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Khodakovsky M. Regional anesthesia in ophthalmic surgery (overview of the problem). PAIN MEDICINE 2022. [DOI: 10.31636/pmjua.v6i4.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The article is devoted to the optimization of anesthetic management using regional methods of anesthesia in ophthalmic surgery. Methods and techniques of anesthetic management provide a sufficient level of anesthetic protection. All variants of regional anesthesia (monocomponent and combined) are used in the ophthalmological clinic “Optimal” on the basis of the Department of Anesthesiology, Intensive Care and Emergency Medicine of National Pirogov Memorial Medical University, Vinnytsia.
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Haripriya A, Ravindran RD, Robin AL, Shukla AG, Chang DF. Changing operating room practices: the effect on postoperative endophthalmitis rates following cataract surgery. Br J Ophthalmol 2022; 107:780-785. [PMID: 35017161 DOI: 10.1136/bjophthalmol-2021-320506] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 12/22/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE To determine whether four new operating room (OR) protocols instituted because of COVID-19 reduced the cataract surgical postoperative endophthalmitis rate (POE). DESIGN Retrospective, sequential, clinical registry study. METHODS 85 552 sequential patients undergoing cataract surgery at the Aravind Eye Hospitals between 1 January 2020 and 25 March 2020 (56 551 in group 1) and 3 May 2020 and 31 August 2020 (29 011 in group 2). In group 1, patients were not gowned, surgical gloves were disinfected but not changed between cases, OR floors were not cleaned between every case, and multiple patients underwent preparation and surgery in the same OR. In group 2, each patient was gowned, surgical gloves were changed between each case, OR floors and counters were cleaned between patients, and only one patient at a time underwent preparation and surgery in the OR. RESULTS Group 1 was older, had slightly more females, and better preoperative vision. More eyes in group 2 underwent phacoemulsification (p=0.18). Three eyes (0.005%) in group 1 and 2 eyes (0.006%) in group 2 developed POE (p=0.77). Only one eye that underwent phacoemulsification developed POE; this was in group 1. There was no difference in posterior capsule rupture rate between the two groups. CONCLUSIONS Adopting a set of four temporary OR protocols that are often mandatory in the Western world did not reduce the POE rate. Along with previously published studies, these results challenge the necessity of these common practices which may be needlessly costly and wasteful, arguing for the reevaluation of empiric and potentially unnecessary guidelines that govern ophthalmic surgeries.
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Affiliation(s)
- Aravind Haripriya
- Cataract and Intraocular Lens Services, Aravind Eye Care System, Chennai, Tamil Nadu, India
| | - Ravilla D Ravindran
- Chairman & Director - Quality Division, Aravind Eye Care System, Madurai, Tamil Nadu, India
| | - Alan L Robin
- Ophthalmology, University of Michigan, Ann Arbor, Michigan, USA
- Ophthalmology and International Health, Johns Hopkins University, Baltimore, Maryland, USA
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Karim HMR, Singha SK, Neema PK, Baruah TD, Ray R, Mohanty D, Siddiqui MS, Nanda R, Bodhey NK. Information technology-based joint preoperative assessment, risk stratification and its impact on patient management, perioperative outcome, and cost. Discoveries (Craiova) 2021; 9:e130. [PMID: 34849397 PMCID: PMC8627278 DOI: 10.15190/d.2021.9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 04/23/2021] [Accepted: 05/08/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Despite negative recommendations, routine preoperative testing practice is nearly universal. Our aim is to bring the healthcare providers on one platform by using information-technology based preanaesthetic assessment and evaluate the routine preoperative testing’s impact on patient outcome and cost.
Methods: A prospective, non-randomised study was conducted in a teaching hospital during January 2019-August 2020. A locally developed software and cloud-computing were used as a tool to modify preanaesthesia evaluation. The number of investigations ordered, time taken, cost incurred, were compared with the routine practice. Further data were matched as per surgical invasiveness and the patient's physical status. Appropriate tests compared intergroup differences and p-value <0.05 was considered significant.
Results: Data from 114 patients (58 in routine and 56 in patient and surgery specific) were analysed. Patient and surgery specific investigation led to a reduction in the investigations by 80-90%, hospital visit by 50%, and the total cost by 80%, without increasing the day of surgery cancellation or complications.
