A review of the surgical options for the correction of presbyopia

Presbyopia is an age-related eye condition where one of the signs is the reduction in the amplitude of accommodation, resulting in the loss of ability to change the eye's focus from far to near. It is the most common age-related ailments affecting everyone around their mid-40s. Methods for the correction of presbyopia include contact lens and spectacle options but the surgical correction of presbyopia still remains a significant challenge for refractive surgeons. Surgical strategies for dealing with presbyopia may be extraocular (corneal or scleral) or intraocular (removal and replacement of the crystalline lens or some type of treatment on the crystalline lens itself). There are however a number of limitations and considerations that have limited the widespread acceptance of surgical correction of presbyopia. Each surgical strategy presents its own unique set of advantages and disadvantages. For example, lens removal and replacement with an intraocular lens may not be preferable in a young patient with presbyopia without a refractive error. Similarly treatment on the crystalline lens may not be a suitable choice for a patient with early signs of cataract. This article is a review of the options available and those that are in development stages and are likely to be available in the near future for the surgical correction of presbyopia.

Surgical correction of astigmatism during cataract surgery

High levels of corneal astigmatism are prevalent in a significant proportion of the population. During cataract surgery pre-existing astigmatism can be corrected using single or paired incisions on the steep axis of the cornea, using relaxing incisions or with the use of a toric intraocular lens. This review provides an overview of the conventional methods of astigmatic correction during cataract surgery and in particular, discusses the various types of toric lenses presently available and the techniques used in determining the correct axis for the placement of such lenses. Furthermore, the potential causes of rotation in toric lenses are identified, along with techniques for assessing and quantifying the amount of rotation and subsequent management options for addressing post-operative rotation.

Melt processable biomaterials for degradable surgical fixation devices

There are currently few biomaterials which combine controlled degradation rates with ease of melt processability. There are however, many applications ranging from surgical fixation devices to drug delivery systems which require such combination properties. The work in this thesis is an attempt to increase the availability of such materials. Polyhydroxybutyrate-polyhydroxyvalerate copolymers are a new class of potentially biodegradable materials, although little quantitative data relating to their in vitro and in vivo degradation behaviour exists. The hydrolytic degradation of these copolymers has been examined in vitro under conditions ranging from `physiological' to extremes of pH and elevated temperature. Progress of the degradation process was monitored by weight loss and water uptake measurement, x-ray diffractometry, optical and electron microscopy, together with changes in molecular weight by gel permeation chromatography. The extent to which the degradation mechanism could be modified by forming blends with polysaccharides and polycaprolactone was also investigated. Influence of the valerate content, molecular weight, crystallinity, together with the physical form of the sample, the pH and the temperature of the aqueous medium on the hydrolytic degradation was investigated. Its progress was characterised by an initial increase in the wet weight, with concurrent decrease in the dry weight as the amorphous regions of the polymer are eroded, thereby producing an increase in matrix porosity. With the polysaccharide blends, this initial rate is dramatically affected, and erosion of the polysaccharide from the matrix markedly increases the internal porosity which leads to the eventual collapse of the matrix, a process which occurs, but less rapidly, in the degradation of the unblended polyhydroxybutyrate-polyhydroxyvalerate copolymers. Surface energy measurement and goniophotometry proved potentially useful in monitoring the early stages of the degradation, where surface rather than bulk processes predominate and are characterised by little weight loss.

An investigation into the impact of safety features on the ergonomics of surgical scalpels

In the case of surgical scalpels, blade retraction and disposability have been incorporated into a number of commercial designs to address sharps injury and infection transmission issues. Despite these new designs, the traditional metal reusable scalpel is still extensively used and this paper attempts to determine whether the introduction of safety features has compromised the ergonomics and so potentially the take-up of the newer designs. Examples of scalpels have been analysed to determine the ergonomic impact of these design changes. Trials and questionnaires were carried out using both clinical and non-clinical user groups, with the trials making use of assessment of incision quality, cutting force, electromyography and video monitoring. The results showed that ergonomic performance was altered by the design changes and that while these could be for the worse, the introduction of safety features could act as a catalyst to encourage re-evaluation of the ergonomic demands of a highly traditional product.

