Vision Loss After Non-Ocular Surgery
At Press Time
Vision Loss After Non-Ocular Surgery
This Complication Has Increased in Recent Years.
By Jerry Helzner, Senior Editor
■ Almost every ophthalmologist has had the experience of a patient complaining of significant vision loss after undergoing cardiac bypass or other non-ocular surgery. Unfortunately, ophthalmologists are relatively powerless to deal with postoperative visual loss (POVL) because the damage is usually caused by an ischemic or other event that occurs during surgery and is irreversible.
Reports of POVL have become more numerous in recent years, correlating strongly with the increase in coronary bypass procedures. However, other non-ocular surgeries can also lead to POVL. Though many cases of POVL are never reported, a recent article by Molly E. Gilbert, M.D., of the Department of Neuro-Ophthalmology, University of Illinois Eye and Ear Infirmary, notes that it has been estimated that this complication is occurring in as many as 4.5% of cardiac surgeries.
Dr. Gilbert's article, which appeared in the journal Neuro-Ophthalmology, identifies a variety of factors that are believed to contribute to POVL. Some of these risks are intrinsic to the individual patient, such as diabetes, hypertension, age, vascular disease, history of smoking, optic nerve head morphology and variable optic nerve blood supply. Other risk factors are related to the surgical procedure, such as prone positioning, extraocular pressure, increased venous pressure, prolonged surgical time and hypotension.
"A variety of factors make POVL difficult to predict and prevent," writes Dr. Gilbert. "Many patients have certain clinical factors that could predispose them to developing POVL. In addition, many surgeries use deliberate hypotension, prone positioning, long surgical times or are associated with acute blood loss without leading to POVL."
Dr. Gilbert writes that direct pressure on the eye has long been associated with POVL.
"It has been noted numerous times in the medical literature and is associated with extraocular pressure leading to decreased blood flow to the central retinal artery. It is the most important cause of POVL medicolegally because it is avoidable."
Dr. Gilbert concludes that education of anesthesiologists and (non-ocular) surgeons is paramount in the prevention of POVL. Among the precautions these practitioners should take is obtaining a complete preoperative history to identify any preexisting patient risk factors that predispose to POVL, evaluating the use of deliberate hypotension in patients at risk, avoidance of compression of the eye, abdomen or chest in patients placed prone, and correction of anemia and/or hypotension as early as feasible upon identification of these risk factors.
|IN THE NEWS|
|■ AMO welcomes Abbott as parent. The recent acquisition of Advanced Medical Optics by Abbott Laboratories has resulted in very few early changes except for a new name. Now known as Abbott Medical Optics (it's still AMO), the eye care unit of Abbott will continue under the leadership of James Mazzo, president. AMO will operate somewhat independently as Abbot had no presence in eye care prior to acquiring AMO.|
"Abbott approached us about a combination," Mr. Mazzo told Ophthalmology Management. "They had been following our company — and our industry — for several years. They were very knowledgeable. They liked the overall demographics for eye care. They liked our assets and our clear leadership positions in several major areas: number 1 in refractive surgery, number 2 in cataract and number 3 in contact lens care."
Mr. Mazzo said that synergies between Abbott Labs and AMO include complementary R&D capabilities that will be beneficial to both organizations. He also cited Abbott's broad distribution network that will enable existing and future AMO products to be marketed more widely.
■ Restasis scores high in QOL study. Topical cyclosporine 0.05% (Restasis) can have a major impact on improving the quality-of-life of patients with moderate-to-severe dry eye, according to a study done by the Center for Value-Base Medicine (CVBM).
Using a proprietary methodology that takes into account the overall costs and utility of a specific medical intervention, cyclosporine 0.05% was judged as improving quality-of-life by an average of 4.3% when compared to commonly used lubricants. On a scale developed by the CVBM, this makes cyclosporine 0.05% a more effective therapy than an adrenergic blocker for prostate hyperplasia but a less life-changing intervention than cataract surgery or ranibizumab for choroidal neovascularization. The research was reported in a recent issue of the Archives of Ophthalmology.
Melissa Brown, M.D., an ophthalmologist who founded the CVBM a decade ago, says the Center's goal is to evaluate specific medical interventions encompassing a wide range of medical specialties as a way to discover the most effective — and cost-effective — therapies.
"Our research is definitely in tune with a number of initiatives that strive to bring down the costs of health care while improving the quality," says Dr. Brown. "We are striving to remove the obstacles to providing the best products to the best-suited patients."
■ Plane crash claims California eye M.D. Erin Jacobson, M.D., 37, an ophthalmologist affiliated with the Eye Care Center of Napa Valley and St. Helena Hospital, was one of 14 victims of a late March plane crash in Montana.
Dr. Jacobson, his wife and three young children were among three families who were aboard the plane and headed for a week of skiing at an exclusive resort.
Dr. Jacobson received his medical degree from Loma Linda University in California, where he also completed resident training in ophthalmology. He had participated in medical missions to Haiti and the Dominican Republic. He was described as a dedicated husband and father, who was an avid skier, cyclist and photographer.
■ Dr. Parke assumes AAO post. David W. Parke II, M.D., is now executive vice president and CEO of the American Academy of Ophthalmology. He succeeded H. Dunbar Hoskins Jr., M.D., who retired after leading the Academy since 1993.
"I am looking forward to working with and representing the Academy's members," said Dr. Parke. "It is an honor to be able to serve the profession I love. Ophthalmology faces opportunities and challenges in the coming months and years, and I pledge to dedicate my best efforts to address both. I am especially indebted to Dr. Hoskins, whose skill and commitment has left the Academy well positioned to face the tasks ahead of us."