Conclusion: Information technology-based joint preoperative assessment and risk stratification are feasible through locally developed software with minimal cost. It helps in applying patient and surgery specific investigation, reducing the number of tests, hospital visit, and cost, without adversely affecting the perioperative outcome. The application of the modified method will help in cost-effective, yet quality and safe perioperative healthcare delivery. It will also benefit the public from both service and economic perspective.
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Affiliation(s)
| | - Subrata Kumar Singha
- Department of Anaesthesiology, India Institute of Medical Sciences, Raipur, India
| | - Praveen Kumar Neema
- Department of Anaesthesiology, India Institute of Medical Sciences, Raipur, India
| | - Tridip Dutta Baruah
- Department of General Surgery, India Institute of Medical Sciences, Raipur, India
| | - Rubik Ray
- Department of General Surgery, India Institute of Medical Sciences, Raipur, India
| | - Debajyoti Mohanty
- Department of General Surgery, India Institute of Medical Sciences, Raipur, India
| | - Md Sabah Siddiqui
- Department of General Medicine, India Institute of Medical Sciences, Raipur, India
| | - Rachita Nanda
- Department of Clinical Biochemistry, India Institute of Medical Sciences, Raipur, India
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Irizarry-Alvarado JM, Beltran M, Motoa G, Carpenter EK, Sanchez-Valenzuela MC, Garcia-Saucedo JC, Castano YG, Malavet P. Impact of Preoperative Testing on Patients Undergoing Ophthalmologic Surgery: A Retrospective Cohort Study. Am J Med 2021; 134:1514-1521.e1. [PMID: 34428460 DOI: 10.1016/j.amjmed.2021.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 07/11/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Routine medical testing is not recommended before cataract surgery, but no consensus exists about preoperative testing before general ophthalmologic surgery. We aimed to assess the impact of preoperative testing on patients undergoing ophthalmologic surgery by analyzing their surgical outcomes and complications. METHODS We retrospectively reviewed electronic health records of patients who had preoperative evaluations before cataract or noncataract ophthalmologic surgery at a tertiary care center from January 1, 2015, through December 31, 2019. RESULTS The cohort consisted of 2268 patients (1270 [56.0%] women). The most frequent ophthalmologic procedure was cataract extraction (n = 1450 [63.9%]). Laboratory tests results were available for 489 patients (33.7%) in the cataract group; of these, 275 results (56.2%) had abnormal values, and 18 patients (6.5%) required preoperative interventions. Preoperative test results were available for 772 out of 818 patients (94.4%) having noncataract procedures. Of these, 384 results (49.7%) had abnormal values, and 10 patients (2.6%) required additional intervention. No significant differences were observed for the rate of surgery cancellations between the cataract and noncataract patient groups (0.6% vs 1.0%; P = .24). Of the 12 patients (0.5%) who had complications, all had undergone preoperative testing. CONCLUSIONS No differences in outcomes and complications were observed among patients who underwent cataract or noncataract surgery. It is reasonable to consider avoiding preoperative testing in patients undergoing ophthalmologic surgery.
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Affiliation(s)
| | - Manuel Beltran
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, Fla; Research Trainee, Mayo Clinic, Jacksonville, Fla
| | - Gabriel Motoa
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, Fla; Research Trainee, Mayo Clinic, Jacksonville, Fla
| | - Emily K Carpenter
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, Fla; Mayo Clinic, Jacksonville, Fla
| | - Maria C Sanchez-Valenzuela
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, Fla; Research Trainee, Mayo Clinic, Jacksonville, Fla
| | - Juan C Garcia-Saucedo
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, Fla; Research Trainee, Mayo Clinic, Jacksonville, Fla
| | - Yennifer Gil Castano
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, Fla; Research Trainee, Mayo Clinic, Jacksonville, Fla
| | - Pedro Malavet
- Division of General Internal Medicine, Mayo Clinic, Jacksonville, Fla
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Kaur TS, Chatterjee BP. "Too much information with little meaning," relevance of preoperative laboratory testing in elective oral and maxillofacial surgeries: A systematic integrative review. Natl J Maxillofac Surg 2020; 11:3-9. [PMID: 33041569 PMCID: PMC7518500 DOI: 10.4103/njms.njms_60_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/12/2019] [Accepted: 02/02/2020] [Indexed: 12/19/2022] Open
Abstract
Aim: In the recent times due to accessibility of tools and advent of technology advising battery of laboratory tests prior to any electeve surgical procedure has become a norm. This review aims at investigating relevance of such tests in healthy patients undergoing routine elective oral and maxillofacial surgical procedures. Methods: Various search engines were thoroughly searched to identify relevant literature. The population of interest was asymptomatic adults above 18 years of age undergoing elective surgery. Results: The preoperative tests of interest for the current study included complete blood count, coagulation tests, biochemistry, and chest X-rays. An algorithm for preoperative tests has been proposed. Conclusion: We conclude that advising battery of routine tests in such patients leads to further delays and rise in overall cost of the surgery.
