Is it safe to use telephone for anaesthesia consultation in high-risk patients before non-invasive surgery? A pilot study in ophthalmology.

BACKGROUND: Although telemedicine with video support for preoperative evaluation has been found effective, there is limited research on anaesthesia consultation by phone without video support, particularly among high-risk patients. To evaluate the effectiveness, safety and potential benefits of performing pre-anaesthesia evaluation by phone before eye surgery in patients having non-invasive surgery, we performed an observational study in a French teaching hospital. METHOD: All elective patients having elective ophthalmic surgery were included to have a consultation by phone instead of an in-person consultation, regardless of the type of anaesthesia or ASA score. The incidence of day-of-surgery cancellations, patient satisfaction and time/distance saved through phone consultations were assessed. RESULTS: From February to October 2022, data of 3480 patients were analyzed, including 370 (11%) high-risk patients (ASA 3-4). Anaesthesia-related day-of-surgery cancellation rate was 0.5% (n = 20) due to non-compliance with pre-operative instructions. No cancellation was due to inadequate pre-operative evaluation. No difference in cancellation rate was observed between low-risk patients and high-risk patients. Telephone consultations saved patients a mean of 126 min and 86 km. A younger age, an active status and living far from the hospital were associated with phone consultation preference. CONCLUSION: Phone anaesthesia consultation seems to be effective and safe before ophthalmic surgery, regardless of patient's perioperative risk. In addition, phone consultation provides significant time and distance savings. Our results must be confirmed through a multicentric randomised study comparing phone and traditional consultation in ophthalmology as well as in other non-invasive surgical procedures in a high-risk patients population.

Multimodal imaging in early onset non-neovascular pigment epithelial detachments.

PURPOSE: To describe multimodal imaging of two cases of bilateral non-vascularized pigment epithelial detachments (PED) in young patients with a long-term follow-up. METHODS: A complete ophthalmological examination was performed at each follow-up visit including best corrected visual acuity (BCVA), intraocular pressure, slit lamp examination, spectral domain optical coherence tomography (SD-OCT), fluorescein and indocyanine green angiography, OCT angiography. RESULTS: Multimodal imaging of two women presenting avascular PED, aged 43 and 57, respectively, was described. In both patients, SD-OCT revealed a high central macular hyporeflective elevation corresponding with PED. Both patients showed a choroidal layer thicker than 420 µm. Fluorescein and indocyanine green angiography didn't show any choroidal neovascularization either at early or late frames. Cross-sectional and en face optical coherence tomography angiography (OCTA) didn't show any flow beneath the PED. During the follow up period one eye showed a retinal pigment epithelium tear and all eyes showed the presence of apical sub-retinal fluid and hyperreflective material on the top of the PED. None of the two patients showed any sign of atrophy during the follow-up period. CONCLUSION: The peculiar characteristics of the presented cases suggest that specific pathogenetic mechanisms, not necessarily related to age related macular degeneration, may play a key role in the development of these lesions. Whether early onset of such drusenoid PED is a specific entity resulting from a genetic deficit of lipid transporters in the RPE is unknown. Further genetic and metabolic studies should be conducted.

MACULAR ATROPHY AFTER MACULAR HOLE SURGERY ASSISTED BY MEMBRANE BLUE DUAL: A CASE SERIES.

PURPOSE: The aim of this study is to describe the clinical and multimodal imaging findings in patients with macular atrophy after macular hole surgery assisted by Membrane Blue Dual. METHOD: This study is a monocenter, retrospective, observational case series that included patients who presented with macular atrophy following macular hole surgery. RESULTS: Among the patients included in this study, four were operated for idiopathic macular hole and one for total retinal detachment associated with macular hole. In all patients, the internal limiting membrane was brittle and adherent, and multiple stains were required. One month postoperatively, all patients showed a reduced visual acuity except the patient with total retinal detachment. At fundus examination all patients showed patchy atrophy with a mottled hypopigmented and hyperpigmented appearance in the macular region. Optical coherence tomography scans demonstrated a closed macular hole with retinal thinning, disruption of the external retinal layers, and irregular retinal pigment epithelium thickening. Fundus autofluorescence showed a well-defined area of both hypoautofluorescence and hyperautofluorescence involving the macular area. CONCLUSION: Macular atrophy after Membrane Blue Dual-assisted internal limiting membrane peeling represents a severe complication that vitreoretinal surgeons should be aware of and that should be taken into account in preoperative evaluation and surgical procedure planning. To reduce the risk of this complication, we recommend to ensure the best conditions of visibility, to reduce as much as possible the intensity and the distance of the endoillumination from the retina, and to use as little dye as possible.

