Perioperative Management of Coagulation Disorders in Ophthalmic Surgery. / Perioperatives Management bei Gerinnungsstörungen in der Ophthalmochirurgie.

Disorders of blood coagulation can lead to manifest spontaneous bleeding and an increased risk of bleeding during surgical procedures and interventions. Pathophysiologically, a distinction can be made between defects in primary haemostasis, which lead to impaired platelet adhesion and platelet aggregation, and disorders of secondary (plasmatic) haemostasis, which are characterised by impaired fibrin formation or fibrin stabilisation. Aetiologically, a distinction can be made between rare genetically-determined hereditary defects and common acquired coagulation disorders, which may be based on different pathomechanisms. This overview is intended to provide ophthalmic surgeons with a basis for the perioperative management of patients with genetically determined coagulation disorders undergoing ophthalmic surgery. As there are no specific recommendations in this regard, the recommendations are based on the procedure for other surgical interventions, taking into account the specific bleeding risk associated with ophthalmic surgery.

The effect of cyclosporine a in pterygium surgery using fibrin glue.

BACKGROUND/OBJECTIVES: To evaluate the effect of topical cyclosporine A (CsA) 0.05% in patients with pterygium surgery using fibrin glue (FG). SUBJECTS/METHODS: Patients with primary nasal pterygium were retrospectically analyzed and categorized into two groups: Group 1 with 41 eyes from 38 patients as a control group and group 2 with 39 eyes from 36 patients who received topical CsA twice a day for 6 months. Patients were assessed for recurrence rate, tear film parameters, side effects, and complications at postoperative intervals of 1-7 days; 1st, 3rd, 6th and 12th months. The follow-up period was 1 year. RESULTS: The two groups were age (p = 0.934) and sex (p = 0.996) matched. CsA drop was discontinued in one patient due to burning sensation and conjunctival hyperemia after 1 week. There was no statistically significant difference between the mean preoperative and postoperative 1st year Schirmer I and tear break-up time (TBUT) values in group 1 (p = 0.136; p = 0.069). Although the difference between the mean preoperative and postoperative 1st year TBUT values in group 2 was not statistically different (p = 0.249), Schirmer I results were higher postoperatively (p = 0.003). There was no statistically significant difference between preoperative Schirmer (p = 0.496), postoperative Schirmer (p = 0.661), preoperative TBUT (p = 0.240) and postoperative TBUT (p = 0.238) results of the two groups. Recurrence was observed in only one patient from group 1. CONCLUSION: No recurrent pterygium cases were observed in group 2. Schirmer I values were higher postoperatively in group 2; thus,topical CsA treatment may improve lacrimal secretion and be effective after pterygium surgery with FG.

Experience with Strabologic Surgery on Pediatric Patients with Divergence Excess Exotropia.

AIM: This retrospective clinical study evaluates the results of surgical treatment of patients diagnosed with intermittent exotropia of the divergence excess type. The study compares the results of surgery delayed due to the Covid-19 pandemic (patients underwent the surgery after the age of eight), versus a group of younger children. MATERIALS AND METHODS: The objective angle of deviation and quality of binocular functions were examined. The follow-up period was six months after surgery. The patients were divided into two groups according to age: 4-7 years and 8-13 years. Each group included 20 patients. The second group comprised patients whose surgery was postponed due to restrictions on elective surgery during the ongoing pandemic. The surgery took place at the University Hospital in Pilsen. Angle of deviation and binocular functions were examined before surgery, postoperatively, and three and six months after surgery. Data were collected retrospectively and statistically processed. The main values were plotted in charts. RESULTS: Accordance between the angle of deviation before surgery in both groups was statistically demonstrated. During the six-month follow-up period, the median angle of deviation was statistically without proof of disparity between the groups. Six months after surgery, an objective angle of deviation within the limit ±5 degrees was achieved in 65% of patients from the first group and in 75% from the second group. Binocular vision before surgery was statistically without proof of difference between both groups. However the statistical processing demonstrated a difference between the two groups six months after the surgery. Better binocular functions were achieved by the younger children in the first group. CONCLUSION: The objective deviation angle was comparable in both study groups prior to surgery as well as six months after the surgery. The first group of younger patients attained a higher quality of binocular functions within the six-month follow-up period compared to children operated on after the age of eight. This claim was statistically verified.

The changes in ocular torsion after unilateral lateral rectus recession-medial rectus resection for intermittent exotropia.

