Operating times of experienced cataract surgeons beginning femtosecond laser-assisted cataract surgery.

PURPOSE: To compare the time a patient spent in the operating room during femtosecond laser-assisted with that during traditional cataract surgery. SETTING: Academic tertiary referral center. DESIGN: Retrospective review. METHODS: Data from 3 attending surgeons who operated in the room that housed the femtosecond laser were collected from the first 6 months of the femtosecond laser's use. The time in the operating room was measured from when the patients entered the room to the time they left. Traditional-approach cases done in the room were compared with cases performed using the femtosecond laser (Catalys Precision Laser System). RESULTS: During the first 6 months, 420 cataract cases were performed in the operating room housing the femtosecond laser; the femtosecond laser was used in 162 cases (38.6%). Femtosecond laser-assisted surgeries were 11.1 to 12.1 minutes longer than traditional surgeries (P<.0001). When only routine cases were included in the comparison, the femtosecond laser-assisted approach remained 11.6 to 13.4 minutes longer (P<.0001). CONCLUSION: The additional steps required to perform femtosecond laser-assisted cataract surgery resulted in a statistically significant longer time per case than the time required with a traditional approach. FINANCIAL DISCLOSURES: Dr. Culbertson is a consultant to Abbott Medical Optics, Inc., and Optimedica Corp. Dr. Yoo is a consultant to Alcon Laboratories, Inc., and Abbott Medical Optics, Inc.. No other author has a financial or proprietary interest in any material or method mentioned.

Grid pattern delivered to the cornea during femtosecond laser-assisted cataract surgery.

UNLABELLED: A 63-year-old patient had cataract surgery in the left eye performed using the femtosecond laser. The laser successfully created the capsulotomy, but as the femtosecond lens fragmentation was being performed, the patient suddenly moved and the eye disengaged from the patient interface. As this happened, the surgeon stopped the treatment, but inspection of the cornea revealed a partial lens fragmentation grid pattern in the temporal cornea. This inadvertent occurrence did not affect the final surgical result. FINANCIAL DISCLOSURE: Dr. Yoo is a consultant to Abbott Medical Optics, Inc. No author has a financial or proprietary interest in any material or method mentioned.

Resolution of conjunctival sessile hemangioma with topical timolol.

PURPOSE: To report a single case of acquired sessile hemangioma of the conjunctiva which resolved after treatment with topical timolol. METHODS: Case report and literature review. RESULTS: A 77-year-old African American woman developed an acquired sessile hemangioma of the conjunctiva of the right eye. She was followed for primary open-angle glaucoma, and the lesion was monitored for 12 months without change. Topical timolol-dorzolamide was then added to her glaucoma medication regimen twice daily. On follow-up examination 6 months later, the lesion had completely resolved. CONCLUSIONS: In this case report, an acquired sessile hemangioma of the conjunctiva resolved with topical timolol therapy.

Refractive and topographic fluctuations due to intracorneal ring segments motility.

PURPOSE: To describe a patient with refractive and topographic fluctuations 5 years after intracorneal ring segments (ICRS) implantation for the management of corneal ectasia after LASIK. METHODS: Case report. RESULTS: A 48-year-old woman presented complaining of intermittent decreased vision over 1 year that improved with eye rubbing. Slit-lamp and optical coherence tomography (OCT) examinations revealed overriding ring segments that could be restored to normal position after minor corneal massage. Topographic and refractive findings were significantly influenced by the ICRS positioning and caused decreased visual function when overriding. To avoid ICRS override, surgical dissection of the corneal tunnel along with ring segment repositioning was performed. A suture was placed through the ring's positioning hole to stabilize the ICRS at its optimal position and to avoid recurrence of this phenomenon. CONCLUSIONS: Patients undergoing femtosecond laser-assisted ICRS implantation may experience ring segment migration and override of the segments that could lead to decreased visual function. Proper surgical repositioning and ring segment fixation may address this complication and offer satisfactory visual and refractive outcomes along with avoidance of ICRS migration and override.