The Role of Subretinal Injection in Ophthalmic Surgery: Therapeutic Agent Delivery and Other Indications.

Subretinal injection is performed in vitreoretinal surgery with two main aims, namely, the subretinal delivery of therapeutic agents and subretinal injection of fluid to induce a controlled and localized macular detachment. The growing interest in this technique is mainly related to its suitability to deliver gene therapy in direct contact with target tissues. However, subretinal injection has been also used for the surgical management of submacular hemorrhage through the subretinal delivery of tissue plasminogen activator, and for the repair of full-thickness macular holes, in particular refractory ones. In the light of the increasing importance of this maneuver in vitreoretinal surgery as well as of the lack of a standardized surgical approach, we conducted a comprehensive overview on the current indications for subretinal injection, surgical technique with the available variations, and the potential complications.

Risk Factors of Cystoid Macular Edema After Pars Plana Vitrectomy for Pseudophakic Retinal Detachment.

INTRODUCTION: This study aimed to investigate the prevalence of cystoid macular edema after pars plana vitrectomy for the treatment of pseudophakic rhegmatogenous retinal detachment and identify possible related risk factors. METHODS: A retrospective monocentric study was conducted within a cohort of pseudophakic patients undergoing vitrectomy for rhegmatogenous retinal detachment between January 2019 and December 2022. Demographic data, initial and intraoperative characteristics of rhegmatogenous retinal detachment, and postoperative data were analyzed. Cystoid macular edema was defined on optical coherence tomography exclusively. RESULTS: A total of 164 eyes of 164 patients were included for analysis. The mean age of the patients at surgery was 65.7 ± 12.0 years. The mean best-corrected visual acuity was 2.1 ± 1.0 logMAR preoperatively and 1.0 ± 0.7 logMAR postoperatively. The mean follow-up was 13.4 ± 7.7 months. The prevalence of cystoid macular edema was 17.1% [9.8-26.4]. In multivariate analysis, severe proliferative vitreoretinopathy (relative risk 3.6 [1.3-9.7]) and laser retinopexy (relative risk 8.4 [1.1-64.7]) were independently and significantly associated with cystoid macular edema. CONCLUSION: The prevalence of cystoid macular edema in pseudophakic rhegmatogenous retinal detachment after pars plana vitrectomy was 17.1%. Severe proliferative vitreoretinopathy stage and the use of endolaser retinopexy were independent risk factors for development of cystoid macular edema.

Investigating pupillometry to detect preoperative anxiety: a pilot study.

Guidelines from the European Society of Anesthesia (ESA) insist on the importance of preoperative anxiety management. However, its assessment currently relies on questionnaires that are long to submit and sometimes difficult to interpret. Exploring the balance between sympathetic and parasympathetic neural systems through the use of pupillometry is a promising path to identify anxiety and thus provides an objective and reproducible assessment tool. A single-center prospective observational study was conducted in a population of ambulatory ophthalmological surgery patients. Preoperative anxiety was assessed using the Surgical Fear Questionnaire (SFQ). Measurements were taken using an Algiscan® (IDMed) type pupillometer before, during, and after insertion of the peripheral IV catheter. A statistical correlation test was carried out between the different evaluations of anxiety and the coefficient of variation of the pupillary diameter (VCPD). A total of 71 patients were included in the study between July 2020 and February 2021, with a median SFQ score of 23 [IQR 11-34]. No significant statistical correlation was found between the baseline pupillary diameter, or VCPD, and preoperative anxiety levels. Similarly, the pupillometric variables did not differ significantly when adjusting for the level of anxiety during and after painful stimulation due to canulation. More studies are necessary to explore the potential correlation between preoperative anxiety and pupillometry.

Ocular Surface Features in Patients with Parkinson Disease on and off Treatment: A Narrative Review.

