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.

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.

Nuevo nomenclátor estandarizado en oftalmología: Criterios e indicadores cuantitativos de baremación de actos médicos / A new standardised nomenclature in ophthalmology: Criteria and quantitative evaluation indicators of medical procedures

OBJETIVO: Elaborar un nuevo nomenclátor de actos y procedimientos médicos en oftalmología, basado en la Clasificación Internacional de Enfermedades CIE-9-MC. Establecer los principios generales y definir los criterios de baremación, indicadores cuantitativos y escalas de valoración. Determinar los algoritmos necesarios para el cómputo de las tarifas retributivas por acto médico. MÉTODOS: Sobre el nomenclátor vigente, se eliminaron los procesos obsoletos, añadieron otros nuevos, modificaron descriptores, agruparon procedimientos con descripciones similares y trasladaron de grupo otros, por razones de complejidad quirúrgica. Se definieron los criterios de baremación para el cálculo de las retribuciones médicas: formación y complejidad (U), responsabilidad profesional (R) y valor salud (V), con sus indicadores cuantitativos, respectivamente: periodo de formación necesario para dominar una técnica, frecuencia de complicaciones que agravan la situación preoperatoria, y días de incapacidad laboral que ocasiona el proceso. Se definieron las Unidades Relativas de Valor (URV) como la suma de puntos de U, R y V. La tarifa final por acto médico se calculará como el producto del número de URV por su coste unitario y por el coeficiente de ponderación (CP). RESULTADOS: Se elaboró un nuevo nomenclátor con 161 actos médicos agrupados en consultas, procedimientos diagnósticos (PR.DX), procedimientos terapéuticos (PR.TX) e intervenciones quirúrgicas (IQ) crecientes en complejidad desde el grupo 0 hasta el grupo 8. Para cada uno de los actos se describieron los siguientes caracteres: códigos OMC y CIE-9-MC, término descriptor, grupo, modificación propuesta: sin cambios o mínimos en los descriptores, agrupación de actos por definiciones similares, cambio de grupo de origen, actos eliminados y nuevos procedimientos. Asimismo, fueron puntuados los tres criterios de baremación: U entre 1-4, R entre 0-3 y V entre 0-3. Mediante su suma se calcularon el número de URV por acto médico (entre 1 y 10), que junto con el coste unitario de la URV y el CP (entre 0,05 y 1) determinarán la tarifa final. CONCLUSIONES: El nuevo nomenclátor de oftalmología actualiza y mejora el catálogo antiguo, adecuando los procedimientos a los descriptores recogidos en la CIE-9-MC e incorporando todas las técnicas actuales. Adicionalmente, la declaración de los principios generales permite definir nuevos criterios de baremación, indicadores cuantitativos, escalas de valoración y algoritmos de cómputo de las tarifas por acto médico

PURPOSE: To create a new list of medical procedures in ophthalmology based on the International Classification of Diseases ICD-9-CM. To establish the general principles that define criteria, quantitative indicators, and scales. To develop the algorithms needed to calculate fees for medical procedures. METHODS: The out-of-date processes were removed from the list, and new techniques were added, descriptors were modified, procedures with similar descriptions were grouped together, and others were relocated to other group according to surgical complexity conditions. The criteria to calculate the medical fees were defined: training and complexity (U), proficient responsibility (R), and health value (V), with their respective quantitative indicators: period of training necessary to master a technique, frequency of complications that worsen the preoperative situation, and days of incapacity for work due to the process. The Relative Value Unit (RVU) was defined as the score sum of R, V and U. The final fee per medical procedure was calculated as the product of the RVU by its unit cost and by the weighting coefficient (WC). RESULTS: A new catalogue was prepared with 161 medical procedures, grouped into consultations, diagnostic procedures (DX.PR), therapeutic procedures (TX.PR), and surgical interventions, increasing in complexity from group 0 to group 8. The following characters were described for each one of the procedures: OMC and ICD-9-MC code, descriptor term, group, proposed modification: no changes or minimums in the descriptors, grouping of acts by similar definitions, change of origin group, new procedures, and procedures removed. The indicators for assessment were also scored: U between 1-4 points, and R and V between 0-3 points. Using their sum, the number of RVUs per medical procedure (between 1 and 10) was calculated which, together with the unit cost of the RVU and the WC (between 0.05 and 1), will determine the final rate. CONCLUSIONS: The new standardised ophthalmological nomenclature updates and improves the old classification, adapting the procedures to the descriptors included in the ICD-9-CM, and incorporating all the new techniques. Additionally, the declaration of the general principles allows defining new criteria, quantitative indicators, rating scales, and algorithms to calculate fees for medical procedures

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.