We aim to explore the alterations of objective ocular torsion after unilateral lateral rectus recession-medial rectus resection (R&R) for intermittent exotropia (IXT). Seventy-two IXT patients undergoing R&R between March and June 2023 were enrolled. Ophthalmological examinations were performed before surgery and at 1 week and 1 month after surgery, mainly including prism and alternate cover test and optical coherence tomography. The mean disc-foveal angle of eyes showing intorsion significantly increased from - 1.5 ± 0.9° preoperatively to 2.0 ± 2.0° at 1 week (P = 0.0227) and 2.2 ± 1.6° at 1 month postoperatively (P = 0.0054). The mean disc-foveal angle of eyes exhibiting extorsion significantly reduced from 12.8 ± 1.9° preoperatively to 9.8 ± 3.1° at 1 week (P < 0.0001) and 9.7 ± 2.7° at 1 month postoperatively (P < 0.0001). The improvement of ocular extorsion at postoperative 1 month was more pronounced in patients with extorsion in operative eye compared to those with extorsion in inoperative eye (P = 0.0101). The improvement of ocular torsion was observed following R&R for IXT, with a greater effect noted in cases where the surgery was performed on the eye exhibiting extorsion.

Prolonged hypotony maculopathy following uneventful strabismus surgery.

Hypotony is a rare postoperative complication of strabismus surgery. Resolution has been reported to occur within 1 month of surgery. Here, we describe the case of a 14-year-old boy with prolonged hypotony maculopathy following uneventful bilateral medial rectus recession. The hypotony resolved without long-term sequela after 7 months of treatment with topical steroids and atropine. Ultrasound biomicroscopy revealed a ciliary body effusion, which we hypothesize was the cause of decreased aqueous humor production and hypotony.

Risks and Complications Discussed in Consent for Strabismus Surgery.

This study is a qualitative analysis of the consent process for strabismus surgery, using recordings of physicians doing a mock consent for bilateral medial rectus recession. There is considerable variation in the risks of surgery and odds of complications that are cited by pediatric ophthalmologists during the consent process. We propose a reference table with complication rates for use during the consent process.

Modified sutureless and glue-free method versus conventional sutures for conjunctival autograft fixation in primary pterygium surgery: a systematic review and meta-analysis.

BACKGROUND: Pterygium is a common ocular surface disorder that requires surgical intervention for treatment. Conjunctival autografts are preferred over simple excision due to lower recurrence rates. This systematic review and meta-analysis compared the modified sutureless glue-free (MSGF) method with conventional sutures (CS) for conjunctival autograft fixation in primary pterygium surgery. METHODS: A comprehensive search was conducted in MEDLINE, Embase, CENTRAL, Google Scholar and ClinicalTrials.gov for randomised controlled trials (RCTs) comparing MSGF and CS conjunctival autografts. Outcome measures included operation time, recurrence and postoperative complications. Standardised mean difference (SMD) and risk ratio (RR) were used for continuous and dichotomous outcomes, respectively. RESULTS: 11 RCTs involving 833 participants were included. The analysis revealed that MSGF had a significantly shorter operation time compared with CS (SMD -3.704, 95% CI -5.122 to -2.287, p<0.001). CS was associated with a higher risk of foreign body sensation (RR 0.22, 95% CI 0.06 to 0.74, p=0.01). MSGF was associated with a higher risk of graft dehiscence (RR 9.01, 95% CI 2.74 to 29.68, p=0.000) and graft retraction (RR 2.37, 95% CI 1.17 to 4.77, p=0.02). No significant differences were found in recurrence, graft haemorrhage, granuloma, Dellen and conjunctival oedema. CONCLUSION: Using the MSGF technique in conjunctival autograft fixation for pterygium surgery reduces operation time by relying solely on the patient's blood for fixation. However, it increases the risk of graft dehiscence and retraction. However, CS is linked to a higher likelihood of experiencing foreign body sensations. Understanding the learning curve and surgeon familiarity with novel techniques is crucial for optimising patient care and surgical outcomes, while individualised decision-making is necessary considering the advantages and disadvantages of each approach. Further research is warranted to minimise complications and optimise surgical outcomes.

An atypical case of bilateral optic neuritis after strabismus surgery under general anesthesia.

