or even three surgeries. Nevertheless, with careful planning and duction-testing, a satisfactory central field of binocular single vision can be achieved in the primary position and downgaze, returning this group of patients to a comfortable binocular status for the majority of their day-to-day life.

[Influence of floor disinfection on microbial and particulate burden measured under low turbulance air flow in ophthalmological operation theatres]. / Einfluss der Fußbodendesinfektion auf die mikrobielle und partikuläre Belastung der Raumluft in Augen-OP-Räumen mit Verdrängungslüftungsbereichen.

AIM: The necessity for routine disinfection of floors between two surgical procedures or disinfection only after visible contamination was assessed in two identical ophthalmological operating theatres equipped with laminar air flow ventilation. METHOD: Over a period of four weeks, one of the two tested operating rooms was disinfected after every surgical procedure, and the other only in the case of visible contamination. This regimen was inverted every week. To compare the air quality, particle count and total bacteria count were measured inside and outside the laminar air flow. Additionally, bacteria count was measured in the operating field, consisting of the operating table and the instrument tray. Patients were monitored for surgical site infection over a period of one year after operation. RESULTS: No difference in particle count or number of viable bacteria was found between the two investigated procedures. Also, no wound infections were observed after one year of surveillance for surgical site infection. CONCLUSION: It appears that frequent cleaning disinfection of floors is not necessary if a laminar air flow ventilation system is installed. Under these conditions, targeted disinfection of visibly soiled surfaces appears to be sufficient. Generally, the duration of surgical procedures should be kept as short as possible.

Comparison of Strabismus Surgical Efficiency and Complications Between Attending Surgeon Versus Supervised Ophthalmology Residents.

PURPOSE: To compare surgical operating times and complication rates in strabismus surgery undertaken by attending surgeons versus supervised residents. Eye muscle surgeries are one of the first operations in which ophthalmology residents can actively participate for a majority of the surgery. These surgeries provide an ideal controlled environment to compare attending surgeon and resident surgical performance. METHODS: A total of 36 surgeries were included: 19 were bilateral muscle surgeries and 17 were unilateral surgeries. Residents completed a microsurgical course prior to operating. One attending surgeon was present for all surgeries, but there were 10 different residents throughout the cases. Primary outcomes were attending surgeon and resident surgical times and complications. RESULTS: On average, residents took 35.5 minutes to perform eye muscle surgeries compared to 19.3 minutes for the attending surgeon (P < .0001). Of the resident surgeries, there was one complication requiring a return to the operating room. There were six minor complications during resident surgeries and one minor complication during attending surgeon surgery. CONCLUSIONS: As expected, resident operation times were nearly double attending surgeon surgical times. Although there was one significant and several minor complications resulting from resident surgeries, none were vision threatening. This microsurgical course likely contributed to the low number of complications. The longer surgical times and minor complications resulting from resident surgeries require physicians to disclose resident involvement during the consenting process for pediatric strabismus surgeries. [J Pediatr Ophthalmol Strabismus. 2020;57(4):235-237.].

Use of a Modified Plastic Viewing System for Safer General Anesthesia Care in Pediatric Ophthalmic Surgery During the COVID-19 Pandemic.

Certain pediatric ophthalmology procedures require time-sensitive surgical care to prevent long-term morbidity and mortality. In the era of the COVID-19 pandemic, it has become increasingly important for anesthesia and surgical care providers to protect themselves during medically necessary procedures requiring general anesthesia care. In this study, an intubating viewing system with plexiglass shield and drape was designed. The viewing system allowed effective and safe intubation of pediatric patients for ophthalmological surgery while minimizing the risk of disseminating aerosolized droplets. The authors concluded that this viewing system and modified intubation technique may reduce the risk of transmitting SARSCoV-2 and other highly transmissible pathogens to operating room personnel. The continued study of measures to protect operating room personnel is encouraged to provide more evidence-based recommendations. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:651-652.].

Guidelines for the management of ocular trauma during the COVID-19 pandemic.

As the COVID-19 pandemic rages on, India is recording a very high number of new cases daily; even as the country prepares to gradually "unlock", after months of lockdown. While elective eye surgeries such as uncomplicated cataract surgeries, blepharoplasty and eyelid procedures and refractive surgeries can be planned at a later date; emergency cases pertaining to ocular trauma cannot be deferred. This manuscript gives a brief overview of the general guidelines for the management of ocular trauma during the COVID-19 pandemic.

Kestenbaum procedure with posterior fixation suture for anomalous head posture in infantile nystagmus.