Psychological risk factors for chronic post-surgical pain after inguinal hernia repair surgery:a prospective cohort study.

A significant proportion of patients experience chronic post-surgical pain (CPSP) following inguinal hernia surgery. Psychological models are useful in predicting acute pain after surgery, and in predicting the transition from acute to chronic pain in non-surgical contexts. This is a prospective cohort study to investigate psychological (cognitive and emotional) risk factors for CPSP after inguinal hernia surgery. Participants were asked to complete questionnaires before surgery and 1 week and 4 months after surgery. Data collected before surgery and 1 week after surgery were used to predict pain at 4 months. Psychological risk factors assessed included anxiety, depression, fear-avoidance, activity avoidance, catastrophizing, worry about the operation, activity expectations, perceived pain control and optimism. The study included 135 participants; follow-up questionnaires were returned by 119 (88.1%) and 115 (85.2%) participants at 1 week and 4 months after surgery respectively. The incidence of CPSP (pain at 4 months) was 39.5%. After controlling for age, body mass index and surgical variables (e.g. anaesthetic, type of surgery and mesh type used), lower pre-operative optimism was an independent risk factor for CPSP at 4 months; lower pre-operative optimism and lower perceived control over pain at 1 week after surgery predicted higher pain intensity at 4 months. No emotional variables were independently predictive of CPSP. Further research should target these cognitive variables in pre-operative psychological preparation for surgery. © 2011 European Federation of International Association for the Study of Pain Chapters.

Chlorhexidine and the prevention of surgical site infection

Surgical site infections (SSI) are a prevalent health care-associated infection (HAl). Prior to the mid-19th century, surgical sites commonly developed postoperative wound complications. It was in the 1860's, after Joseph Lister introduced carbolic acid and the principles of antisepsis that postoperative wound infection significantly decreased. Today, patient preoperative skin preparation with an antiseptic agent prior to surgery is a standard of practice. Povidone-iodine and chlorhexidine gluconate are currently the most commonly used antimicrobial agents used to prep the patient's skin. In this current study, the epidemiology, diagnosis, surveillance and prevention of SSI with chlorhexidine were investigated. The antimicrobial activity of chlorhexidine was assessed. In in-vitro and in-vivo studies the antimicrobial efficacy of 2% (w/v) chlorhexidine gluconate (CHG) in 70% isopropyl alcohol (IPA) and 10% povidoneiodine (PVP-I) in the presence of 0.9% normal saline or blood were examined. The 2% CHG in 70% IPA solutions antimicrobial activity was not diminished in the presence of 0.9% normal saline or blood. In comparison, the traditional patient preoperative skin preparation, 10% PVP-I antimicrobial activity was not diminished in the presence of 0.9% normal saline, but was diminished in the presence of blood. In an in-vivo human volunteer study the potential for reduction of the antimicrobial efficacy of aqueous patient preoperative skin preparations compromised by mechanical removal of wet product from the application site (blot) was assessed. In this evaluation, 2% CHG and 10% povidone-iodine (PVP-I) were blotted from the patient's skin after application to the test site. The blotting, or mechanical removal, of the wet antiseptic from the application site did not produce a significant difference in product efficacy. In a clinical trial to compare 2% CHG in 70% IPA and PVP-! scrub and paint patient preoperative skin preparation for the prevention of SSI, there were 849 patients randomly assigned to the study groups (409 in the chlorhexidine-alcohol and 440 in the povidone-iodine group) in the intention-to-treat analysis. The overall surgical site infection was significantly lower in the 2% CHG in 70% IPA group than in the PVP-I group (9.5% versus 16.1 %, p=0.004; relative risk, 0.59 with 95% confidence interval of 0.41 to 0.85). Preoperative cleansing of the patient's skin with chlorhexidine-alcohol is superior to povidone-iodine in preventing surgical site infection after clean-contaminated surgery.