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.].

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.

[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.

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.

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.

Cyclodialysis: an updated approach to surgical strategies.

Cyclodialysis is a rare occurrence and is difficult to treat, it being concealed behind the iris. In view of the varied success outcomes of the different available surgical repair techniques, there is at present no clear consensus regarding their management strategies. Through this article, we intend to appraise the established surgical methods, update the novel techniques in vogue, discuss their outcomes and propose a uniform system to codify these corrective techniques. They have been reclassified under the terms 'exocyclopexy', 'endocyclopexy', 'exocyclotamponade' and 'endocyclotamponade' based on the approach used and their mode of action. The ab-interno techniques (endocyclopexy and endocyclotamponade) are easier to perform, offer good success rates and better safety profiles such that they may be considered as a viable alternative to the standard exocyclopexy in either cataractous or pseudophakic and aphakic eyes.

Practice Patterns in the Management of Primary Pterygium: A Survey Study.

PURPOSE: To characterize cornea specialists' current practice preferences in the management of primary pterygium. METHODS: A 25-item survey regarding indications for surgery, surgical technique, use of adjuvant therapy, type and duration of postoperative therapy, and treatment of early recurrences was designed and sent to members of the Cornea Society through the kera-net listserv. RESULTS: In total, 199 cornea specialists completed the questionnaire. More than 90% considered that surgery should be performed when there is proximity of the pterygium to the visual axis, pain or redness, eye movement restriction, or induction of astigmatism. Cosmesis was considered as an indication by 41.7% of the participants. The most frequent technique for pterygium excision was complete resection including the base and a moderate quantity of Tenon capsule followed by autologous conjunctival or limbal-conjunctival graft. The preferred graft fixation method in this survey was fibrin glue (61.2%). Most respondents reported a recurrence rate of less than 5% and no use of adjuvant agents to prevent recurrence. When early recurrence did occur, the preferred agents were corticosteroids. CONCLUSIONS: This study reflects the preferences of cornea experts regarding primary pterygium treatment and may serve as a guide for the management of this pathology.

Clinical coding and data quality in oculoplastic procedures.

INTRODUCTION: Hospitals in England are reimbursed via national tariffs set out by NHS England. The tariffs payable to hospitals are determined by the activity coded for each patient's hospital visit. There are no national standards or publications within oculoplastics for coding accuracy. Our audit aimed to determine the accuracy of coding oculoplastic procedures carried out in theatres and to assess the financial implications of any discrepancies. METHODS: We carried out a prospective audit of consecutive oculoplastic procedures performed at one hospital site over a 6-week period. We subsequently created a coding proforma and performed a re-audit using the same methods. RESULTS: In the first cycle, clinical coding was 'correct' in 30.7% of cases, 'incomplete' for 12.9% and 'incorrect' for 56.5%. Of the 'incorrect' codes, 54.3% were coded as non-oculoplastic procedures (e.g. extraocular muscle surgery). We discussed our findings with the coding team in order to address the sources of error. We also created a 'tick box' coding proforma, for completion by surgeons. Our re-audit results showed an improvement of 'correct' coding to 85.7%. CONCLUSION: Clinical coding is complex and vulnerable to inaccuracy. Our audit showed a high rate of coding error, which improved following collaboration with our coding team to address the sources of error and by creating a coding proforma to improve accuracy. Accurate clinical coding has financial implications for hospital trusts and consequently Clinical Commissioning Groups. In times of severe financial pressures, this could be a valuable tool, if rolled out over all specialities, to make much needed savings.