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Affiliation(s)
- Taranjit S Kaur
- Department of Oral and Maxillofacial Surgery, Government Dental College and Hospital, Jamnagar, Gujarat, India
| | - Bijoya P Chatterjee
- Department of Biochemistry, M. P. Shah Government Medical College, Guru Gobind Singh Government Hospital, Jamnagar, Gujarat, India
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Pike A, Mahoney K, Patey AM, Inwood S, Mortazhejri S, Lawrence R, Hall A. Protocol for assessing the determinants of preoperative test-ordering behaviour for low-risk surgical procedures using a theoretically driven, qualitative design. BMJ Open 2020; 10:e036511. [PMID: 32398338 PMCID: PMC7223279 DOI: 10.1136/bmjopen-2019-036511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Current evidence suggests that preoperative tests such as chest X-rays, electrocardiograms and baseline laboratory studies may not be useful for healthy patients undergoing low-risk surgical procedures. Routine preoperative testing for healthy patients having low-risk surgery is not a scientifically sound practice. In this study, we will interview healthcare providers working at medical facilities where low-risk surgical procedures are carried out. This will allow us to gain insight into the determinants of preoperative testing behaviours for healthy patients undergoing low-risk surgeries and their barriers and enablers to guideline adherence. METHODS AND ANALYSIS We will use semistructured interviews with anaesthesiologists, surgeons and preadmission clinic nurses to assess the determinants of preoperative testing behaviours. The interview guide was designed around the Theoretical Domains Framework (TDF), developed specifically to determine the barriers and enablers to implementing evidence-based guidelines. Interviews will be audio-recorded, transcribed verbatim and coded according to the TDF. Key themes will be generated for each of the identified domains. ETHICS AND DISSEMINATION We have received ethics approval from the Health Research Ethics Board in Newfoundland and Labrador (HREB #2018.190) for this study. The results of this work will be disseminated through a peer-reviewed publication, presentation at a healthcare forum and plain-language infographic summaries. Additionally, deidentified data collected and analysed for this study will be available for review from the corresponding author on reasonable request.
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Affiliation(s)
- Andrea Pike
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Krista Mahoney
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Andrea M Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Samantha Inwood
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Sameh Mortazhejri
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Rebecca Lawrence
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Amanda Hall
- Primary Healthcare Research Unit, Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
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Alabi RO, Turnbull ZA, Coombs PG, Wu Y, Orlin A, Chan RP, Kiss S, D'Amico DJ, Gupta MP. Assessing the value of preoperative medical clearance in patients with primary rhegmatogenous retinal detachment. Clin Ophthalmol 2019; 13:1711-1718. [PMID: 31564820 PMCID: PMC6732513 DOI: 10.2147/opth.s209681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/03/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine rates of intraoperative and postoperative systemic and ocular adverse events and establish the value of preoperative medical assessment in patients undergoing surgery for primary rhegmatogenous retinal detachment repair at a single academic center. Patients and methods Retrospective cohort study of 185 patients undergoing surgery for repair of primary rhegmatogenous retinal detachment (RRD) at a single academic center. Medical records were reviewed for medical comorbidities, completion of preoperative medical examination, anesthesia used during surgery, intraoperative adverse medical events, intraoperative ocular complications, and systemic and ocular postoperative complications. The main outcome of interest was the association of comorbidities and preoperative medical evaluation with intraoperative and postoperative complications. Results Approximately 48% of the patients presented with no medical comorbidities of interest. Formal preoperative evaluation by an independent medical provider was completed in 36% of the patients. Overall, intraoperative and postoperative systemic complications (5.7% and 1%, respectively) and intraoperative and postoperative ocular complications (0.5% for both) were uncommon. Patients with a history of chronic heart failure (OR 24.5, P=0.02) or who received general anesthesia (OR 9.56, P<0.001) had increased risk of having experienced any intraoperative or postoperative complication. No relationship between preoperative medical evaluation and intraoperative and postoperative complications was observed. Conclusion Patients undergoing surgery for RRD repair presented with fewer medical comorbidities than previously reported in patients undergoing all vitreoretinal surgeries. Intraoperative and postoperative complications were uncommon and were increased in patients with chronic heart failure or who received general anesthesia. Complications were not significantly associated with preoperative evaluation by an independent medical provider.