Rapid serodiagnosis of Staphylococcus aureus surgical site infection following median sternotomy

Objectives: To determine the sensitivity and specificity of a novel ELISA for the serodiagnosis of surgical site infection (SSI) due to staphylococci following median sternotomy. Methods: Twelve patients with a superficial sternal SSI and 19 with a deep sternal SSI due to Staphylococcus aureus were compared with 37 control patients who also underwent median sternotomy for cardiac surgery but exhibited no microbiological or clinical symptoms of infection. A further five patients with sternal SSI due to coagulase-negative (CoNS) staphylococci were studied. An ELISA incorporating a recently recognised exocellular short chain form of lipoteichoic acid (lipid S) recovered from CoNS, was used to determine serum levels of anti-lipid S IgG in all patient groups. Results: Serum anti-lipid S IgG titres of patients with sternal SSI due to S. aureus were significantly higher than the control patients (P<0.0001). In addition, patients with deep sternal SSI had significantly higher serum anti-lipid S IgG titres than patients with superficial sternal SSI (P=0.03). Serum anti-lipid S IgG titres of patients with sternal SSI due to CoNS were significantly higher than the control patients (P=0.001). Conclusion: The lipid S ELISA may facilitate the diagnosis of sternal SSI due to S. aureus and could also be of value with infection due to CoNS. © 2005 Published by Elsevier Ltd. on behalf of The Bristish Infection Society.

Controlled synthesis and processing of a poly(L-lactide-co-ε-caprolactone) copolymer for biomedical use as an absorbable monofilament surgical suture

Poly(L-lactide-co-ε-caprolactone) 75:25% mol, P(LL-co-CL), was synthesized via bulk ring-opening polymerisation (ROP) using a novel tin(II)alkoxide initiator, [Sn(Oct)]2DEG, at 130oC for 48 hrs. The effectiveness of this initiator was compared withthe well-known conventional tin(II) octoateinitiator, Sn(Oct)2. The P(LL-co-CL) copolymersobtained were characterized using a combination of analytical technique including: nuclear magnetic resonance spectroscopy (NMR), differential scanning calorimetry (DSC), thermogravimetry (TG) and gel permeation chromatography (GPC). The P(LL-co-CL) was melt-spun into monofilament fibres of uniform diameter and smooth surface appearance. Modification of the matrix morphology was then built into the as-spun fibresvia a series of controlled off-line annealing and hot-drawing steps. © (2014) Trans Tech Publications, Switzerland.

Preparation of a poly(L-lactide-co-caprolactone) copolymer using a novel tin(II) alkoxide initiator and its fiber processing for potential use as an absorbable monofilament surgical suture

A poly(L-lactide-co-caprolactone) copolymer, P(LL-co-CL), of composition 75:25 mol% was synthesized via the bulk ring-opening copolymerization of L-lactide and ε-caprolactone using a novel bis[tin(II) monooctoate] diethylene glycol coordination-insertion initiator, OctSn-OCH2CH2OCH2CH2O-SnOct. The P(LL-co-CL) copolymer obtained was characterized by a combination of analytical techniques, namely nuclear magnetic resonance spectroscopy, gel permeation chromatography, dilute-solution viscometry, differential scanning calorimetry, and thermogravimetric analysis. For processing into a monofilament fiber, the copolymer was melt spun with minimal draw to give a largely amorphous and unoriented as-spun fiber. The fiber's oriented semicrystalline morphology, necessary to give the required balance of mechanical properties, was then developed via a sequence of controlled offline hot-drawing and annealing steps. Depending on the final draw ratio, the fibers obtained had tensile strengths in the region of 200–400 MPa.