Diagnosing cardiac sarcoidosis clinically without tissue confirmation.

A 52-year-old woman is described in whom cardiac sarcoidosis was diagnosed clinically on the basis of high-grade heart block, recurring ventricular tachyarrhythmias, and acute cardiac decompensation. Confirmation of sarcoidosis was not determined until necropsy. When it causes cardiac dysfunction, sarcoidosis rarely causes dysfunction of another body organ, although small sarcoid granulomas may also be present in noncardiac organs or tissues. In the present patient, neurosarcoidosis accompanied the cardiac sarcoidosis, but it was the latter that produced the life-threatening symptoms and was fatal.

NORMAL QUALITY OF LIFE AFTER THE COX MAZE PROCEDURE FOR ATRIAL FIBRILLATION.

BACKGROUND/OBJECTIVE: Atrial fibrillation(AF) has been shown in numerous studies to significantly decrease patient quality of life. The Cox-Maze procedure has excellent long-term efficacy in curing AF. However, it is unknown whether this procedure improves long-term quality of life in these patients. The purpose of this study was to examine late quality of life in patients that underwent a lone Cox-Maze procedure. METHODS: Between 1987 and 2003, 163 patients underwent a Cox-Maze procedure for lone AF at our institution. Of these, 68 patients agreed and completed the Medical Outcomes Study Short Form 36 Health Survey. Scores from the age-matched general US population were normalized to a mean of 50 and standard deviation of 10 to facilitate comparison. Collected data were compared to the norm-based score for each domain using a one-sample t-test. Four patients were removed from analysis because of AF recurrence. RESULTS: There were 52 males(81%). Mean age was 52.6±9.5 years. Preoperatively, 37 patients(58%) had paroxysmal and 25 patients(39%) had persistent or permanent AF. The mean duration of AF before surgery was 9.8±8.2 years. There was no statistical difference in norm-based scores between the Cox-Maze procedure group and the age-matched general US population in any of the eight health domains at a mean follow-up of 8.7±3.7 years. CONCLUSION: Our results suggest that the Cox-Maze procedure cures atrial fibrillation in the majority of patients, and that those patients that are cured obtain a normal quality of life as compared to the general population at late follow-up.

Efficacy and safety of right and left atrial ablations on the beating heart with irrigated bipolar radiofrequency energy: a long-term animal study.

OBJECTIVE: The Cox maze procedure is the most effective surgical treatment for atrial fibrillation; however, its complexity has limited its clinical utility. The purpose of this study was to simplify the procedure by using an irrigated bipolar radiofrequency ablation device on the beating heart without cardiopulmonary bypass. METHODS: Six domestic pigs underwent median sternotomy. The pulmonary veins were circumferentially ablated. Electrical isolation was confirmed by pacing. Eight lesions were performed epicardially, and three lesions were performed through purse-string sutures with one of the jaws of the device introduced into the right atrium. After 30 days, magnetic resonance imaging was performed to assess atrial function, pulmonary vein anatomy, and coronary artery patency. Cholinergic stimulation and burst pacing were administered to induce atrial fibrillation. Histologic assessment of the heart was performed after the animal was killed. RESULTS: A modified Cox maze procedure was successfully performed with the irrigated bipolar radiofrequency device with no deaths. In every instance, the pulmonary veins were electrically isolated. Cholinergic stimulation with burst pacing failed to produce atrial fibrillation. Imaging studies revealed tricuspid regurgitation without evidence of pulmonary vein stenosis, coronary artery stenosis, or intra-atrial thrombus. Total atrial ejection fraction was 16.9% +/- 7.5%, a significant reduction. Histologically, 99% of the lesions were transmural, and there was no evidence of coronary sinus injury. CONCLUSION: Lesions on both the right and left atria can be created successfully on the beating heart with irrigated bipolar radiofrequency. The great majority of lesions with this device were transmural. This device should not be used on valvular tissue.

