Refractive surgery for the glaucoma suspect.

PURPOSE OF REVIEW: The aim of this study was to provide an update on perioperative considerations in the evaluation and management of patients undergoing primary corneal and intraocular refractive procedures who are at risk for progressive glaucomatous optic neuropathy. RECENT FINDINGS: The necessity of a comprehensive baseline assessment prior to refractive procedures with structural and functional testing, along with documentation of preoperative intraocular pressure (IOP) measurements, is highlighted in recent literature. Substantiation of the increased risk of postoperative IOP elevation in keratorefractive procedures in patients with higher baseline IOP and lower baseline CCT, but not necessarily the degree of myopia, has been variably evidenced. Tonometry methods which are less influenced by postoperative corneal structural change should be considered in patients undergoing keratorefractive procedures. Vigilence in postoperative monitoring for progressive optic neuropathy is suggested given evidence of an increased risk of steroid-response glaucoma in these patients. Additional evidence for the IOP-lowering impact of cataract surgery in patients with an increased risk of glaucoma is provided, irrespective of intraocular lens choice. SUMMARY: Performing refractive procedures on patients at risk for glaucoma remains controversial. Definitive steps to optimize patient selection along with vigilance in disease state monitoring with longitudinal structural and functional testing can help mitigate potential adverse events.

Implantable Electronic Cardiovascular Device Complications Related to Electrocautery During Ophthalmology Surgery: A Systematic Review.

PURPOSE: Implantable electronic cardiovascular device such as cardiac pacemakers and implantable defibrillators are common life-saving devices. Device-related complications can arise when undergoing surgical interventions with electrosurgical tools due to electromagnetic interference, based on electrocautery type, implantable electronic cardiovascular device type, electrocautery location, and a number of other factors. The risk of device-related complications due to electrocautery in oculoplastic surgery has not been established. This systematic literature review assesses prevalence, risk factors, and outcomes of electrocautery-related device complications in oculoplastic surgery. METHODS: Systematic literature review followed Preferred Reporting Items for Systematic and Meta-Analysis guidelines and used the search terms "pacemaker," "implantable cardioverter defibrillator," "electrocautery," "cautery," and "electrosurgery" through June 2022. Inclusion criteria were full-text articles, discussing ocular, oculoplastic, or other facial surgery. Exclusion criteria were non-English language or surgery focused on other parts of the body. Full-text manuscripts of identified articles were reviewed and relevant data were extracted. RESULTS: Twelve studies met inclusion criteria. Two studies were level I and II evidence, while 10 studies were level III or IV. There were no reports of electromagnetic interference with bipolar cautery use. With monopolar cautery use, cases of electromagnetic interference were reported, but without related significant morbidity or mortality. Safety recommendations to minimize electrical flow through the implantable electronic cardiovascular device are described. CONCLUSIONS: There were no reports of implantable electronic cardiovascular device-related complications from bipolar or thermocautery use in ophthalmic or oculoplastic surgeries. Monopolar have been associated with electromagnetic interference, but additional preoperative and perioperative measures can be taken to mitigate this risk.

Unilateral vortex keratopathy of unknown etiology.

A 54-year-old man with noncontributory medical history presented to an ophthalmologist in January 2022 after 10 days of irritation in his right eye. The patient recounts having felt something get into his eye and under his contact lens (CL) while he was climbing into his car, but he was unsure what the foreign body may have been. Initial examination by the clinician found uncorrected distance visual acuity of 20/100-2 with a corneal abrasion, 4+ corneal edema, and 3+ conjunctival injection, for which he was placed on topical antibiotics (ocuflox and tobradex) with a bandage CL. 1 week later, visual acuity was 20/80, corneal edema had improved, and he was noted to have corneal scarring and an epithelial defect. Tobradex was continued while prednisolone drops and preservative-free artificial tears were started. 1 week later, the patient had worsening visual acuity to 20/250 and was referred to our tertiary center. On initial consultation, the patient had an uncorrected distance visual acuity of 20/500 and an uncorrected near visual acuity of >J10 in the right eye. Slitlamp examination of the right eye was significant for vortex keratopathy and mild corneal pannus with 360-degree subtle conjunctivalization of the limbus ( Figure 1JOURNAL/jcrs/04.03/02158034-202210000-00022/figure1/v/2022-10-03T121249Z/r/image-tiff ). The corneal topograph was obtained showing significant surface irregularity on the Placido image ( Figure 2JOURNAL/jcrs/04.03/02158034-202210000-00022/figure2/v/2022-10-03T121249Z/r/image-tiff ). Examination of the left eye was unremarkable. The ocular history is significant for myopia of -4.0 diopters and CL use for 20 years. The patient admits to regularly wearing soft CLs for several days straight and only removing them for a few hours. Antibiotics were discontinued, corticosteroid drops were reduced in frequency, and the patient was continued on preservative-free artificial tears. What imaging might you consider? What is your differential diagnosis at this point? What would be the most appropriate surgical and/or medical interventions? What would you counsel in prognosis for this patient?

