Muscle Relaxants as a Risk Factor for Vis-à-tergo During Penetrating Keratoplasty: A Prospective Interventional Study

Descemet Membrane Endothelial Keratoplasty (DMEK) Anesthesia Analysis

PURPOSE

Comparison of safety and clinical results of Descemet membrane endothelial keratoplasty (DMEK) in topical, peribulbar, or general anesthesia.

METHODS

Retrospective, post hoc matched study of 346 patients who received DMEK surgery with different types of anesthesia (n = 54 topical, n = 137 peribulbar, n = 155 general anesthesia). Outcome criteria were intraoperative complications, endothelial cell count (ECC), central corneal thickness (CCT) and graft rejection rate, rebubbling rate, and visual acuity (VA). Mean follow-up time was 9.4 ± 2.8 months.

RESULTS

The group with topical anesthesia showed intraoperative difficulties such as vitreous pressure (p = 0.01) and difficult graft unfolding (p = 0.4), possibly leading to a higher rebubbling rate (p = 0.03) and therefore graft failure (p = 0.39). However, rebubbling and graft failure occurred more often when the graft preparation was more difficult (p = 0.2, p = 0.13, respectively), which was independent of anesthesia. All three groups achieved comparable functional results regarding VA, ECC, and CCT after 6 months.

CONCLUSION

DMEK under topical anesthesia is feasible and shows comparable final visual outcomes but should be limited to selected cooperative patients and performed by experienced surgeons due to the potential for increased intraoperative challenges.

Inventory of Ocular Pulse Amplitude Values in Healthy Subjects and Patients With Ophthalmologic Illnesses: Systematic Review and Meta-analysis

PURPOSE

Many studies have examined the ocular pulse amplitude (OPA) to better understand its physiology and clinical relevance, but the papers are scattered, not consistently indexed, and sometimes difficult to locate. We aimed to identify and summarize the relevant published evidence on OPA and, in a meta-analysis, outline specific differences of this parameter between healthy individual, primary open-angle glaucoma, normal-tension glaucoma, ocular hypertension, and cataract patients.

DESIGN

Systematic review and meta-analysis.

METHODS

A thorough literature search and data extraction were conducted by 2 reviewers independently. Reports on OPA measured by the dynamic contour tonometry in conjunction with different ocular and systemic diseases or potential influencing factors were included.

RESULTS

Of the 527 initially found reports, 97 met the inclusion criteria assessing 31 clinical conditions. A meta-analysis based on 6850 eyes and 106 study arms (68.8%) revealed differences in mean OPA values in millimeters of mercury between various entities. Among healthy eyes, the OPA was 2.58 mm Hg (95% CI: 2.45-2.71), whereas OPA values were higher in glaucoma (unspecified glaucoma 2.73 mm Hg, 95% CI: 2.38-3.08; normal-tension glaucoma 2.66 mm Hg, 95% CI: 2.36-2.97; and primary open-angle glaucoma 2.92 mm Hg, 95% CI: 2.75-3.08). Although ocular hypertension showed the highest OPA values (3.53 mm Hg, 95% CI: 3.05-4.01), the lowest values were found in cataract eyes (2.26 mm Hg, 95% CI: 1.57-2.94).

CONCLUSION

We found different OPA values characteristic of different clinical entities, with above-normal values in glaucoma and ocular hypertension and lower values in cataract patients. Our work is intended for clinicians and researchers who want to get a quick overview of the available evidence or who need statistical data on OPA distributions in individual diseases.

Indications and Results of Emergency Penetrating Keratoplasty With Simultaneous Cataract Surgery ("Triple-PKP à Chaud")

PURPOSE

The purpose of this study was to analyze the indications and clinical results of emergency penetrating keratoplasty with simultaneous cataract surgery ("Triple-PKP à chaud").

METHODS

This study included all subjects who underwent Triple-PKP à chaud between 2006 and 2020 at the Department of Ophthalmology, Saarland University Medical Center, Homburg/Saar in Germany. Data obtained from patient records were retrospectively analyzed.

RESULTS

Triple-PKP à chaud was successfully performed in 27 of 29 eyes with a mean age of 66.0 ± 19.9 years. Previous surgery was performed in 20 eyes (69.0%), most frequently amniotic membrane transplantation in 11 eyes (37.9%) and previous keratoplasty in 9 eyes (31.0%). The most common indication was infectious keratitis (62.1%). In 27 subjects (93.1%), capsulorhexis was performed using the open-sky technique. The most frequent intraoperative complication was positive vitreous pressure (24.1%). In 2 eyes (6.9%), no intraocular lens implantation was performed because of posterior capsule rupture. The preoperative uncorrected visual acuity improved from 2.2 ± 0.6 logMAR (range = 3.0-0.7 logMAR) to 1.3 ± 0.7 logMAR (range = 3.0-0.18 logMAR) postoperatively ( P < 0.001). Common postoperative complications were suture loosening (44.4%) and corneal epithelial defects (33.3%). Repeat keratoplasty was necessary in 14 eyes (51.9%), including 9 eyes (64.2%) within 12 months postoperatively. The mean graft survival was 12.2 ± 17.9 months (range = 1-69 mo).

CONCLUSIONS

Triple-PKP is also feasible in emergency conditions. Nevertheless, the surgery is associated with an increased risk of intraoperative and postoperative complications. Combined surgery should, therefore, only be performed in severely diseased eyes with progressed stage of cataract.

