Cost-effectiveness and cost-benefit analysis of using methotrexate vs Goeckerman therapy for psoriasis. A pilot study

PURPOSE: To compare topical tetracaine 0.5% alone and with intracameral lidocaine 1% as a local anesthetic agent in phacoemulsification with intraocular lens (IOL) implantation. SETTING: The Toronto Hospital-Western Division, Toronto, Canada. METHODS: Fifty-nine consecutive patients (60 eyes) having phacoemulsification with implantation of a foldable acrylic IOL (AcrySof) were randomized into 1 of 2 groups: The intracameral balanced salt solution (BSS) group received topical tetracaine 0.5% plus intracameral BSS; the intracameral lidocaine group received topical tetracaine 0.5% with preservative-free intracameral lidocaine 1%. The patients' subjective experience of pain was measured at 4 points during surgery using a 4-point pain scale. Patient and surgeon satisfaction with the anesthesia used was measured using a 5-point satisfaction scale. Central endothelial cell counts were obtained preoperatively and 1 month postoperatively. Best corrected visual acuity (BCVA) was measured preoperatively and 1 hour, 1 day, 1 week, and 1 month postoperatively. RESULTS: The mean pain score after phacoemulsification was significantly higher in the intracameral BSS group than in the intracameral lidocaine group (0.63 +/- 0.7 [SD] and 0.23 +/- 0.4, respectively, P < .019). The mean pain score at the end of surgery was also significantly higher in the intracameral BSS group than in the intracameral lidocaine group (0.60 +/- 0.6 and 0.21 +/- 0.4, respectively; P < .014). The surgeon satisfaction score was significantly lower for the intracameral BSS group than for the intracameral lidocaine group (3.90 +/- 1.2 and 4.73 +/- 0.8, respectively; P < .0007). There was no difference in patient satisfaction between the intracameral BSS and intracameral lidocaine groups (4.60 +/- 0.6 and 4.70 +/- 0.8). Endothelial cell loss 1 month postoperatively was similar between the 2 groups (6.1% +/- 8% and 6.7% +/- 6%). Ninety-seven percent of patients (29/30) in each group noted BCVA improvement from preoperatively. The rate of potential visual acuity recovery was similar in both groups. CONCLUSION: Topical tetracaine 0.5% with intracameral lidocaine was safe and effective in patients having phacoemulsification with IOL implantation. The advantage of using intracameral lidocaine 1% over a placebo was a significant decrease in the patients' subjective experience of pain and in the surgeon's satisfaction with the anesthesia used. None of the other parameters measured in this study differed significantly between the 2 groups.     

Forum on ethics. Genetics: manipulating mother nature

BACKGROUND AND OBJECTIVE: To report the results of silicone oil removal from aphakic eyes using a self-sealing clear corneal incision under topical anesthesia. PATIENTS AND METHODS: Twenty-two eyes of 22 patients who had pars plana vitrectomy combined with silicone oil injection underwent silicone oil removal under topical anesthesia using a self-sealing clear corneal incision. Mean time between silicone oil injection and removal was 3.1+/-1.42 months. Fourteen eyes were filled with 1300 cs of silicone oil and 8 eyes were filled with 5700 cs of silicone oil. The removal was performed with passive washout in the eyes filled with 1300 cs of silicone oil and with active aspiration in the eyes filled with 5700 cs of silicone oil. RESULTS: All of the 22 silicone oil removal procedures performed under topical anesthesia had clear corneal incisions that did not require suturing at the end of surgery. Three cases that had 1300 cs of silicone oil required aspiration because of residual silicone oil bubbles. CONCLUSION: Silicone oil can be removed from the aphakic eye using a self-sealing corneal tunnel incision under topical anesthesia.     