INTRODUCTION: Strabismus surgery under general anesthesia is a common procedure with rare complications in the form of hemorrhage, infection, slipped muscle, lost muscle, scleral perforation, and anterior segment ischemia. We report a unique case of bilateral optic neuritis following squint surgery under general anesthesia in a 15-year-old girl. METHODS: A 15-year-old girl presented with accommodative esotropia with V pattern. She underwent uneventful bilateral inferior oblique recession surgery under general anesthesia with Propofol 60 mg, Atracurium 30 mg, and Fentanyl 70 mcg. On the first post-operative day, the patient had an acute onset of temporal headache which was non-radiating. She responded to supportive treatment and was discharged. However, on the 7th postoperative day, she presented with a constant severe headache in the bitemporal region (left > right) for 3 days. She also experienced a painless diminution of vision for 2 days. There was no vomiting, fever, loose stools, diplopia, difficulty in breathing, peripheral sensation loss, generalized weakness, or bowel/bladder incontinence. RESULTS: The best corrected visual acuity was 6/9 in right eye, and 6/9p in left eye with a relative afferent pupillary defect (RAPD) in the left eye. Both optic discs appeared hyperemic with blurred margins. Magnetic resonance imaging (MRI) of the brain and orbit showed hyperintensity along the intraorbital and intracanalicular parts of bilateral optic nerves on T2 weighted image suggesting bilateral optic neuritis. She received intravenous methylprednisolone pulse therapy followed by oral steroids and responded to the medical treatment with improvement in vision but developed steroid-induced glaucoma requiring medical management over several weeks. DISCUSSION: Neuro-ophthalmic complication in the form of non-arteritic ischemic optic neuropathy has been reported after various ophthalmic surgeries, but bilateral optic neuritis has not been reported to date. This possibility should be kept in mind if any patient presents with similar symptoms. This report also highlights IOP monitoring in pediatric patients receiving systemic steroids to prevent loss of vision due to steroid-induced glaucoma.

Incidence of Sympathetic Ophthalmia after Intraocular Surgery: A Systematic Review and Meta-analysis.

TOPIC: Sympathetic ophthalmia (SO) is a rare bilateral granulomatous panuveitis that can present after trauma or intraocular surgery (IOS). The incidence of SO after IOS varies among studies. The purpose of this review was to determine the incidence proportion of SO after IOS. CLINICAL RELEVANCE: The incidence proportion of SO after IOS can provide physicians and patients with information on the risk of SO during the consent process before surgery. METHODS: In this systematic review and meta-analysis, MEDLINE, EMBASE, and Cochrane databases were searched from inception to January 1, 2023 for population-based studies of SO after IOS. Two reviewers independently screened the results. Random-effects meta-analyses calculated incidence proportion. Subgroup analysis assessed SO incidence based on IOS type and technological advancements. Study quality and bias were assessed using the Newcastle-Ottawa scale and the Grades of Recommendation, Assessment, Development, and Evaluation framework. RESULTS: The final meta-analyses included 19 studies, with 118 cases of SO occurring after 505 178 inciting events. The estimated overall incidence proportion of SO after IOS was 0.061% (95% confidence interval [CI], 0.033%-0.111%; I2 = 83%), and the estimated incidence rate was 9.24 cases per 100 000 person-years (95% CI, 4.03-21.19; I2 = 88%). The average study duration across these studies was 10.8 years. Within the reviewed literature, SO after glaucoma and vitreoretinal IOS was studied most, with 9 and 6 studies, respectively. Observed differences in incidence between glaucoma (0.098%; 95% CI, 0.042%-0.232%; I2 = 40%) and vitreoretinal (0.043%; 95% CI, 0.022%-0.085%; I2 = 88%) IOS were not statistically significant (P = 0.14). Also, no significant difference was found in the incidence proportion before and after 1975, when modern intraocular surgical techniques emerged (0.060% vs. 0.058%; P = 0.98). The outcome measures showed low-certainty Grades of Recommendation, Assessment, Development, and Evaluation evidence. DISCUSSION: Sympathetic ophthalmia after IOS is rare and might not have changed over the past 5 decades. The estimated incidence proportion of SO may be useful during the consent process before surgery. Also, no significant difference may exist in the incidence of SO between glaucoma and vitreoretinal IOS, based on low-certainty evidence. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Cauterization-mediated restriction from penetrating orbital trauma.

A healthy 32-year-old woman presented with binocular diplopia immediately after sustaining a penetrating injury to the left periocular adnexa with a hot metal skewer. Examination revealed an incomitant esotropia, with complete limitation of abduction of the left eye with downshoot in left gaze and normal afferent visual function. Computed tomography and magnetic resonance imaging demonstrated no fracture, but there was mild thickening of the medial rectus muscle and associated fat stranding. Lack of orbitomuscular tethering or hematoma led to the presumptive diagnosis of thermal cauterization injury causing left medial rectus restriction. Given the lack of literature on this mechanism of injury, the patient was monitored closely. She exhibited remarkable spontaneous improvement in motility over 6 months, with near orthophoria in primary gaze. However, bothersome residual esotropic diplopia in left gaze prompted a left medial rectus recession, with a good outcome. This case demonstrates that isolated extraocular muscle thermal injuries and consequential strabismus can recover spontaneously; longitudinal observation before surgical intervention may be appropriate in such cases.