[Optical rehabilitation and pediatric ophthalmological care following keratoplasty for childhood corneal opacities]

BACKGROUND

The younger the children are at the time of corneal transplantation, the worse the survival prognosis of the graft.

PREOPERATIVE CONSIDERATIONS

Preoperative considerations are significant in terms of accurate parental education, ensuring adherence to treatment and choosing the appropriate surgical time frame (amblyopia versus graft failure, compliance of the patient). Parental education must include the reduced visual prognosis in young children, exceptions being later acquired corneal pathologies such as inflammatory corneal scars (herpes) and keratoconus.

POSTOPERATIVE CARE

A distinction must be made between morphological care after transplantation and refractive correction as well as treatment of amblyopia. The younger the children, the less favorable the prognosis for the transplant and the more often multiple examinations with anesthesia are necessary in order to detect complications, such as infiltrates or suture loosening at an early stage. Especially unilateral congenital pathologies often do not lead to a sufficient improvement of amblyopia (refractory amblyopia, poor compliance).

CONCLUSION

The prognosis after keratoplasty in childhood is already partly decided by the careful evaluation of indications (no surgery of a sclerocornea) and the detailed and realistic clarification for the parents (cooperation with long-term ocular and systemic treatment even if the child has poor compliance, frequent check-ups, reduced chances of amblyopia treatment). The younger the child is at the time of transplantation, the more frequent are graft failure and the development of complications. Later manifesting diseases in older children (herpetic corneal scars, keratoconus) have a better prognosis.

[Forms of anesthesia in ophthalmology]

The range of anesthesiological procedures in ophthalmology has not changed significantly over the last decades, with local anesthesia clearly coming to the fore. The development of minimally invasive surgical techniques requires significantly less analgesia and economic constraints to shorten operating times. The increasing proportion of outpatient ophthalmic surgery requires a short analgesia of the surgical area with as few complications as possible. Nevertheless, the selection of the procedures, which are described here in detail, must be made individually for each patient. General anesthesia continues to have its place, especially in cases of reduced compliance and difficult surgical conditions. The close cooperation between anesthetists and ophthalmic surgeons, e.g. for analgosedation in the outpatient area, can create a very pleasant surgical experience for the patient. An important goal should always be sufficient anxiolysis, analgesia and, in special operations, sufficient akinesia.

Analysis of different types of anesthesia in descemet membrane endothelial keratoplasty

PURPOSE

The purpose of this study is to compare the safety and clinical results of descemet membrane endothelial keratoplasty (DMEK) in topical, peribulbar or general anesthesia.

METHODS

This is a retrospective, post hoc matched study of 120 patients having received DMEK surgery with different types of anesthesia (n = 40 topical, n = 40 peribulbar, n = 40 general anesthesia). Endpoint criteria were intraoperative complications, endothelial cell count, central corneal thickness and graft rejection rate, rebubbling rate and best-corrected visual acuity after 1, 3 and 6 months.

RESULTS

The group with topical anesthesia showed more often intraoperative difficulties such as vitreous pressure (p < 0.05), difficult graft unfolding (p = 0.14) and patient restlessness (p = 0.07). However, all three groups achieved comparable functional visual results after 6 months (p = 0.96).

CONCLUSION

DMEK in topical anesthesia is feasible and shows comparable final visual results but should be restricted to selected cooperative patients and performed by experienced surgeons due to possible higher intraoperative challenges.

The effect of spinal versus general anesthesia on intraocular pressure in lumbar disc surgery in the prone position: A randomized, controlled clinical trial

OBJECTIVE

To compare IOP changes between spinal anesthesia (SA) and general anesthesia (GA) in patients who underwent lumbar disc surgery in the prone position.

DESIGN

Prospective, randomized, controlled trial.

SETTING

Operating room.

PATIENTS

Forty ASA I-II patients scheduled for lumbar disc surgery in prone position.

INTERVENTION

Patients were randomly allocated to the SA or GA groups.

MEASUREMENTS

IOP was measured before anesthesia (IOP1), 10 min after spinal or general anesthesia in supine position (IOP2), 10 min after being placed in the prone position (IOP3), and at the end of the operation in the prone position (IOP4).

MAIN RESULTS

There was no significant difference between baseline IOP1 (group GA = 19.4 ± 3.2 mmHg; group SA = 18.6 ± 2.4 mmHg) and IOP2 values (group GA = 19.7 ± 4.1 mmHg; group SA = 18.4 ± 1.9 mmHg) between and within the groups. IOP values after prone positioning and group GA measurements (IOP3 = 21.6 ± 3.1 mmHg; IOP4 = 33.9 ± 3.1 mmHg) were significantly higher when compared with the SA group (IOP3 = 19.3 ± 2.7 mmHg, IOP4 = 26.9 ± 2.4 mmHg) (p = 0.018 and p < 0.001, respectively). Furthermore, IOP3 was significantly increased when compared with IOP2 in the GA group but not in the SA group (p = 0.019 and p = 0.525, respectively). In both groups, IOP4 values were significantly higher than the other three measurements (p < 0.001).

CONCLUSION

The results indicated that IOP increase is significantly less in patients who undergo lumbar disc surgery in the prone position under SA compared with GA.