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Affiliation(s)
- Rolake O Alabi
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Zachary A Turnbull
- Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Peter G Coombs
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Yiyuan Wu
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy & Research, Weill Cornell Medical College, New York, NY, USA
| | - Anton Orlin
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Rv Paul Chan
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA
| | - Szilard Kiss
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Donald J D'Amico
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
| | - Mrinali P Gupta
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, USA
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Abstract
BACKGROUND Cataract surgery is practiced widely, and substantial resources are committed to an increasing cataract surgical rate in low- and middle-income countries. With the current volume of cataract surgery and future increases, it is critical to optimize the safety and cost-effectiveness of this procedure. Most cataracts are performed on older individuals with correspondingly high systemic and ocular comorbidities. It is likely that routine preoperative medical testing will detect medical conditions, but it is questionable whether these conditions should preclude individuals from cataract surgery or change their perioperative management. OBJECTIVES 1. To investigate the evidence for reductions in adverse events through preoperative medical testing2. To estimate the average cost of performing routine medical testing SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2018, Issue 6); Ovid MEDLINE; Embase.com; PubMed; LILACS BIREME, the metaRegister of Controlled Trials (mRCT) (last searched 5 January 2012); ClinicalTrials.gov and the WHO ICTRP. The date of the search was 29 June 2018, with the exception of mRCT which is no longer in service. We searched the references of reports from included studies for additional relevant studies without restrictions regarding language or date of publication. SELECTION CRITERIA We included randomized clinical trials in which routine preoperative medical testing was compared to no preoperative or selective preoperative testing prior to age-related cataract surgery. DATA COLLECTION AND ANALYSIS Two review authors independently assessed abstracts to identify possible trials for inclusion. For each included study, two review authors independently documented study characteristics, extracted data, and assessed risk of bias. MAIN RESULTS We identified three randomized clinical trials that compared routine preoperative medical testing versus selective or no preoperative testing for 21,531 cataract surgeries. The largest trial, in which 19,557 surgeries were randomized, was conducted in Canada and the USA. Another study was conducted in Brazil and the third in Italy. Although the studies had some issues with respect to performance and detection bias due to lack of masking (high risk for one study, unclear for two studies), we assessed the studies as at overall low risk of bias.The three randomized clinical trials included in this review reported results for 21,531 total cataract surgeries with 707 total surgery-associated medical adverse events, including 61 hospitalizations and three deaths. Of the 707 medical adverse events reported, 353 occurred in the pre-testing group and 354 occurred in the no-testing group (odds ratio (OR) 1.00, 95% confidence interval (CI) 0.86 to 1.16; high-certainty evidence). Most events were cardiovascular and occurred during the intraoperative period. Routine preoperative medical testing did not reduce the risk of intraoperative (OR 0.99, 95% CI 0.71 to 1.38) or postoperative ocular adverse events (OR 1.11, 95% CI 0.74 to 1.67) when compared to selective or no testing (2 studies; 2281 cataract surgeries; moderate-certainty evidence). One study evaluated cost savings, estimating the costs to be 2.55 times higher in those with preoperative medical testing compared to those without preoperative medical testing (1 study; 1005 cataract surgeries; moderate-certainty evidence). There was no difference in cancellation of surgery between those with preoperative medical testing and those with selective or no preoperative testing, reported by two studies with 20,582 cataract surgeries (OR 0.97, 95% CI 0.78 to 1.21; high-certainty evidence). No study reported outcomes related to clinical management changes (other than cancellation) or quality of life scores. AUTHORS' CONCLUSIONS This review has shown that routine preoperative testing does not increase the safety of cataract surgery. Alternatives to routine preoperative medical testing have been proposed, including self administered health questionnaires, which could substitute for health provider histories and physical examinations. Such avenues may lead to cost-effective means of identifying those at increased risk of medical adverse events due to cataract surgery. However, despite the rare occurrence, adverse medical events precipitated by cataract surgery remain a concern because of the large number of elderly patients with multiple medical comorbidities who have cataract surgery in various settings. The studies summarized in this review should assist recommendations for the standard of care of cataract surgery, at least in low- and middle-income settings. Unfortunately, in these settings, medical history questionnaires may be useless to screen for risk because few people have ever been to a physician, let alone been diagnosed with any chronic disease.