BACKGROUND: The purpose of this study was to report the effect of combining the Kestenbaum procedure with posterior fixation suture for infantile horizontal nystagmus with anomalous head posture (AHP) in children. METHODS: Nine consecutive patients who underwent combined Kestenbaum procedure plus posterior fixation suture to the recessed muscles at the same time were retrospectively studied. All patients were orthotropic before surgery and were followed for at least 6 months. Pre- and postoperative AHP and binocular corrected visual acuity (BCVA), and ocular alignment were assessed. RESULTS: Mean age at surgery was 4.8 +/- 1.5 years. The average follow-up was 29.7 months. The average head turn preoperatively was 27.4 degrees and postoperatively 7.2 degrees . The average net change in AHP was 24.8 degrees (P = 0.008). Seven of 9 patients (78%) achieved a residual head turn of 10 degrees or less. The average Log Mar BCVA was 0.33 preoperatively and 0.31 postoperatively (P = 0.68). Only 1 patient needed additional surgery for residual horizontal AHP. No patient developed strabismus. CONCLUSION: Combined Kestenbaum procedure with posterior fixation suture was an effective and stable procedure in reducing AHP of the range of 20 degrees to 35 degrees in children with infantile nystagmus.

Use of eye shields and eye lubricants among oculoplastic and Mohs surgeons: a survey.

BACKGROUND: Eye shields and lubricants are recommended for use in the eye during periorbital surgery to prevent injury to the globe. Nonetheless, data regarding their use is sparse, and no study to date has examined the prevalence of their usage and complications. PURPOSE: To investigate how commonly eye shields and lubricants are used during periorbital surgery and whether there are complications from their use. METHODS: The authors conducted a survey of oculoplastic and Mohs surgery fellowship directors. The questionnaire investigated the prevalence of use of eye shields and lubricants, complications encountered, and whether the standard of care requires or prohibits their use. RESULTS: A majority of those surveyed at least sometimes use eye shields in periorbital surgery, particularly to prevent patient injury. Most surgeons believe there are more pros than cons to their use. However, corneal abrasions may be encountered and may be related to the type of lubricant chosen. Surgeons using fat-based lubricants tended to encounter more complications with eye shield use. CONCLUSION: Eye shield and lubricant use is common among oculoplastic and Mohs surgeons. However, most disagree as to whether the standard of care requires or forbids their use.

Use of the Delphi process for defining successful outcomes for strabismus surgery.

The purpose of this review was to identify areas of consensus and disagreement among experts for the definition of success following strabismus surgery using the Delphi process. Three rounds of electronic questionnaires were sent to a panel of 28 strabismus experts. Throughout the process, members of the panel were masked to one another's identities to minimize the possibility of influence among members. Prior to data collection, we defined consensus as an 85% agreement on the answer to each question. Questions for which there was no consensus were reworded, and the resultant new questions were used in each subsequent round of questioning. We arrived at consensus for 23 of the 36 questions (64%). Consensus was obtained for recommending unique criteria for the definition of success for certain specific strabismus conditions. In addition, it was considered important that stereopsis and the range of single binocular vision be included in the definition of success for certain types of strabismus.

The Only Eye Study (OnES): a qualitative study of surgeon experiences of only eye surgery and recommendations for patient safety.

OBJECTIVE: Performing surgery on patients with only one seeing-eye, where complications may result in catastrophic vision loss, presents unique challenges for the ophthalmic care team. There is currently no evidence regarding how surgeons augment their care when treating only eye patients and no guidelines for how these patients should be managed in hospital eye services. This study aimed to explore ophthalmic surgeons' experiences of only eye surgery and perceptions of current practice. DESIGN AND PARTICIPANTS: Ten ophthalmic surgeons were asked to relate their experiences and views on performing only eye surgery in indepth, semistructured interviews. Interviews were audio-recorded and transcribed. Qualitative data were subjected to thematic analysis to identify key themes. SETTING: Hospital eye service. RESULTS: Five key themes emerged relating to surgeons' experiences and perceptions of only eye surgery: (1) differences in approach to consent, (2) strategies for risk reduction, (3) unmet training needs, (4) value of surgical mentor and (5) emotional impact of unsuccessful outcomes. Recommendations for improving the surgical journey for both the patient and the surgeon related primarily to better recognition and understanding of the complexities inherent with only eye surgery. CONCLUSIONS: Outcomes of only eye surgery may be improved through a number of methods, including development of purpose-designed training fellowships, adoption of stress-reducing strategies and enhancement of available support services. The findings identify emerging themes unique to only eye surgery and the need for guidelines on the provision of care for these high-stakes surgical patients.