Hemorrhage Following Muller's Muscle Conjunctival Resection: Description and Case-Control Study.

PURPOSE: The purpose of this study was to report a series of patients with postoperative hemorrhage after Muller's muscle conjunctival resection surgery and compare risk factors and outcomes with a control population. METHODS: In this case-control study, records of patients who underwent Muller's muscle conjunctival resection over 5 years were reviewed for a history of postoperative hemorrhage occurring >24 hours after surgery. A 4:1 control population was matched for age and sex. Clinical data collected included demographics, medical history, medications, and subsequent surgery. Preoperative and 3-month postoperative marginal reflex distance 1 were measured digitally using ImageJ. The hemorrhage and control groups were compared using Fisher's exact tests for categorical variables and independent samples t tests for continuous variables. RESULTS: The hemorrhage group contained 10 patients (mean age 66.4 ± 18.5 years). The control group consisted of 40 age and sex-matched controls. Of 350 charts reviewed, there were 10 cases of postoperative hemorrhage (incidence 2.9%). Hemorrhage occurred a mean of 4.2 ± 1.3 (range 2-7) days after surgery and lasted for a mean of 29.3 ± 19.1 (range 12-72) hours. In all 10 cases, the bleeding resolved with conservative measures. There was no difference between the hemorrhage and control groups in terms of medical conditions, blood thinners, and surgical revision. Preoperative, postoperative, and change in marginal reflex distance 1 did not differ between the hemorrhage and control groups. CONCLUSIONS: Hemorrhage occurs approximately 4-5 days postoperatively in a small percentage of patients undergoing Muller's muscle conjunctival resection surgery. This investigation did not identify any consistent risk factors, and outcomes in this patient population appear no different than controls.

The effect of previous orbital decompression on outcomes of rectus muscle recession surgery in patients with thyroid ophthalmopathy.

PURPOSE: To evaluate the effect of previous orbital decompression on outcomes of rectus muscle recession surgery in patients with thyroid-associated ophthalmopathy. METHODS: This retrospective study enrolled 55 eyes of 33 patients treated in our hospital for restrictive strabismus caused by thyroid-associated ophthalmopathy. We performed muscle recession for the obviously restricted extraocular muscles, with 6 weeks of follow-up. Surgical outcomes were compared between the orbital decompression group (DG, n=15) and non-orbital decompression group (NDG, n=18). RESULTS: A total of 33 patients with Graves' ophthalmopathy who underwent rectus muscle recession surgery were included. Of these, 15 patients had undergone orbital decompression prior to strabismus surgery, and 18 had not. The two groups did not differ in terms of the preoperative horizontal or vertical ocular deviation, degree of restriction of eye movement, degree of diplopia, or mean number of muscles that underwent surgery (P>0.05). There was no significant difference in the preoperative horizontal or vertical ocular deviation, level of eye movement restriction, degree of diplopia and the success rate of the surgery (P>0.05). CONCLUSION: Rectus muscle recession surgery in patients with thyroid-associated ophthalmopathy during the quiescent period could improve the ocular deviation and diplopia, and orbital decompression performed before strabismus surgery had no significant effect on surgical technique or outcomes of rectus muscle recession surgery.

Incidence, Risk Factors and Management of Postoperative Complications in Horizontal Strabismus Surgery.

OBJECTIVE: To report the incidence, risk factors and management of postoperative complications after horizontal strabismus surgery. DESIGN: Retrospective Cohort study. PARTICIPANTS: The study assessed 1,273 patients with 1,035 cases of exotropia and 238 cases of esotropia, with a minimum 18-month follow-up. METHODS: Retrospective review of strabismus operation patients' medical records included baseline demographics, age at surgery, pre/postoperative visual acuity, and deviation. Complications were categorized as surgical site (infection, scarring, cyst, granuloma, ischemia) and strabismus-related (recurrence, diplopia), with analysis of incidence, risk factors, and management. RESULTS: Among surgical site complications, the incidence of infection, pyogenic granuloma, and anterior segment ischemia were similar between the exotropia (0.3%, 0.3%, 0.2%) and esotropia (0.8%, 0%, 0.4%) groups (p = .221, 0.406, 0.515). In contrast, the esotropia group presented a higher risk of conjunctival inclusion cyst and conjunctival scar than the exotropia group, with incidences of 5.0% vs 2.2% and 6.3% vs 1.3%, respectively (p = .004, <0.001). Regarding strabismus complications, the incidence of early recurrence was not significant between the two groups, with 10.0% in the exotropia group and 10.5% in the esotropia group (p = .553). Older age and poor initial visual acuity were associated with early recurrence (p < .001). The esotropia group had a higher risk of persistent diplopia than the exotropia group, with incidences of 4.2% vs 2.0%, respectively (p = .003). CONCLUSION: Esotropia carries a higher risk of conjunctival inclusion cysts, conjunctival scarring, and persistent diplopia compared to the exotropia group, while both groups exhibit similar rates of early recurrence and other surgical site complications.