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Affiliation(s)
- Lisa Keay
- The University of SydneyThe George Institute for Global HealthLevel 24, Maritime Trade Towers207 Kent StreetSydneyNSWAustralia2000
| | - Kristina Lindsley
- Johns Hopkins Bloomberg School of Public HealthDepartment of Epidemiology615 North Wolfe Street, Mail Room E6132BaltimoreMarylandUSA21205
| | - James Tielsch
- George Washington UniversityDepartment of Global Health, Milken Institute of Public Health950 New Hampshire Avenue, NW, Suite 400Washington DCUSA20052
| | - Joanne Katz
- Johns Hopkins Bloomberg School of Public HealthDepartment of International Health615 N. Wolfe StreetBaltimoreMarylandUSA21209
| | - Oliver Schein
- Johns Hopkins University School of MedicineWilmer Eye Institute600 N. Wolfe Street, Wilmer 116BaltimoreMarylandUSA21287‐9019
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Abstract
Significant surgical advances have been made recently in corneal transplantation. Penetrating keratoplasty was the dominant method from 1905, until selective lamellar keratoplasty emerged as the preferred technique over the last 20 years. Advanced techniques such as corneal limbal stem cell transplant and keratoprosthesis are also available. The major surgical complications of corneal transplantation are extrusion of ocular content and expulsive choroidal haemorrhage. It is essential for an ophthalmic anaesthetist to have a good understanding of these new surgical procedures so as to provide optimal surgical conditions. This article aims to inform anaesthetists about the recent surgical advances in corneal transplantation and explore the anaesthetic considerations of these new techniques. General anaesthesia remains suitable for a wide range of these procedures especially in repeat surgery, difficult, or prolonged procedures. Regional ophthalmic blocks are ideal for endothelial keratoplasty but can be used in penetrating keratoplasty based on individual risk-benefit assessment, and as a supplement to general anaesthesia. Topical anaesthesia provides an alternative when general anaesthesia and ophthalmic regional blocks are less desirable but overall its use is limited.