A retrospective cost-effectiveness analysis of interferon as adjuvant therapy in high-risk resected cutaneous melanoma

PURPOSE: To determine the relative corneal endothelial toxicities of the following topical anesthetic agents: bupivacaine HCl 0.75%, unpreserved lidocaine HCl 4%, proparacaine HCl 0.5%, and tetracaine HCl 0.5%. METHODS: The experiment was conducted using pigmented rabbits. Approximately nine animals each were randomly assigned to eight groups. Right eyes received injections of 0.2 ml of one of the four anesthetic agents at one of two concentrations and left eyes received injections of 0.2 ml of balanced salt solution. Corneal thickness and clarity were measured before surgery and on postoperative days 1, 3, and 7. RESULTS: A statistically significant increase (P < 0.05) in corneal thickness and opacification over preoperative measurements was noted with injections of bupivacaine, lidocaine, and proparacaine, controlling for changes occurring in control eyes from surgery alone. Proparacaine was statistically more toxic than were the others. The toxicity of tetracaine was statistically indistinguishable from balanced salt solution, although mild toxicity was evident clinically. Injection of 1:10 dilutions of the same anesthetic agents failed to produce a statistically significant increase in corneal thickness or opacification on any postoperative examination. CONCLUSIONS: Anterior chamber injection of bupivacaine HCl 0.75%, unpreserved lidocaine HCl 4%, and proparacaine HCl 0.5% produces corneal thickening and opacification that is clinically and statistically significant. Tetracaine HCl 0.5% injection produces corneal thickening and opacification that is clinically apparent in some eyes but statistically insignificant. Ophthalmic surgeons should be aware of the potential for endothelial cell injury if anesthetic agents enter or are injected into the eye during cataract surgery in the concentrations supplied commercially.     

Topical plus subconjunctival anesthesia for phacotrabeculectomy: one year follow-up

PURPOSE: To evaluate the results of topical plus subconjunctival anesthesia for phacotrabeculectomy surgery and postoperative glaucoma control over 1 year. SETTING: Pacific Eye Center, Brisbane, Australia. METHODS: In this retrospective study of consecutive patients with glaucoma and cataract, topical plus subconjunctival anesthesia was used for combined phacoemulsification, posterior chamber intraocular lens implantation, and trabeculectomy (phacotrabeculectomy). Patients with proliferative diabetic retinopathy or neovascular glaucoma were excluded. RESULTS: Thirty-eight eyes had phacotrabeculectomy using topical plus subconjunctival anesthesia over 2 years. Patients reported no discomfort intraoperatively or postoperatively, and none required intravenous sedation. Eighty-one percent of patients achieved a best corrected visual acuity of 20/40 or better 6 months after surgery. Mean drop in intraocular pressure (IOP) was 5.91 mm Hg at 3 months and 5.86 mm Hg at 12 months, at which time IOP was controlled without additional medication in 72% of patients. There were no serious complications postoperatively. CONCLUSION: In this series, no patient reported intraoperative or postoperative discomfort and surgical results were excellent in terms of visual outcome and IOP control.     

Topical versus peribulbar anesthesia in cataract surgery

PURPOSE: To compare the use of topical anesthesia with that of peribulbar anesthesia in cataract surgery. SETTING: Quinze-Vingts Hospital, Paris, France. METHODS: This prospective study comprised 45 patients who had phacoemulsification and intraocular lens implantation in both eyes with 1 to 9 months between surgeries. Each patient had peribulbar anesthesia for one surgery and topical anesthesia for the other. The anesthesia method for the first eye was randomly selected. After surgery, patients were asked to rate their pain and whether they preferred one anesthesia technique over the other. RESULTS: When topical anesthesia was given, 82.2% of patients required no intravenous medications. Overall, 62.2% preferred topical over peribulbar anesthesia, with most patients citing the lack of periocular injection as the reason. CONCLUSION: Despite the increased technical difficulty, topical anesthesia proved an effective alternative to peribulbar anesthesia for cataract surgery that avoids the risks of periocular injection and reduces the need for intravenous medications.     

Pretreatment with topical 60% lidocaine tape reduces pain on injection of propofol

We determined whether pretreatment with topical 60% lidocaine tape reduced the incidence of pain on injection of propofol compared with mixing intravenous lidocaine with propofol. In a randomized, double-blind trial, 90 patients were allocated to one of three groups: pretreatment with a bioocclusive dressing and administration of a premixed solution of propofol 180 mg and 2 mL of normal saline (Group A); pretreatment with 60% lidocaine tape and a premixed solution of propofol and normal saline (Group B); or pretreatment with a bioocclusive dressing and a premixed solution of propofol 180 mg and lidocaine 40 mg (Group C). The incidences of pain in Groups A, B, and C were 86.7%, 33.4%, and 20%, respectively. Group B and Group C had a significantly lower incidence of pain than Group A. There was no significant difference in the incidence of pain between Group B and Group C. There was no significant difference in the distribution of site of pain on injection of propofol among the three groups. Pretreatment with topical 60% lidocaine tape reduced the incidence of pain on injection of propofol similar to that of intravenous lidocaine mixed with propofol. IMPLICATIONS: Pretreatment with topical 60% lidocaine tape reduces the pain associated with injection of propofol, a frequently used intravenous anesthetic. This approach should increase patient comfort during induction of anesthesia.     