Spontaneous expulsive choroidal hemorrhage in an elderly female with microbial keratitis.

PURPOSE: To report spontaneous choroidal hemorrhage with the expulsion of intraocular contents in an elderly female as a complication of microbial keratitis. METHODS: Retrospective case report along with imaging. RESULTS: A 60-year-old female on treatment for microbial keratitis, presented with protrusion of intraocular contents and no perception of light in the right eye. Ophthalmic ultrasound demonstrated choroidal hemorrhage with coexistent retinal detachment and vitreous hemorrhage. She underwent uneventful evisceration for her condition. CONCLUSION: Microbial keratitis needs aggressive medical treatment to prevent associated stromal infiltration and corneal weakening. In cases of microbial keratitis, if spontaneous choroidal hemorrhage occurs, due to thinning of the cornea and compromised integrity of the eyeball, it can lead to the complete expulsion of intraocular contents with unsalvageable loss of vision.

[Micro-invasive glaucoma surgery]. / Mikroinvazivnaya khirurgiya glaukomy.

Glaucoma is a severe, rapidly progressing disease that in the absence of proper treatment leads to blindness in 20% of patients. According to the World Glaucoma Association, this disease is the most socially significant in modern ophthalmology and requires searching for new and effective methods of treatment. This article presents the results of research and reviews on this issue, considers both conservative therapy and surgical methods of treatment, analyzes in detail modern methods of micro-invasive eye surgery actively used in clinical practice. The article also describes indications for a various types of interventions, as well as the effect achieved by them and the possible complications, and presents the conclusions about the possibility of using these procedures in wide clinical practice.

Reporting serious incidents in medical devices used in intraocular surgery: Proposing ideas.

The entry into force of the regulation on medical devices obliges clinicians to identify and report to the Health Authorities possible serious incidents arising from their use. In view of the doubts that may arise as to whether or not it may be considered a serious incident, a working group, set up by members of the Spanish Society of Retina and Vitreo and the cluster of ophthalmology and vision sciences (Cluster4Eye) have prepared a document that aims to guide ophthalmologists about some of the incidents that, in the experience of the work team, are not common or can cause serious damage to the patient's function.

Esotropia-hypertropia complex in a patient with myopic strabismus fixus.

Patients with highly myopic strabismus generally develop esotropia and hypotropia. We report the case of a 54-year-old woman with a combination of esotropia-hypertropia complex in the right eye and esotropia-hypotropia complex in the left eye, with unilateral congenital severe ptosis. The patient had inferotemporal prolapse of the globe in the right eye. Inferotemporal prolapse in this case could have been due to extraocular muscle pulley dehiscence in this area, causing the inferior oblique muscle to slip around the globe along the path of least resistance. Subsequently, the inferotemporal staphyloma would have prevented the typical esotropia and hypotropia of the globe.

Modified horizontal muscle transposition without tenotomy and splitting for a case of inferior rectus and inferior oblique muscles aplasia with hemifacial microsomia.

Aplasia of the inferior rectus and inferior oblique muscles is extremely rare. Failure of the normal embryologic development of the inferior mesodermal complex can lead to agenesis of inferior rectus, inferior oblique, and lower sections of the lateral rectus muscles. This rare condition is usually seen in association with craniofacial syndromes or in conjunction with microcornea, microphthalmos, Axenfeld-Rieger syndrome, and coloboma. The usual treatment for this condition is a reverse Knapp procedure to improve the vertical alignment; however, this procedure can lead to complications, such as anterior segment ischemia, undercorrection, and torsional problems. To our knowledge, unilateral inferior rectus and inferior oblique muscle aplasia has not been described previously in a patient with congenital facial nerve palsy and optic nerve hypoplasia. In the present case, the patient was successfully treated with a modified minimally invasive horizontal rectus muscle transposition procedure.