Elective surgery for thoracic aortic aneurysms: late functional status and quality of life.

BACKGROUND: Elective surgical treatment for thoracic aortic aneurysms is unique in that it is often performed on asymptomatic patients. Although it has been found to improve survival, the impact of elective surgery on late functional status and quality of life have yet to be examined. METHODS: Over a 5-year period, 110 asymptomatic patients underwent elective thoracic aortic replacement for ascending, descending, or thoracoabdominal aneurysms. Mean age was 67 +/- 9 years (53 > or = 70 years). Functional status, physical and psychological quality of life (Medical Outcome Study 36-Item Short Form Health Survey, in which 50 represents normalized age-matched US population), and survival (Kaplan-Meier) were assessed. RESULTS: Return to normal activity level was independent of age (p > 0.59) and procedure (p > 0.18). At 35 +/- 20 months, psychological quality of life was similar between surgical groups (p > 0.71), but physical quality of life was lower after thoracoabdominal versus ascending or descending aneurysms (p < 0.02). Age did not impact physical quality of life (40 +/- 13 > or = 70 years versus 42 +/- 11 < 70 years, p > 0.58), but older patients had improved psychological quality of life (52 +/- 9 > or = 70 years versus 47 +/- 8 < 70 years, p > 0.03). Overall survival was 79% +/- 4% at 2 years and 70% +/- 5% at 4 years, but was lower with thoracoabdominal versus ascending or descending aneurysms (p < 0.002). Multivariate analysis identified thoracoabdominal (p < 0.004), advanced age (p < 0.03), chronic renal failure (p < 0.03), and congestive heart failure (p < 0.001) as predictors of late death. CONCLUSIONS: Advanced age did not impair return to normal functional status, and older patients had improved psychological quality of life. Survival and physical quality of life were lowest with thoracoabdominal versus ascending or descending aneurysms. Thus, patients with asymptomatic thoracic aneurysms should not be denied elective replacement based on age alone, as functional recovery was not significantly impaired.

Contemporary techniques and safety of cardiovascular procedures in the surgical management of renal cell carcinoma with tumor thrombus.

OBJECTIVE: Renal cell carcinomas often form venous thrombi that extend into the vena cava. Frequently, cardiovascular consultation is necessary for complete surgical excision. We sought to investigate the risk factors, surgical techniques, and outcomes of patients treated for renal cell carcinoma with venous extension. METHODS: We reviewed the records of 46 consecutive patients who underwent surgical management of renal cell carcinoma with venous extension between 1991 and 2005. Data on patient history, staging, surgical techniques, morbidity, and survival were analyzed. RESULTS: There were 29 men and 17 women with a mean age of 60.2 +/- 12.0 years. Twenty-five (54%) procedures were completed with cardiovascular assistance. Nephrectomy was performed in 44 (96%) cases. Three (7%) patients underwent right heart venovenous bypass, and 2 (5%) patients underwent cardiopulmonary bypass with circulatory arrest. Fourteen (32%) patients had perioperative complications, including 1 (2%) perioperative death. Patients who required cardiovascular procedures (inferior vena cava clamping, right heart venovenous bypass, and cardiopulmonary bypass with circulatory arrest) had higher risks of perioperative complications (P < .02). The 1-, 2-, and 5-year overall survival rates were 78%, 69%, and 56%. CONCLUSIONS: This large series demonstrates that aggressive treatment of renal cell carcinoma with venous thrombus provides favorable outcomes. Our 5-year survival is among the highest of recent reviews, and our perioperative morbidity and mortality rates are comparable with those of other series. Tumors that require cardiovascular procedures are associated with increased complications when compared with radical nephrectomy and thrombectomy alone. Nevertheless, this aggressive treatment approach offers encouraging patient survival.