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Rajavi Z, Javadi MA, Daftarian N, Safi S, Nejat F, Shirvani A, Ahmadieh H, Shahraz S, Ziaei H, Moein H, Motlagh BF, Feizi S, Foroutan A, Hashemi H, Hashemian SJ, Jabbarvand M, Jafarinasab MR, Karimian F, Mohammad-Rabei H, Mohammadpour M, Nassiri N, Panahi-Bazaz M, Rohani MR, Sedaghat MR, Sheibani K. Customized Clinical Practice Guidelines for Management of Adult Cataract in Iran. J Ophthalmic Vis Res 2016; 10:445-60. [PMID: 27051491 PMCID: PMC4795396 DOI: 10.4103/2008-322x.176913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Purpose: To customize clinical practice guidelines (CPGs) for cataract management in the Iranian population. Methods: First, four CPGs (American Academy of Ophthalmology 2006 and 2011, Royal College of Ophthalmologists 2010, and Canadian Ophthalmological Society 2008) were selected from a number of available CPGs in the literature for cataract management. All recommendations of these guidelines, together with their references, were studied. Each recommendation was summarized in 4 tables. The first table showed the recommendation itself in clinical question components format along with its level of evidence. The second table contained structured abstracts of supporting articles related to the clinical question with their levels of evidence. The third table included the customized recommendation of the internal group respecting its clinical advantage, cost, and complications. In the fourth table, the internal group their recommendations from 1 to 9 based on the customizing capability of the recommendation (applicability, acceptability, external validity). Finally, customized recommendations were sent one month prior to a consensus session to faculty members of all universities across the country asking for their comments on recommendations. Results: The agreed recommendations were accepted as conclusive while those with no agreement were discussed at the consensus session. Finally, all customized recommendations were codified as 80 recommendations along with their sources and levels of evidence for the Iranian population. Conclusion: Customization of CPGs for management of adult cataract for the Iranian population seems to be useful for standardization of referral, diagnosis and treatment of patients.
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Affiliation(s)
- Zhaleh Rajavi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Ali Javadi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Narsis Daftarian
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sare Safi
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farhad Nejat
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Armin Shirvani
- Office for Healthcare Standards, Deputy of Curative Affairs, Ministry of Health and Medical Education, Tehran, Iran; Department of Medical Education, Faculty of Medical Education, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Ahmadieh
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Hossein Ziaei
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamidreza Moein
- Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Sepehr Feizi
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Foroutan
- Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Hassan Hashemi
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Javad Hashemian
- Department of Ophthalmology, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mahmoud Jabbarvand
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Jafarinasab
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farid Karimian
- Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Mohammad-Rabei
- Department of Ophthalmology, Imam Hussein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehrdad Mohammadpour
- Department of Ophthalmology, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Nader Nassiri
- Department of Ophthalmology, Imam Hussein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Reza Rohani
- Department of Ophthalmology, Al-Zahra Eye Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | | | - Kourosh Sheibani
- Basir Eye Safety Research Center, Basir Eye Clinic, Tehran, Iran
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Thilen SR, Treggiari MM, Lange JM, Lowy E, Weaver EM, Wijeysundera DN. Preoperative consultations for medicare patients undergoing cataract surgery. JAMA Intern Med 2014; 174:380-8. [PMID: 24366269 PMCID: PMC4167873 DOI: 10.1001/jamainternmed.2013.13426] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Low-risk elective surgical procedures are common, but there are no clear guidelines for when preoperative consultations are required. Such consultations may therefore represent a substantial discretionary service. OBJECTIVE To assess temporal trends, explanatory factors, and geographic variation for preoperative consultation in Medicare beneficiaries undergoing cataract surgery, a common low-risk elective procedure. DESIGN, SETTING, AND PARTICIPANTS Cohort study using a 5% national random sample of Medicare part B claims data including a cohort of 556,637 patients 66 years or older who underwent cataract surgery from 1995 to 2006. Temporal trends in consultations were evaluated within this entire cohort, whereas explanatory factors and geographic variation were evaluated within the 89,817 individuals who underwent surgery from 2005 to 2006. MAIN OUTCOMES AND MEASURES Separately billed preoperative consultations (performed by family practitioners, general internists, pulmonologists, endocrinologists, cardiologists, nurse practitioners, or anesthesiologists) within 42 days before index surgery. RESULTS The frequency of preoperative consultations increased from 11.3% in 1998 to 18.4% in 2006. Among individuals who underwent surgery in 2005 to 2006, hierarchical logistic regression modeling found several factors to be associated with preoperative consultation, including increased age (75-84 years vs 66-74 years: adjusted odds ratio [AOR], 1.09 [95% CI, 1.04-1.13]), race (African American race vs other: AOR, 0.71 [95% CI, 0.65-0.78]), urban residence (urban residence vs isolated rural town: AOR, 1.64 [95% CI, 1.49-1.81]), facility type (outpatient hospital vs ambulatory surgical facility: AOR, 1.10 [95% CI, 1.05-1.15]), anesthesia provider (anesthesiologist vs non-medically directed nurse anesthetist: AOR, 1.16 [95% CI, 1.10-1.24), and geographic region (Northeast vs South: AOR, 3.09 [95% CI, 2.33-4.10]). The burden of comorbidity was associated with consultation, but the effect size was small (<10%). Variation in frequency of consultation across hospital referral regions was substantial (median [range], 12% [0-69%]), even after accounting for differences in patient-level, anesthesia provider-level, and facility-level characteristics. CONCLUSIONS AND RELEVANCE Between 1995 and 2006, the frequency of preoperative consultation for cataract surgery increased substantially. Referrals for consultation seem to be primarily driven by nonmedical factors, with substantial geographic variation.