Parkinson disease (PD) is a progressive, neurodegenerative disease of the central nervous system. Visual disturbance is one of the most frequent nonmotor abnormalities referred to by patients suffering from PD at early stages. Furthermore, ocular surface alterations including mainly dry eye and blink reduction represent another common finding in patients with PD. Tears of PD patients show specific alterations related to protein composition, and in vivo confocal microscopy has demonstrated profound changes in different corneal layers in this setting. These changes can be attributed not only to the disease itself, but also to the medications used for its management. In particular, signs of corneal toxicity, both at epithelial and endothelial level, are well described in the literature in PD patients receiving amantadine. Management of PD patients from the ophthalmologist's side requires knowledge of the common, but often underdiagnosed, ocular surface alterations as well as of the signs of drug toxicity. Furthermore, ocular surface biomarkers can be useful for the early diagnosis of PD as well as for monitoring the degree of neural degeneration over time.

The StarvAnx Study-Comparison Between the Effects of Non-fasting Vs. Fasting Strategy on Surgical Outcomes, Anxiety and Pain in Patients Undergoing Cataract Surgery Under Topical Anesthesia: A Randomized, Crossover, Controlled Trial.

Background: Fasting is usually recommended in patients undergoing cataract surgery under topical anesthesia. However, starving before surgery may increase preoperative anxiety and affect surgical outcomes. It is not known which fasting or non-fasting strategy is best for cataract surgery. The aim of this study was to compare non-fasting and fasting strategy in patients undergoing cataract surgery under topical anesthesia with regard to surgical outcomes, anxiety and pain. Methods: This randomized, crossover, controlled trial enrolled patients undergoing surgery for bilateral cataract under topical anesthesia at Cochin Hospital (Paris, France), from February to May 2021. Patients were randomly assigned to the non-fasting or fasting group for the first eye surgery and were switched to the other group for the second eye surgery. The primary endpoint was to compare the rate of anesthetist's interventions during surgery. The secondary endpoints included intra-operative complications, duration of surgery, surgeon perception of surgical difficulty, anesthesia-related complications and anxiety and pain level. Results: one hundred and nine consecutive patients were included, with 60 of them being fasted first and non-fasted for the second eye surgery, while the other 59 were non-fasted first and fasted for the next surgery. The number of patients requiring sedation was significantly lower in the non-fasting group compared with the fasting group [1%; 95%IC (0-3.2) vs. 6%; 95%IC (2.9-8.9), P = 0.04]. No anesthesia-related complications were observed. There was no difference in the number of intra-operative complications between the non-fasting and the fasting groups (,respectively, 0 and 1; P = 1). Anxiety level and surgical pain were significantly lower in the non-fasting group compared to the fasting group (,respectively, 2.3 ± 2.0 vs. 4.1 ± 2.4, P = 0.01 and 0.6 ± 0.6 vs. 2.6 ± 3.4, P = 0.003). The mean duration of surgery was significantly shorter in the non-fasting group compared with the fasting group (,respectively, 16.0 ± 5.9 vs. 22.3 ± 6.1 min; P = 0.03). Conclusion: In conclusion pre-operatory non-fasting strategy provides a better patient experience with regards to preoperative anxiety and surgical pain. It allows to reduce operating times and is safe and well-tolerated as regards the anesthetic intervention.

Comparison between air and gas as tamponade in 25-gauge pars plana vitrectomy for primary superior rhegmatogenous retinal detachment.

BACKGROUND/OBJECTIVES: The aim of this study was to compare surgical outcomes and postoperative characteristics, between eyes that underwent pars plana vitrectomy (PPV) for RRD, with air or different gas agents as tamponade. SUBJECTS/METHODS: The records of 262 patients that underwent PPV for RRD with air or different gas tamponades and a follow-up of at least 6 months were examined. Only cases with superior retinal breaks were included. Demographic, pre-, intra- and postoperative characteristics including rate of recurrence and complications were analysed. RESULTS: 48 patients were treated with air and 214 were treated with gas. No differences were found in success rate between air and gas group at both 3 and 6 months (respectively, 93.8% vs 93.6 and 100% vs 100%, all P values > 0.05). Postoperative best-corrected visual acuity (BCVA) was significantly higher in the air group compared with the gas group 7 days and 1 month postoperatively (respectively, 0.2 ± 0.4 vs 2.6 ± 0.5, P < 0.001 and 0.1 ± 0.4 vs 0.4±0.9, P = 0.04). The occurrence ocular hypertension at 1 month postoperatively was significantly higher in the gas group compared with the air group (15.4 % vs 0%, P < 0.001). At 6 months, the prevalence of epiretinal membrane (ERM) was significantly higher in the gas group compared with air group (4.2% vs 16.8%, P = 0.02). CONCLUSIONS: Air was comparable to gas tamponades in terms of surgical outcome and BCVA at 6 months. In addition, air allowed an earlier visual recovery and resulted in a lower rate of postoperative ocular hypertension and ERM.