Evaluation of local anesthesia techniques for small incision cataract surgery

PURPOSE: To evaluate the surgical experiences and patient preference with 3 local anesthesia techniques for small incision cataract surgery. SETTING: Department of Ophthalmology, Hj?rring Hospital, Denmark. METHODS: This prospective, randomized study included 66 patients having simultaneous bilateral cataract surgery. There were 3 test groups, each containing 2 of the following local anesthesia techniques: retro/peribulbar (RBA), sub-Tenon's (STA), or topical (TA). Each patient served as his or her own control. No medical sedation was used. Patient response to each anesthesia technique was evaluated by the surgeon based on surgical difficulties, a nurse using hand-holding tension and verbal interaction, and a visual analog pain score. Patients were also asked which of the 2 techniques they preferred and their reasons. RESULTS: No local anesthesia techniques interfered with surgery. The order of a positive pain/discomfort response during surgery was TA > STA > RBA. Significantly more pain occurred with application of RBA than with STA or TA. No postoperative pain was recorded with any method. Fifty-six percent of patients said they preferred 1 technique over the other; 16% of patients having STA would not do so again, 19% would not have TA again, and 40% would not have RBA again. The main reasons for preferring STA and TA were fear of or pain from a retrobulbar injection. The main reasons for preferring RBA were less awareness, anxiety, and surgical pain. Immediate visual recovery seemed to be of minor importance in patients' choice of an anesthesia technique. CONCLUSION: Although less discomfort/pain occurred during surgery with RBA, patients preferred STA and TA primarily because of the inconvenience or pain of the retrobulbar injection. Although medical sedation was not used in this study, the pain/discomfort ratio from surgery was not greater than in studies using intravenous sedation, indicating that the use of medical sedation should be re-evaluated.     

Surgically induced astigmatism with superior and temporal incisions in cases of with-the-rule preoperative astigmatism

PURPOSE: To evaluate surgically induced astigmatism (SIA), postoperative astigmatism, and uncorrected visual acuity (UCVA) after cataract surgery with superior corneal, superior scleral, and temporal corneal 4.0 mm sutureless incisions in cases of preoperative with-the-rule (WTR) astigmatism. SETTING: Hopital des Quinze-Vingts, Paris, France. METHODS: This prospective evaluation included patients having phacoemulsification with foldable lens implantation through a 4.0 mm incision. Patients with preoperative WTR astigmatism were randomly assigned to 1 of 3 incisions: superior corneal (Group 1), superior scleral (Group 2), or temporal corneal (Group 3). All patients had autokeratometry preoperatively and postoperatively (1 day, 1 week, 1 month, 1 year). Surgically induced astigmatism using the vector method, postoperative astigmatism, and UCVA (patients whose spherical equivalent was with +/- 1 diopter) were evaluated. RESULTS: Ninety patients were included in the study; there were 30 in each incision group. One year postoperatively, Group 1 had 1.52 diopters (D) of SIA and 1.36 D of postoperative astigmatism; 53.5% of patients had a UCVA of 20/32 or better, Group 2 had 0.69 D of SIA (P < .05) and 0.67 D of postoperative astigmatism (P < .05); 82.7% of patients had a UCVA of 20/32 or better (P < .05). Group 3 had 0.69 D (P > .05), 0.98 D (P < .05), and 79.3% (P > .05), respectively. CONCLUSIONS: In this study, the superior corneal incision produced significant SIA, leading to high postoperative astigmatism and poor UCVA. The scleral and temporal incisions produced minimal SIA and good UCVA.     

Concept of stress ulcer prevention. Is re-thinking necessary?