The preoperative management of meibomian gland dysfunction prior to corneal refractive surgery.

PURPOSE OF REVIEW: To describe the significance of meibomian gland dysfunction (MGD) in corneal refractive surgery and to describe available approaches to preoperative evaluation and treatment based on current research. RECENT FINDINGS: There are several methods available for the evaluation and treatment of MGD. These are relevant for refractive surgeons to understand, as the presence of MGD preoperatively plays a role in the severity of MGD after corneal refractive surgery. Refractive surgery itself can exacerbate MGD. Treatment of MGD prior to surgery may have a meaningful impact on postoperative MGD. SUMMARY: Surgeons should include meibomian gland assessment in the preoperative refractive evaluation and should treat MGD proactively prior to performing refractive surgery. Relevant information in this field is growing; additional prospectively designed studies are needed to further enhance our understanding.

Impact of the COVID-19 Pandemic on Quantity and Characteristics of Ophthalmology Consults.

Purpose: To assess the COVID-19 exposure risk to consulting ophthalmologists and the pandemic effect on consultations at one of the most impacted hospital systems in New York. Methods: In a retrospective, cross-sectional study, ophthalmology consult notes and COVID-19 test results were collected from the electronic medical record from February to May in 2019 and 2020. Results: Of 2,215 total notes analyzed, consults decreased from 1,374 to 841 between years (p = 0.0002). In 2020, 22.5% of all consults were COVID tested and 2.4% were positive within 2 weeks of in-person evaluation. In 2020, 1.8% of consults were electronic. Ventilated patients increased between years (7.5% to 10.8%; p = 0.04). Conclusions: Although consultations decreased during the Spring 2020 peak, the majority (98.2%) remained as in-person evaluations. While few patients tested COVID positive, this likely reflects the limited availability of testing early in the pandemic. Consulting ophthalmologists remained at high risk of COVID-19 exposure during the pandemic peak.

Assessing the Demand for Teleophthalmology in Florida Emergency Departments.

Background: Teleophthalmology programs are expanding, but have not been adapted into many emergency departments (EDs) in the United States. Introduction: Determining the potential demand for teleophthalmology services in the United States. EDs could enable development of new strategies to improve access to eye care in resource-limited regions. Methods: Telephone surveys were administered to ED physicians and nurses in Florida. Perceptions of ophthalmologist availability, equipment availability, and perceived utility of teleophthalmology services were measured. Results: Responses were from 104 of 207 facilities (50.2%); 88/181 (48.6%) designated as nonrural hospitals (NRHs) and 16/26 (61.5%) as rural hospitals (RHs). NRHs reported a median of 1 ophthalmologist available on call compared with a median of 0 at RHs (p < 0.001). NRHs were more likely to have a slit lamp (98.9% NRH, 50.0% RH; p < 0.001) and tonometer (100% NRH, 75.0% RH; p < 0.001). On a scale from 1 (lowest) to 5, most (68/93; 73.1%) perceived the value of teleophthalmology for remote consults as a 4 or 5. The most common perceived benefit of teleophthalmology use was to provide second/expert opinion (26.5% of responses). The most commonly cited perceived disadvantage was the physical unavailability of an ophthalmologist for examination and follow-up care (35.5% of responses). Discussion: RHs have less access to ophthalmologists and ophthalmic equipment when managing eye-related complaints in the ED. At both RHs and NRHs, providers face limitations in managing eye complaints and perceived teleophthalmology as a potentially valuable tool for remote expert consultation. Conclusions: Results suggest teleophthalmology services may be used to improve access to expert ophthalmic care, particularly in rural communities.

Quantification of the Cost and Potential Environmental Effects of Unused Pharmaceutical Products in Cataract Surgery.