■ Wanted: preservative-free glaucoma meds. A recently conducted survey of 124 ophthalmologists indicates that 89% of these physicians would like to see a greater number of preservative-free glaucoma medications.
In addition, a similar percentage of the doctors surveyed said that preservative-free glaucoma medications can enhance ocular comfort and quality of life. Conversely, 70% said of respondents said preservatives in glaucoma medications were a cause of ocular surface disease.
The survey was sponsored by Aton Pharma, manufacturer of Timoptic, a preservative-free glaucoma medication.
■ Staar IOL gets NTIOL status. Staar Surgical announced the release of its Afinity Collamer Aspheric Single Piece New Technology Intraocular Lens (NTIOL). NTIOLs are IOLs designated by the CMS as providing new clinical benefits. The lens can be delivered into the eye through a 2.2 mm microincision using Staar's new NanoPoint Injector System, allowing the smallest incision of any NTIOL on the market. Staar says the collamer material is a unique lens material composed of collagen, a UV-absorbing chromophore, and a poly-HEMA based copolymer.
■ B&L licenses IOL materials. Bausch & Lomb has entered into a licensing agreement with Santen Pharmaceutical Co., Ltd., for the development of certain IOL materials. Under the terms of the agreement, Bausch & Lomb has obtained the rights to Santen's hydrophobic acrylic polymers, from which it may commercialize new IOLs for sale worldwide. Santen reserves the right for the use of these materials in the Japanese market. Financial terms will not be disclosed.
■ Canada approves AzaSite. InSite Vision Inc.'s AzaSite therapy for bacterial conjunctivitis has been approved by Canadian regulators. AzaSite was approved in April 2007 in the United States, where it is distributed by Inspire Pharmaceuticals. Inspire also is the exclusive licensee of AzaSite in Canada.
■ B&L names Harris. Bausch & Lomb has appointed Brian J. Harris as chief financial officer and corporate vice president. Harris is a business and finance executive having more than three decades of experience with multinational organizations.
The company also selected Mitsuo (Mike) Hirose as chairman of Bausch & Lomb Japan. Hirose had been serving on the subsidiary's board of directors.
Hirose brings considerable depth in healthcare management. He has served as president and representative director for both Johnson & Johnson Japan Inc. and Johnson & Johnson Medical Company, as well as in other capacities for the Johnson & Johnson Group of Companies. OM
A Mission Links Family to Its History
Dr. Conrad Brings Eye Care to Rural China.
It's no accident that William C. Conrad, M.D., of Warner Robins, Ga., is the founder of one of the few American-based eye care efforts serving China. Since 1993, Dr. Conrad has returned each summer to rural and rugged Gansu Province in northwest China, primarily to remove vision-robbing white-pupil cataracts that are prevalent in this poor and mountainous area of the country.
In all, Dr. Conrad has made 25 trips to China, while his wife Peggy has made 23 of them.
However, Dr. Conrad's link to Gansu Province actually goes back to the late 19th century when his grandparents spent 32 years as missionaries in that area.
"My mother spent her first 8 years in Gansu Province," Dr. Conrad says. "I took my family on a heritage trip to Gansu in 1987 and one of the first things I noticed was the great need for eye care. In the rural areas, many of the people had white cataracts."
It took 5 years to negotiate a contract with the provincial government to obtain permission to perform ophthalmic procedures. "We created an organization called GANSU, INC (Gaining A New Sight for Unseeing in China), and developed a proposed contract," recalls Dr. Conrad. "We negotiated for 10 days with the provincial health bureau and created a good working relationship that spelled out each party's responsibilities."
Dr. Conrad's strategy was to outfit a pop-up camping trailer as a mobile surgical cataract suite and bring eye care to the rural people who could not travel to a central location. The provincial health bureau does the initial screening of patients and provides the visiting surgical team with a list of patients to treat.
"This concept has worked out very well for us," Dr. Conrad notes. "Most of the patients need cataract surgery, but we can treat pterygium, perform iridotomies and do basic glaucoma surgery. We also have a YAG laser. At the end of the summer, we pack up the equipment, and the trailer, putting all in storage until we return the next year."
Dr. Conrad in China with a delighted cataract patient. Photo courtesy of GANSU, INC.
As the years passed, GANSU, INC has attracted an increasing number of supporters, including many Chinese-Americans. It takes more than $200,000 a year to fund the humanitarian effort. Companies such as Alcon, Abbott Medical Optics and Becton Dickinson have been exceptionally generous with supplies and IOLs.
"This summer, we expect to bring eight surgical teams, each with five people, for 4-week rotations," says Conrad. "Four of the teams will go to Gansu and four to neighboring Qinghai Province." One of the goals of GANSU, INC is to train local ophthalmologists so they can perform the extracapsular cataract procedure that the organization uses (more than 5,200 cataracts since 1993).
"We have also initiated 2-week training seminars in the provincial capital of Lanzhou," says Conrad. "We bring subspecialists in retina, pediatrics, glaucoma, phaco and oculoplastics. The seminars attract 80 to 100 local doctors who benefit from the interaction with these experts." These efforts have earned GANSU, INC the highest awards that Gansu Province, and the Central Government (The China Friendship Award) can bestow on foreigners.
Dr. Conrad, who is now 73, and retired from active practice, says there have only been two glitches in the many years that GANSU, INC has been operating in China. "In 2003, we had to shorten the mission because of the SARS epidemic and last year we had to wait until the Olympics were over because the Chinese government was concerned about the Tibetan protests. But overall, our relationships with the Chinese provincial and central governments have gone very smoothly."
Anyone interested in getting involved with GANSU, INC can go to the organization's Web site at www.gansuinc.org
Ophthamology Management, Issue: May 2009