BACKGROUND: Continuous spinal anesthesia (CSA) has been considered to be better in temporal and dose flexibility, as well as hemodynamic stability than single dose spinal anesthesia. However, the failure of spinal anesthesia is not a rare experience for anesthesiologists. Here we present our experience in solving the problem and discuss the possible causes for the failure. METHODS: 236 cases were studied retrospectively from January to December in 1996. All were over 65 years old, ASA III, scheduled for transurethral procedures or orthopedic operation. CSA was performed with 0.2% bupivacaine. Failed CSA was confirmed by positive pin-prick test at T10 dermatome(umbilicus) 30 minutes after 20 mg bupivacaine was injected. For failed cases, 5 mL 1% lidocaine was injected intrathecally for rescue. The failure rate, sensory and motor blockade, success rate by changing to lidocaine and its dosage were recorded. RESULTS: Eleven of 236 cases (4.7%) were considered spinal failure since the initial 20 mg bupivacaine could not provide adequate T10 anesthesia in 30 minutes. Addition of 5 mL 1% lidocaine produced a profound sensory and motor blockade in 9 cases, while further lidocaine injection was required in two cases. The success rate by rescuing lidocaine was 100% with an average lidocaine consumption by 52.5 +/- 4.5 mg. DISCUSSION: Factors contributed to failure spinal anesthesia including failure of technique, errors of judgment, maldistribution and failure of local anesthetic itself. However, we thought that change of pH value of local anesthetic in CSF may play a great part in these failed CSAs. Despite the reasons for failure, we demonstrate that failure of continuous spinal anesthesia by 0.2% bupivacaine can be readily resolved by 1% lidocaine.     

International variation in anesthesia care during cataract surgery: results from the International Cataract Surgery Outcomes Study

OBJECTIVES: To describe international variation in anesthesia care and monitoring during cataract surgery and to discuss its implications for cost and safety. METHODS: A standardized questionnaire was sent to random samples of ophthalmologists in the United States, Canada, and Barcelona, Spain, and to all ophthalmologists in Denmark. The survey was conducted in 1993 and 1994. Certified ophthalmologists who had performed 1 or more cataract extractions in the previous year were eligible for enrollment. RESULTS: The response rates were 62% in the United States (n=148), 67% in Canada (n=276), 70% in Barcelona (n=89), and 80% in Denmark (n=82). The anesthetic technique for cataract surgery varied significantly between sites (P<.001). Surgeons reported that retrobulbar blocks were used for 46% of the cataract extractions in the United States, 70% in Canada, 66% in Denmark, and 31% in Barcelona. In Barcelona, general anesthesia was used for 23% of the cataract extractions; it was used for less than 3% of the extractions at the other 3 sites. Peribulbar blocks or topical anesthesia was used for the remaining extractions. In the United States, Canada, and Barcelona, surgeons reported that vital functions were monitored during more than 97% of the extractions and anesthesia surveillance was used during more than 78% of the extractions. In Denmark, ophthalmologists reported that vital functions were monitored and anesthesia surveillance was used for 1% of the cataract extractions (P<.001). CONCLUSIONS: Substantial international variation in anesthesia care and monitoring during cataract surgery was observed. The findings suggest a need for further research to determine whether less intensive monitoring is cost-effective.     

Suprasellar germinomas in childhood and adolescence: diagnostic pitfalls

STUDY OBJECTIVE: To compare the adequacy and efficacy of anesthesia experienced with lidocaine-epinephrine-tetracaine (LET) solution versus LET gel during suturing of uncomplicated lacerations on the face or scalp in children. METHODS: Two hundred children with lacerations of the face and scalp requiring suturing were enrolled in this blinded, randomized controlled trial, in the emergency department of a university-affiliated children's hospital. After the application of anesthetic solution or gel, adequacy of anesthesia was determined before suturing. Efficacy of anesthesia during laceration repair was determined by the length of time after removal of the topical anesthetic to the first sign of discomfort that required additional anesthesia or until suture completion. RESULTS: Adequacy of initial anesthesia was equivalent between LET solution and LET gel. There was a significant difference in efficacy of anesthesia between the LET formulations. There were more patients with complete anesthesia (85% versus 76%), fewer persons with partial anesthesia (5% versus 21%), and more persons with incomplete anesthesia (9% versus 3%) in the gel group. CONCLUSION: LET gel is at least as effective as LET solution and possesses theoretical advantages for topical anesthesia during suturing of uncomplicated lacerations on the face and scalp in children.     