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Affiliation(s)
- Stephan R Thilen
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Miriam M Treggiari
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle2Department of Epidemiology, University of Washington, Seattle
| | - Jane M Lange
- Department of Biostatistics, University of Washington, Seattle
| | - Elliott Lowy
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington5Department of Health Services, University of Washington, Seattle
| | - Edward M Weaver
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington6Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle
| | - Duminda N Wijeysundera
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada8Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada9Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada10
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Pollock A, Hazelton C, Henderson CA, Angilley J, Dhillon B, Langhorne P, Livingstone K, Munro FA, Orr H, Rowe FJ, Shahani U. Interventions for age-related visual problems in patients with stroke. Cochrane Database Syst Rev 2012:CD008390. [PMID: 22419333 DOI: 10.1002/14651858.cd008390.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The prevalence of eye problems increases with age and, consequently, so does the level of visual impairment. As the incidence of stroke also increases with age, a significant proportion of stroke patients will have age-related visual problems. It is possible that the effect of interventions for age-related visual problems may differ in the population of stroke patients compared to the wider population of older people. The interaction between the problems arising directly from stroke and those arising directly from age-related visual problems will be complex. Interventions for age-related visual problems may also be affected by the presence of other stroke-related co-morbidities. Consequently, the nature and outcome of interventions for age-related visual problems may be different in patients with stroke. OBJECTIVES The aim of this review is to determine if interventions for age-related visual problems improve functional ability following stroke. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (March 2011), the Cochrane Eyes and Vision Group Trials Register (December 2009) and nine electronic bibliographic databases including: the Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), MEDLINE (1950 to February 2011), EMBASE (1980 to February 2011), CINAHL (1982 to February 2011), AMED (1985 to February 2011) and PsycINFO (1967 to February 2011). We also searched reference lists and trials registers, handsearched journals and conference proceedings, and contacted experts. SELECTION CRITERIA Randomised trials in adults after stroke, where the intervention is specifically targeted at assessing, treating or correcting age-related visual problems, or improving the ability of the patient to cope with visual impairment. Primary outcome was functional ability in activities of daily living and secondary outcomes included functional ability in extended activities of daily living, visual acuity, visual field, visual function, balance, falls, depression and anxiety, discharge destination/residence after stroke, quality of life and social isolation, adverse events and death. DATA COLLECTION AND ANALYSIS Two review authors independently screened abstracts and planned to extract data and appraise trials. We planned that assessment of methodological quality would be undertaken for allocation concealment, blinding of outcome assessor, method of dealing with missing data and other potential sources of bias. MAIN RESULTS We considered 7357 titles, 460 abstracts and 85 full papers. We identified no studies for inclusion in this review. AUTHORS' CONCLUSIONS There are no implications for practice arising from this review. Evidence relating to the management of patients (from the general population) with age-related visual problems is available from other Cochrane reviews and is likely to be the best evidence available for making treatment decisions about individual patients. Subgroup analyses within these reviews to explore the effect of interventions for age-related visual problems in patients with stroke are recommended. We recommend that the objectives and selection criteria for this Cochrane review are amended and clarified prior to any future updates.
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Affiliation(s)
- Alex Pollock
- Nursing, Midwifery and AlliedHealth Professions Research Unit, Glasgow Caledonian University, Glasgow, UK.