Reducing Preoperative Waiting-time in a Pediatric Eye Operation Theater by Optimizing Process Flow: A Pilot Quality Improvement Project.

OBJECTIVE: To decrease the preoperative area waiting-time for children posted for eye surgery. METHODS: A pilot quality improvement project was conducted in a single paediatric eye operation theatre in our tertiary-care hospital. Operation theatre process flow was analyzed, baseline data was collected, and two Plan-Do-Study-Act cycles were performed on consecutive days. Average and maximal waiting-time were recorded across six operation theatre days. RESULTS: The average and maximal waiting time at baseline were 221 and 390 minutes, respectively. After two rapid Plan-Do-Study-Act cycles, these were reduced to 29 (87% reduction) and 52 minutes (87% reduction) from baseline, respectively, and could subsequently be sustained. CONCLUSION: Preoperative waiting time in ophthalmic operation theatre was significantly reduced by simple process flow optimization, thereby improving quality of care.

Evaluación del clima de seguridad del paciente en un hospital quirúrgico oftálmico / Avaliação do clima de segurança do paciente em um hospital cirúrgico oftalmológico / Evaluation of patient safety climate in an ophthalmic surgical hospital

Objetivo: Evaluar el clima de seguridad en un hospital quirúrgico oftálmico a través de la percepción de sus profesionales. Método: Estudio exploratorio, descriptivo y transversal de naturaleza cuantitativa. Desarrollado desde octubre hasta enero de 2016 a través de la aplicación del cuestionario de actitudes de seguridad (seguridad actitudes cuestionario-SAQ) a 61 diferentes categorías de profesionales de la salud siendo considerados solamente para 27 de los análisis de cuestionarios aplicados. Resultados: La puntuación media obtenida a través de los seis dominios de SAQ - clima de trabajo en equipo, seguridad, clima, satisfacción laboral, reconocimiento, percepción de la gestión de estrés y las condiciones de trabajo mostraron índice de concordancia por debajo de 75 puntos de la escala de Likert que indica percepción negativa del clima de seguridad. Conclusiones: El estudio señala debilidades en los seis dominios lo que sugiere el desarrollo de acciones enfocadas a mejorar el clima de seguridad como medida prioritaria para garantizar la seguridad del paciente quirúrgico

Objetivo: Avaliar o clima de segurança em um hospital cirúrgico oftalmológico através da percepção de seus profissionais. Método: Estudo exploratório, descritivo e transversal de natureza quantitativa. Desenvolvido de outubro a janeiro de 2016 por meio da aplicação do Questionário de Atitudes de Segurança (Safety Attitudes Questionnaire - SAQ) a 61 profissionais de saúde de diferent es categorias sendo somente considerado para análise 27 dos questionários aplicados Resultados: O escore médio obtido através dos seis domínios do SAQ-Clima de Trabalho em equipe, Clima de segurança, Satisfação no Trabalho, Reconhecimento do estresse, Percepção da gerência e Condições de trabalho - demonstrou índice de concordância abaixo de 75 pontos a partir da Escala de Likert, indicando resultado negativo a percepção do clima de segurança. Conclusões: O estudo apontou fragilidades nos seis domínios, sugerindo o desenvolvimento de ações com foco na melhoria do clima de segurança como medida prioritária na garantia da segurança cirúrgica do paciente

Objective: Evaluate the security climate in an ophthalmic surgical hospital through the perception of its professionals. Method: Exploratory, descriptive and transversal study of quantitative nature. Developed from October to January 2016 through the application of the Safety Attitudes Questionnaire (SAQ) to 61 different categories of health professionals being only considered for 27 of the questionnaires applied analysis. Results: The average score obtained through the six domains of SAQ-climate of teamwork, safety Climate, job satisfaction, stress Recognition, perception of management and working conditions-showed concordance index below 75 points from the range of Likert, indicating a negative perception of safety climate. Conclusions: The study pointed out weaknesses in six areas, suggesting the development of actions focusing on improving security climate as a priority measure in ensuring the safety of the surgical patient