Distressed or relieved? Psychological side effects of breast cancer screening in The Netherlands

PURPOSE: To compare three methods of combined cataract extraction and glaucoma surgery. METHODS: Retrospective review of 35 eyes of patients who had extracapsular cataract extraction and trabeculectomy using a corneoscleral incision (SAME), 54 eyes undergoing extracapsular cataract extraction and trabeculectomy using a separated corneal incision for cataract extraction and 43 eyes undergoing phacoemulsification and trabeculectomy. RESULTS: Ninety-one percent of the eyes in the SAME group, 85% of the SEPARATE group and 97% of the phacoemulsification and trabeculectomy group had an IOP < 22 mmHg at 6 months with or without medication (NS). Postoperative visual acuity and astigmatism were not significantly different between the groups. The number of eyes requiring YAG laser capsulotomy was significantly greater in the extracapsular cataract extraction and trabeculectomy (same and separated incision) as compared to the phacoemulsification and trabeculectomy group (P < 0.001). CONCLUSION: Phacoemulsification and trabeculectomy was not significantly more successful than the other methods of combined surgery. Although complication rates were similar, visual rehabilitation was faster and there was a reduced incidence of early posterior capsule opacification.     

Short-and long-term effect of clear corneal incisions on intraocular pressure

PURPOSE: To evaluate short- and long-term intraocular pressure (IOP) after cataract surgery using clear corneal incision to assess whether there is a statistically significant postoperative IOP decrease. SETTING: Advanced Vision Care, West Hills, California. METHODS: We retrospectively 135 eyes of 89 randomly selected patients who had scleral tunnel or clear corneal cataract surgery with a follow-up of at least 6 months. Patients with pre-existing glaucoma were excluded. RESULTS: In the clear corneal group (n = 84), mean IOP was statistically significantly lower (P = .019) 12 months after surgery than preoperatively (13.65 versus 15.57 mm Hg). Although there was a trend toward decreased IOP in the scleral tunnel incision group (n = 51), the difference was not statistically significant (P = .178). CONCLUSION: We found a trend toward lower IOP that, if permanent, raises serious implications about the necessity of combined procedures in patients with both glaucoma and cataract.     

Peridural anesthesia versus subarachnoid anesthesia in cesarean section. Prospective clinical study

OBJECTIVE: To compare technical and clinical differences between epidural and spinal anesthesia for cesarean section. STUDY DESIGN: Randomized prospective trial. PATIENTS AND METHODS: 64 pregnant women at term scheduled for elective cesarean section. Two groups were randomized: A) PD Group (n = 32): continuous epidural anesthesia by administration of bupivacaine 0.5% plus epinephrine 1/400,000 via an epidural catheter. Epidural morphine 3 mg was administered at the end of surgery. B) SP Group (n = 32): "single shot" spinal anesthesia by intrathecal administration of hyperbaric 1% bupivacaine 1-1.4 ml plus morphine 0.2 mg. The pin prick block level reached T2-T6 at incision time. DATA COLLECTION: 1) Time from the beginning of anesthesia to surgical incision. 2) Hypotension episodes. 3) Ephedrine consumption. 4) Intraoperative discomfort at delivery, traction and uterine manipulation, peritoneal toilette. 5) Nausea and vomiting. 6) Apgar score. 7) Postoperative headache. RESULTS: Women in the SP group had more hypotensive episodes (81% vs 53%: p < 0.05) and more ephedrine consumption with a large individual variability (29.12 mg +/- 20.4 vs 12.83 +/- 13.8: p < 0.01) when compared to PD group, without any difference in the Apgar score. The SP group required less time consumption (10.5 min. +/- 6.7 vs 35.9 min. +/- 17.3: p < 0.01) and had less intraoperative discomfort with less analgesic and/or sedative drugs consumption (9.7% vs 29%: p < 0.05) and less vomiting (3% vs 22.5%: p < 0.05). No postoperative headache was noticed in both groups. CONCLUSIONS: With the described pharmacological and technical approach, spinal anesthesia is more suitable than continuous epidural technique for cesarean section, unless contraindicated.     