Efficacy of Preoperative Music Intervention on Pain and Anxiety in Patients Undergoing Cataract Surgery.

The aim of the present study was to investigate the impact of preoperative music exposure on intra- and post-operative pain during cataract surgery. This study was conducted alongside a prospective single-masked randomized controlled trial (ClinicalTrials.gov NCT02892825). Patients undergoing first eye cataract surgery were included and randomly assigned to either the intervention or control group. Patients in the intervention group had a 20-min music session through earphones before surgery, while patients in the control group wore earphones without music. Anxiety level evaluated using the visual analog scale and heart rate were collected before and after music intervention. Pain level was assessed using the Numerical Pain Rating Scale, during the surgical procedure, prior to discharge and 7 days postoperatively. A total of 243 patients were included: 119 in the intervention group and 124 in the control group. No significant differences in baseline characteristics, including age, sex and rate of treated hypertension were found between the 2 groups (all p-values > 0.05). In addition, no significantly differences were found in heart rate and anxiety level before music intervention between the 2 groups (all p-values > 0.05). Conversely, anxiety level was significantly lower in the music group after the intervention (respectively, 1.3 ± 1.1 vs 3.2 ± 2.2; p < 0.05). Patients in the music group reported a lower mean pain level during surgical procedure and before discharge compared with control group (respectively, 1.2 ± 0.5 vs 2.1 ± 1.1, p = 0.03 and 0.23 ± 0.4 vs 0.81 ± 0.7, p = 0.04). No difference was found in pain level 7 days postoperatively (0.1 ± 0.3 vs 0.2 ± 0.4, p = 0.1). A significant correlation was found between anxiety level and intraoperative pain level (R = 0.64, p = 0.02). In conclusion, music intervention was effective in reducing anxiety level and self-reported pain both during surgery and in the early postoperative period. Clinical Trial Registration: https://clinicaltrials.gov/ct2/home, identifier NCT02892825.

Efficacy of a Web App-Based Music Intervention During Cataract Surgery: A Randomized Clinical Trial.

IMPORTANCE: Hypertensive events during cataract surgery may induce complications. Information and communication technologies applied to health are popular, but clinical evidence of its usefulness is rare and limited to treating anxiety without specific analysis. Recent publications have described the potential effects of personalized music choices as mobile-based intervention on pain but not on anxiety. OBJECTIVE: To demonstrate the effects of a web app-based music intervention on the incidence of hypertension in participants during cataract surgery performed under local anesthesia. DESIGN, SETTING, AND PARTICIPANTS: This randomized, single masked, controlled clinical trial was composed of 2 arms and took place at a single center at Cochin Hospital in Paris, France. A total of 313 participants were screened between February 2017 and July 2018. Among these, 311 participants undergoing a phacoemulsification procedure for elective surgery for their first eye cataract under local anesthesia were enrolled. Analysis was intention to treat and began in September 2018 and ended November 2018. INTERVENTIONS: Participants requiring cataract surgery were assigned randomly to either the experimental arm (web app-based music listening intervention delivered via headphones) or control arm (noise-canceling headphones without music) for 20 minutes before surgery. MAIN OUTCOMES AND MEASURES: The occurrence of at least 1 hypertensive event during surgery. RESULTS: A total of 310 participants were randomized in the study (155 to each arm) and 309 were analyzed (1 participant in the music arm had already undergone cataract surgery to the other eye). The mean (SD) age of the participants was 68.9 (10.8) years, and there were 176 female individuals (57%). On the primary end point, the incidence of hypertension was significantly lower in the music arm (21 [13.6%]) than in the control arm (82 [52.9%]), with a difference between the 2 arms of 39.3% (95% CI, 21.4%-48.9%; P < .001). Regarding the secondary end points, the mean (SD) visual measure of anxiety was lower in the music arm (1.4 [2.0]) than in the control arm (3.1 [2.4]), with a difference of 1.5 (95% CI, 1.0-2.1; P = .005). The mean (SD) number of sedative drug injections required during surgery was 0.04 (0.24) vs 0.54 (0.74) in the music vs control arms, respectively, with a difference of 0.50 (95% CI, 0.43-0.57; P < .001). CONCLUSIONS AND RELEVANCE: For participants similar to those enrolled in this study, the trial suggests that a web app-based personalized music intervention before cataract surgery may be considered to lower anxiety levels and hypertension or reduce the need for sedative medication. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02892825.