Validity of a prototype surgical aberrometer

Poster Purpose: A study to validate a prototype Hartmann-Shack (HS) wavefront aberrometer. Methods: The dynamic range was assessed using a calibrated model eye. It was validated against a conventional HS-aberrometer (Topcon KR1W) in 75 eyes using both instruments in random order. Additionally, intra-sessional repeatability was tested. Results: The aberrometer showed a large dynamic range of +21.0 D to −25.0 D. It was comparable to a conventional HS aberrometer for spherical-equivalent SE (MD ± 95% CI: 0.02 ± 0.49D; correlation: r = 0.995, p < 0.001), astigmatic components (J0: 0.02 ± 0.15D; r = 0.977, p < 0.001; J45: 0.03 ± 0.28; r = 0.666, p < 0.001) and HOAs RMS (0.02 ± 0.20D; r = 0.620, p < 0.001). Intra-sessional repeatability correlation was also excellent (SE = 1.000, p < 0.001; astigmatic-components J0 = 0.998, p < 0.001, J45 = 0.980, p < 0.01; HOAs RMS = 0.961, p < 0.001). Conclusions: This study confirms the validity of the prototype aberrometer. The prototype aberrometer can measure continuously to provide direct feedback of the optical status of the eye during surgery.

Intraoperative prediction of refractive error using a prototype surgical aberrometer

Purpose: To ascertain the agreement level between intra-operative refraction using a prototype surgical Hartmann-Shack aberrometer and subjective refraction a month later. Methods: Fifty-four consecutive patients had their pseudophakic refractive measured with the aberrometer intra-operatively at the end of their cataract surgery. A masked optometrist performed subjective refraction 4 weeks later. The two sets of data were then analysed for correlation. Results: The mean spherical equivalent was −0.14 ± 0.37 D (Range: −1.41 to +1.72 D) with the prototype aberrometer and −0.34 ± 0.32 (−1.64 to +1.88 D) with subjective refraction. The measurements positively correlated to a very high degree (r =+0.81, p < 0.01). In 84.3% of cases the two measurements were within 0.50D of each other. Conclusion: The aberrometer can verify the aimed refractive status of the eye intraoperatively to avoid a refractive surprise. The aberrometer is a useful tool for real time assessment of the ocular refractive status.

A sensory-guided surgical micro-drill

This article describes a surgical robotic device that is able to discriminate tissue interfaces and other controlling parameters ahead of the drill tip. The advantage in such a surgery is that the tissues at the interfaces can be preserved. A smart tool detects ahead of the tool point and is able to control the interaction with respect to the flexing tissue, to avoid penetration or to control the extent of protrusion with respect to the position of the tissue. For surgical procedures, where precision is required, the tool offers significant benefit. To interpret the drilling conditions and the conditions leading up to breakthrough at a tissue interface, a sensing scheme is used that discriminates between the variety of conditions posed in the drilling environment. The result is a fully autonomous system, which is able to respond to the tissue type, behaviour, and deflection in real-time. The system is also robust in terms of disturbances encountered in the operating theatre. The device is pragmatic. It is intuitive to use, efficient to set up, and uses standard drill bits. The micro-drill, which has been used to prepare cochleostomies in the theatre, was used to remove the bone tissue leaving the endosteal membrane intact. This has enabled the preservation of sterility and the drilling debris to be removed prior to the insertion of the electrode. It is expected that this technique will promote the preservation of hearing and reduce the possibility of complications. The article describes the device (including simulated drill progress and hardware set-up) and the stages leading up to its use in the theatre. © 2010 Authors.

A smart surgical robotic for cochlear implantation

In this paper a surgical robotic device for cochlear implantation surgery is described that is able to discriminate tissue interfaces and other controlling parameters ahead of a drill tip. The advantage in surgery is that tissues at interfaces can be preserved. The smart tool is able to control interaction with respect to the flexing tissue to avoid penetration control the extent of protrusion with respect to the real-time position of the tissue. To interpret drilling conditions, and conditions leading up to breakthrough at a tissue interface, the sensing scheme used enables discrimination between the variety of conditions posed in the drilling environment. The result is a robust fully autonomous system able to respond to tissue type, behaviour and deflection in real-time. The paper describes the robotic tool that has been designed to be used in the surgical environment where it has been used in the operating room.