Further study of hepatitis C virus RNA detection in formalin-fixed, paraffin-embedded liver tissues by ligation-dependent polymerase chain reaction

AIM: Refractive cataract surgery using corneal incisions is aiming at neutralization of preoperative astigmatism. PATIENTS AND METHODS: 61 patients with preoperative astigmatism of 2.25 +/- 0.98 were included in the treatment. A self-sealing corneal tunnel incision measuring 4.0 to 4.1 mm in external diameter and 6.5 to 7.0 mm in internal diameter (stretch incision) was performed on the steeper axis. After capsulorhexis and phacoemulsification a 5 mm PMMA lens was implanted without suturing. Keratometry and corneal topography were performed preoperatively, 3 days and 1 year respectively following surgery. The statistical analysis was based on the Wilcoxon signed ranks test. RESULTS: Surgical induced astigmatism (IA) following superior incisions in cases of astigmatism with the rule (n = 29) amounted to 1.93 +/- 0.97, while lateral incisions in cases of astigmatism against the rule (n = 29) led to an IA of 1.35 +/- 0.73. Axial shifts by more than 30 degrees were 23% following superior incisions and 17%, after lateral incisions. We observed. astigmatic reduction of 1.3 D after superior incisions and 0.7 D following lateral incisions. CONCLUSION: By 4 mm corneal cataract incisions on the steeper axis a high preoperative astigmatism can be reduced significantly without additional keratotomies.     

Cocaine, lidocaine, tetracaine: which is best for topical nasal anesthesia?

The quality of nasal anesthesia obtained with three local anesthetic solutions (4% cocaine, 2% lidocaine in oxymetazoline, and 1% tetracaine in oxymetazoline) was evaluated in a randomized study. Each local anesthetic mixture was applied to the nasal septum of healthy volunteers using medication-soaked pledgets. Measurements of anesthetic effect (sensation threshold and pain perception) were made with Semmes-Weinstein monofilaments. Measurements were performed prior to local anesthetic application and 10 and 70 min after local anesthetic application. Subjects had greater increases in sensation threshold with tetracaine than with lidocaine or cocaine at both 10 and 70 min (P < 0.05). Subjects had greater decreases in pain perception with tetracaine than with lidocaine or cocaine at both time intervals (P < 0.05). Tetracaine mixed with oxymetazoline appears to be a superior topical anesthetic for nasal procedures.     

Corneal topographic changes after frown and straight sclerocorneal incisions

PURPOSE: To compare the corneal topographic changes following cataract surgery with two types of sclerocorneal tunnel incisions for implantation of 6.0 mm optic poly(methyl methacrylate) intraocular lenses. SETTING: University Eye Hospital, Vienna, Austria. METHODS: This prospective, unmasked, and unrandomized study comprised 48 otherwise healthy eyes scheduled for cataract surgery. A 4.5 mm sutureless frown incision was made in 22 eyes and a 6.0 mm straight sclerocorneal incision with a horizontal 10-0 nylon infinity suture in 26 eyes. Preoperatively and 1 week and 1 and 3 months postoperatively, corneal topography was recorded by the TMS-1 computer-assisted videokeratoscope (Computed Anatomy, Inc.). The data were evaluated by batch-by-batch analyses of the paired differences between the records. The significance of topographic changes was calculated by paired Wilcoxon tests; group comparisons were made using Wilcoxon tests. RESULTS: In both groups, horizontal steepening and lower corneal flattening were consistently 0.4 diopter (D). Upper peripheral corneal flattening at 1 week and 1 and 3 months postoperatively was 0.7, 0.7, and 0.7 D, respectively, in the straight-incision group and 0.7, 0.4, and 0.3 D, respectively, in the frown-incision group. Vertical flattening and horizontal steepening were significant in both groups (P < .01). Group comparisons revealed significant differences in only 15 of 225 areas (P < .05). CONCLUSION: There were no major differences between the two incision groups in surgically induced topographic changes.     

Pain in the lower extremities after subarachnoid block with lidocaine

Subarachnoid block is a widely practiced anesthetic technique. With the availability of small-diameter needles and the rises in out-patient surgery, the number of procedures performed with subarachnoid block and short-term local anesthesia have increased. We report two cases of bilateral pain in the lower extremities appearing 20-24 h after intradural anesthesia with 2% hyperbaric lidocaine. We analyze the factors that might have triggered this complication and compare the two patients with 14 others described in the literature. Three points in common were found: the use of hyperbaric lidocaine, administration of the agent through small gauge needles and the performance of out-patient surgery.