Iatrogenic Ocular Surface Diseases Occurring during and/or after Different Treatments for Ocular Tumours.

The ocular surface represents a finely regulated system that allows the protection of the eye. It is particularly susceptible to different treatments for intraocular tumours, such as uveal melanoma and conjunctival cancers. Traditionally, the management of ocular tumours depends on the characteristics of the lesion, and is based on a combination of selective surgery, topical chemotherapy, and/or radiotherapy delivered through different mechanisms (e.g., charged-particle radiotherapy or brachytherapy). Possible complications involving the ocular surface range from transient dry eye disease or keratitis up to corneal melting and perforation, which in any case deserve careful evaluation for the risk of permanent sigh-threatening complications. Clinicians involved in the management of these patients must be aware of this risk, in order to reach an early diagnosis and promptly set up an adequate treatment. The present review of the literature will summarize acute and chronic complications affecting the ocular surface following different therapies for the treatment of ocular tumours.

Choroidal and peripapillary changes in high myopic eyes with Stickler syndrome.

BACKGROUND: To compare different clinical and Spectral-Domain Optical Coherence Tomography (SD-OCT) features of high myopic eyes with Stickler syndrome (STL) with matched controls. METHODS: Patients with genetically confirmed STL with axial length ≥ 26 mm and controls matched for axial length were included. The following data were obtained from SD-OCT scans and fundus photography: choroidal and retinal thickness (respectively, CT and RT), peripapillary atrophy area (PAA), presence of posterior staphyloma (PS). RESULTS: Twenty-six eyes of 17 patients with STL and 25 eyes of 19 controls were evaluated. Compared with controls, patients with STL showed a greater CT subfoveally, at 1000 µm from the fovea at both nasal and temporal location, and at 2000 and 3000 µm from the fovea in nasal location (respectively, 188.7±72.8 vs 126.0±88.7 µm, 172.5±77.7 vs 119.3±80.6 µm, 190.1±71.9 vs 134.9±79.7 µm, 141.3±56.0 vs 98.1±68.5 µm, and 110.9±51.0 vs 67.6±50.7 µm, always P< 0.05). Furthermore, patients with STL showed a lower prevalence of PS (11.5% vs 68%, P< 0.001) and a lower PAA (2.2±2.1 vs 5.4±5.8 mm2, P=0.03), compared with controls. CONCLUSIONS: This study shows that high myopic patients with STL show a greater CT, a lower PAA and a lower prevalence of PS, compared with controls matched for axial length. These findings could be relevant for the development and progression of myopic maculopathy in patients with STL.

Choroidal vascular changes after encircling scleral buckling for rhegmatogenous retinal detachment.