IMPORTANCE: Pharmaceutical products, including unused portions, may contribute to financial and environmental costs in the United States. Because cataract surgery is performed millions of times each year in the United States and throughout the rest of the world, understanding these financial and environmental costs associated with cataract surgery is warranted. OBJECTIVE: To investigate the financial and environmental costs of unused pharmaceutical products after phacoemulsification surgery. DESIGN, SETTING, AND PARTICIPANTS: This descriptive qualitative study included 4 surgical sites in the northeastern United States (a private ambulatory care center, private tertiary care center, private outpatient center, and federally run medical center for veterans). Prices and data for use of services and pharmaceuticals were obtained for the tertiary care and outpatient centers from January 1 through April 30, 2016; for the ambulatory care center from June 1, 2017, through March 31, 2018; and the federal medical center from November 1, 2017, through February 28, 2018. Data were collected from routine phacoemulsification surgical procedures without vitreous loss or other complications. Volume or weight of medications remaining after surgery was measured. Total and mean costs of medications per case and month were calculated. Environmental effects were estimated using economic input-output life cycle assessment methods. Data were analyzed from December 1, 2017, through June 30, 2018. MAIN OUTCOMES AND MEASURES: Cost of unused pharmaceutical products (in US dollars) and kilogram equivalents of carbon emissions (carbon dioxide [CO2-e]), air pollution (fine particulate matter emissions of ≤10 µm in diameter [PM10-e]), and eutrophication potential (nitrogen [N-e]). RESULTS: A total of 116 unique drugs were surveyed among the 4 centers. Assuming unmeasured medications had no materials left unused, a cumulative mean 83 070 of 183 304 mL per month (45.3%) of pharmaceuticals were unused by weight or volume across all sites. Annual unused product cost estimates reached approximately $195 200 per site. A larger percentage of eyedrops (65.7% by volume) were unused compared with injections (24.8%) or systemic medications (59.9%). Monthly unused quantities at the ambulatory care center (65.9% by volume [54 971 of 83 440 mL]), tertiary care center (21.3% [17 143 of 80 344 mL]), federal medical center (38.5% [265 of 689 mL]), and outpatient center (56.8% [10 691 of 18 832 mL]) resulted in unnecessary potential emissions at each center of 2135, 2498, 418, and 711 kg CO2-e/mo, respectively. Unnecessary potential air pollution between sites varied from 0.8 to 4.5 kg PM10-e/mo, and unnecessary eutrophication potential between sites varied from 0.07 to 0.42 kg N-e/mo. CONCLUSIONS AND RELEVANCE: This study suggests that unused pharmaceutical products during phacoemulsification result in relatively high financial and environmental costs. If these findings can be substantiated and shown to be generalizable in the United States or elsewhere, reducing these costs may be of value.

Efficacy of Perioperative Lumbar Drainage following Endonasal Endoscopic Cerebrospinal Fluid Leak Repair.

Objective Perioperative lumbar drain (LD) use in the setting of endoscopic cerebrospinal fluid (CSF) leak repair is a well-established practice. However, recent data suggest that LDs may not provide significant benefit and may thus confer unnecessary risk. To examine this, we conducted a meta-analysis to investigate the effect of LDs on postoperative CSF leak recurrence following endoscopic repair of CSF rhinorrhea. Data Sources A comprehensive search was performed with the following databases: Ovid MEDLINE (1947 to November 2015), EMBASE (1974 to November 2015), Cochrane Review, and PubMed (1990 to November 2015). Review Method A meta-analysis was performed according to PRISMA guidelines. Results A total of 1314 nonduplicate studies were identified in our search. Twelve articles comprising 508 cases met inclusion criteria. Overall, use of LDs was not associated with significantly lower postoperative CSF leak recurrence rates following endoscopic repair of CSF rhinorrhea (odds ratio: 0.89, 95% confidence interval: 0.40-1.95) as compared with cases performed without LDs. Subgroup analysis of only CSF leaks associated with anterior skull base resections (6 studies, 153 cases) also demonstrated that lumbar drainage did not significantly affect rates of successful repair (odds ratio: 2.67, 95% confidence interval: 0.64-11.10). Conclusions There is insufficient evidence to support that adjunctive lumbar drainage significantly reduces postoperative CSF leak recurrence in patients undergoing endoscopic CSF leak repair. Subgroup analysis examining only those patients whose CSF leaks were associated with anterior skull base resections demonstrated similar results. More level 1 and 2 studies are needed to further investigate the efficacy of LDs, particularly in the setting of patients at high risk for CSF leak recurrence.