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Abstract
BACKGROUND Cataract surgery is practiced widely and substantial resources are committed to an increasing cataract surgical rate in developing countries. With the current volume of cataract surgery and the increases in the future, it is critical to optimize the safety and cost-effectiveness of this procedure. Most cataracts are performed on older individuals with correspondingly high systemic and ocular comorbidities. It is likely that routine preoperative medical testing will detect medical conditions, but it is questionable whether these conditions should preclude individuals from cataract surgery or change their perioperative management. OBJECTIVES (1) To investigate the evidence for reductions in adverse events through preoperative medical testing, and (2) to estimate the average cost of performing routine medical testing. SEARCH METHODS We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 12), MEDLINE (January 1950 to December 2011), EMBASE (January 1980 to December 2011), Latin American and Caribbean Literature on Health Sciences (LILACS) (January 1982 to December 2011), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 9 December 2011. We used reference lists and the Science Citation Index to search for additional studies. SELECTION CRITERIA We included randomized clinical trials in which routine preoperative medical testing was compared to no preoperative or selective preoperative testing prior to age-related cataract surgery. DATA COLLECTION AND ANALYSIS Two review authors independently assessed abstracts to identify possible trials for inclusion. For each included study, two review authors independently documented study characteristics, extracted data, and assessed methodological quality. MAIN RESULTS The three randomized clinical trials included in this review reported results for 21,531 total cataract surgeries with 707 total surgery-associated medical adverse events, including 61 hospitalizations and three deaths. Of the 707 medical adverse events reported, 353 occurred in the pretesting group and 354 occurred in the no testing group. Most events were cardiovascular and occurred during the intraoperative period. Routine preoperative medical testing did not reduce the risk of intraoperative (OR 1.02, 95% CI 0.85 to 1.22) or postoperative medical adverse events (OR 0.96, 95% CI 0.74 to 1.24) when compared to selective or no testing. Cost savings were evaluated in one study which estimated the costs to be 2.55 times higher in those with preoperative medical testing compared to those without preoperative medical testing. There was no difference in cancellation of surgery between those with preoperative medical testing and those with no or limited preoperative testing, reported by two studies. AUTHORS' CONCLUSIONS This review has shown that routine pre-operative testing does not increase the safety of cataract surgery. Alternatives to routine preoperative medical testing have been proposed, including self-administered health questionnaires, which could substitute for health provider histories and physical examinations. Such avenues may lead to cost-effective means of identifying those at increased risk of medical adverse events due to cataract surgery. However, despite the rare occurrence, adverse medical events precipitated by cataract surgery remain a concern because of the large number of elderly patients with multiple medical comorbidities who have cataract surgery in various settings. The studies summarized in this review should assist recommendations for the standard of care of cataract surgery, at least in developed settings. Unfortunately, in developing country settings, medical history questionnaires would be useless to screen for risk since few people have ever been to a physician, let alone been diagnosed with any chronic disease.
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Affiliation(s)
- Lisa Keay
- Injury Division, The George Institute for Global Health, The University of Sydney, Sydney, Australia.
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Kramer J, Graf BM, Zausig YA. [Preoperative risk evaluation from the perspective of anaesthesiology]. Chirurg 2011; 82:1037-50; quiz 1051-2. [PMID: 22037717 DOI: 10.1007/s00104-010-2056-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Medical and technical progress together with demographic changes has led to a more complex perioperative care for patients. Accordingly, an optimal preoperative assessment in particular an adequate risk evaluation is more important than ever. A recently published joint recommendation of the German Society of Anaesthesiology and Intensive Care Medicine, the German Society of Surgery and the German Society of Internal Medicine aims to reduce considerable uncertainties in the preoperative risk evaluation especially with regard to"technical tests" by providing transparent and comprehensive arrangements. Consequently, routine screening will be abandoned in favour of targeted patient and operation-oriented individual risk assessment. This approach will change the preoperative risk evaluation in a scientific, organisational and economic way. The following article on preoperative risk evaluation is based on the valuable and helpful recommendation and aims to provide additional important aspects from the perspective of anaesthesiologists.
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Affiliation(s)
- J Kramer
- Klinik für Anästhesiologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
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A tale of two systems. Ophthalmology 2011; 118:1690-1. [PMID: 21813094 PMCID: PMC9909463 DOI: 10.1016/j.ophtha.2011.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 04/26/2011] [Indexed: 11/23/2022] Open
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