BACKGROUND/OBJECTIVES: There is an ongoing debate on whether encircling scleral buckling (SB) procedure for the treatment of rhegmatogenous retinal detachment (RRD) may cause an impairment in choroidal blood flow. The aim of this study was to compare choroidal vascularity index (CVI) and subfoveal choroidal thickness (CT) between eyes that had undergone encircling SB with unoperated fellow eyes (FEs). SUBJECTS/METHODS: Thirty patients treated with encircling SB for unilateral RRD were included. Demographic and clinical characteristics as well as enhanced depth imaging-optical coherence tomography scans were retrospectively collected. Images were binarised using ImageJ software, total choroidal area along with luminal and stromal area (respectively, TCA, LA and SA) were segmented and the CVI was computed as the ratio of LA/TCA. In addition, CT was evaluated. RESULTS: The mean follow-up interval between surgery and examination was 25.5 ± 16.8 months. Choroidal thickness, TCA, LA and SA were significantly increased in the operated eyes compared to FEs (respectively, 271.7 ± 78.0 µm vs. 238.5 ± 83.4, P = 0.001; 1.804 ± 0.491 mm2 vs. 1.616 ± 0.496, P = 0.001; 1.199 ± 0.333 mm2 vs. 1.067 ± 0.337, P < 0.001 and 0.605 ± 0.171 mm2 vs. 0.550 ± 0.171, P = 0.001). Conversely, CVI did not significantly differ between the two groups (66.4 ± 3.6 vs. 65.9 ± 3.2, P = 0.490). CONCLUSIONS: In conclusion, eyes treated with encircling SB for RRD presented increased LA, SA and CT compared with FEs, but showed no difference in CVI.

Preoperative Optical Coherence Tomography Findings of Foveal-Splitting Rhegmatogenous Retinal Detachment.

PURPOSE: To assess preoperative optical coherence tomography (OCT) findings of foveal-splitting retinal detachment (RD) and determine postoperative outcomes. METHODS: Consecutive patients who underwent RD surgery over a 1-year period were included. Patients diagnosed with a detachment extending to the edge of the fovea on fundus examination (i.e., macula-On/Off) underwent macular OCT scanning. Visual acuity (VA) after 1 year of macula-On/Off, macula-On, and macula-Off eyes was compared. RESULTS: A total of 85 eyes were included, 8 of which had a macula-On/Off RD. On preoperative OCT, all macula-On/Off RD eyes had foveal detachment extending beyond the foveal center over a median distance of 632 µm. Mean VA of the macula-On/Off eyes had improved from 20/160 to 20/40 at 1 year postoperatively (p = 0.035). The preoperative VA of macula-On/Off eyes was significantly better than macula-Off eyes (p = 0.032) and lower than macula-On eyes (p = 0.004). At 1 year, the VA of macula-On/Off eyes was no different from that of the macula-On eyes (p = 0.320), and tended to be better than that of the macula-Off eyes (p = 0.062). CONCLUSION: Preoperative OCT revealed a shallow RD extending beyond the foveal center in eyes with clinical foveal-splitting RD. These eyes, termed macula-On/Off RD eyes, had a preoperative VA between macula-On and macula-Off eyes, while their final VA was close to those with macula-On RD.

New clinical forms of hereditary apoA-I amyloidosis entail both glomerular and retinal amyloidosis.

Apolipoprotein A1 amyloidosis (ApoAI) results from specific mutations in the APOA1 gene causing abnormal accumulation of amyloid fibrils in diverse tissues. The kidney is a prominent target tissue in ApoAI amyloidosis with a remarkable selectivity for the renal medulla. Here, we investigated six French families with ApoAI Glu34Lys, p.His179Profs∗47, and a novel p.Thr185Alafs∗41 variant revealing unprecedented clinical association of a glomerular with a retinal disease. Comprehensive clinicopathological, molecular and proteomics studies of numerous affected tissues ensured the correlation between clinical manifestations, including novel unrecognized phenotypes, and apoA-I amyloid deposition. These ophthalmic manifestations stemmed from apoA-I amyloid deposition, highlighting that the retina is a previously unrecognized tissue affected by ApoAI amyloidosis. Our study provides the first molecular evidence that a significant fraction of ApoAI amyloidosis cases with no family history result from spontaneous neomutations rather than variable disease penetrance. Finally, successful hepatorenal transplantation resulted in a life- and vision-saving measure for a 32-year-old man with a hitherto unreported severe ApoAI amyloidosis caused by the very rare Glu34Lys variant. Our findings reveal new modes of occurrence and expand the clinical spectrum of ApoAI amyloidosis. The awareness of glomerular and ocular manifestations in ApoAI amyloidosis should enable earlier diagnosis and avoid misdiagnosis with other forms of renal amyloidosis. Thus, documented apoA-I amyloid deposition in the retina offers new biological information about this disease and may change organ transplantation practice to reduce retinal damage in patients with ApoAI amyloidosis.