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Surgery

Modern Cataract Surgery

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Modern Cataract Surgery

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Cataract surgery is the removal of the natural lens of the eye (also called “crystalline lens”) that has developed an opacification, which is referred to as a cataract. Metabolic changes of the crystalline lens fibers over the time lead to the development of the cataract and loss of transparency, causing impairment or loss of vision. During cataract surgery, a patient’s cloudy natural lens is removed and replaced with a synthetic lens to restore the lens’s transparency. 

Following surgical removal of the natural lens, an artificial intraocular lens implant is inserted (eye surgeons say that the lens is “implanted”). Cataract surgery is generally performed by an ophthalmologist (eye surgeon) in an ambulatory (rather than inpatient) setting, in a surgical center or hospital, using local anesthesia (either topical, peribulbar, or retrobulbar), usually causing little or no discomfort to the patient. Well over 90% of operations are successful in restoring useful vision, with a low complication rate. Day care, high volume, minimally invasive, small incision phacoemulsification with quick post-op recovery has become the standard of care in cataract surgery all over the world.

Types of surgery

Extracapsular cataract extraction involves the removal of almost the entire natural lens while the elastic lens capsule (posterior capsule) is left intact to allow implantation of an intraocular lens. There are two main types of cataract surgery:

Phacoemulsification (Phaco) is the preferred method in most cases. It involves the use of a machine with an ultrasonic handpiece equipped with a titanium or steel tip. The tip vibrates at ultrasonic frequency (40,000 Hz) and the lens material is emulsified. A second fine instrument (sometimes called a cracker or chopper) may be used from a side port to facilitate cracking or chopping of the nucleus into smaller pieces. Fragmentation into smaller pieces makes emulsification easier, as well as the aspiration of cortical material (soft part of the lens around the nucleus). After phacoemulsification of the lens nucleus and cortical material is completed, a dual irrigation-aspiration (I-A) probe or a bimanual I-A system is used to aspirate out the remaining peripheral cortical material.

Conventional extracapsular cataract extraction (ECCE): It involves manual expression of the lens through a large (usually 10–12 mm) incision made in the cornea or sclera. Although it requires a larger incision and the use of stitches, the conventional method may be indicated for patients with very hard cataracts or other situations in which phacoemulsification is problematic. Microincision cataract surgery involves a technique by which a cataract can be reached through an incision of 1.5 millimeters or less.

Cryoextraction is a form of ICCE that freezes the lens with a cryogenic substance such as liquid nitrogen[4]. In this technique, the cataract is extracted through use of a cryoextractor — a cryoprobe whose refrigerated tip adheres to and freezes tissue of the lens, permitting its removal. Although it is now used primarily for the removal of subluxated lenses, it was the favored form of cataract extraction from the late 1960s to the early 1980s

Intraocular lenses

Intraocular lens implantation: After the removal of the cataract, an intraocular lens (IOL) is usually implanted into the eye, either through a small incision (1.8 mm to 2.8 mm) using a foldable IOL, or through an enlarged incision, using a PMMA (polymethylmethacrylate) lens. The foldable IOL, made of silicone or acrylic material of appropriate power is folded either using a holder/folder, or a proprietary insertion device provided along with the IOL. The lens implanted is inserted through the incision into the capsular bag within the posterior chamber (in-the-bag implantation). Sometimes, a sulcus implantation (in front or on top of the capsular bag but behind the iris) may be required because of posterior capsular tears or because of zonulodialysis. Implantation of posterior-chamber IOL (PC-IOL) in patients below 1 to 2 years of age is relatively contraindicated due to rapid ocular growth at this age and the excessive amount of inflammation, which may be very difficult to control. Optical correction in these patients without intraocular lens (aphakic) is usually managed with either special contact lenses or glasses. Secondary implantation of IOL (placement of a lens implant as a second operation) may be considered after 2 years of age. New designs of multi-focal intra-ocular lens are now available. These lenses allow focusing of rays from distant as well as near objects, working much like bifocal or trifocal eyeglasses. Pre-operative patient selection and good counselling is extremely important to avoid unrealistic expectations and post-operative patient dissatisfaction. Acceptability for these lenses has become better and studies have shown good results in selected patients. Brands in the market include: ReSTOR (R), Rezoom (R) and Technis MF (R).

Preoperative evaluation

An eye examination or pre-operative evaluation by an eye surgeon is necessary to confirm the presence of a cataract and to determine if the patient is a suitable candidate for surgery. The patient must fulfill certain requirements such as:The degree of reduction of vision due, at least in large part, to the cataract should be evaluated. While the existence of other sight-threatening diseases, such as age-related macular degeneration or glaucoma, does not preclude cataract surgery, less improvement may be expected than in their absence.

The eyes should have a normal pressure, or any pre-existing glaucoma should be adequately controlled on medications. In cases of uncontrolled glaucoma, a combined cataract-glaucoma procedure (Phaco-trabeculectomy) can be planned and performed.

The pupil should be adequately dilated using eyedrops; if pharmacologic pupil dilation is inadequate, procedures for mechanical pupillary dilatation may be needed during the surgery.

Operation procedures

The surgical procedure in phacoemulsification for removal of cataract involves a number of steps. Each step must be carefully and skillfully performed in order to achieve the desired result. The steps may be described as follows:

Anaesthesia,

Exposure of the eyeball using a lid speculum,

Entry into the eye through a minimal incision (corneal or scleral)

Viscoelastic injection to stabilize the anterior chamber and to help maintain the eye pressurization

Capsulorhexis

Hydrodissection pie

Hydro-delineation

Ultrasonic destruction or emulsification of the cataract after nuclear cracking or chopping (if needed), cortical aspiration of the remanescent lens, capsular polishing (if needed)

Implantation of the artificial IOL

Entration of IOL (usually foldable)

Viscoelastic removal

Wound sealing / hydration (if needed).

The pupil is dilated using drops (if the IOL is to be placed behind the iris) to help better visualise the cataract. Pupil constricting drops are reserved for secondary implantation of the IOL in front of the iris (if the cataract has already been removed without primary IOL implantation). Anesthesia may be placed topically (eyedrops) or via injection next to (peribulbar) or behind (retrobulbar) the eye. Oral or intravenous sedation may also be used to reduce anxiety. General anesthesia is rarely necessary, but may be employed for children and adults with particular medical or psychiatric issues. The operation may occur on a stretcher or a reclining examination chair. The eyelids and surrounding skin will be swabbed with disinfectant. The face is covered with a cloth or sheet, with an opening for the operative eye. The eyelid is held open with a speculum to minimize blinking during surgery. Pain is usually minimal in properly anesthetised eyes, though a pressure sensation and discomfort from the bright operating microscope light is common. The ocular surface is kept moist using sterile saline eyedrops or methylcellulose viscoelatic. The discission into the lens of the eye is performed at or near where the cornea and sclera meet (limbus = corneoscleral junction). Advantages of the smaller incision include use of few or no stitches and shortened recovery time. . A capsulotomy (rarely known as cystotomy) is a procedure to open a portion of the lens capsule, using an instrument called a cystotome. An anterior capsulotomy refers to the opening of the front portion of the lens capsule, whereas a posterior capsulotomy refers to the opening of the back portion of the lens capsule. In phacoemulsification, the surgeon performs an anterior continuous curvilinear capsulorhexis, to create a round and smooth opening through which the lens nucleus can be emulsified and the intraocular lens implant inserted.

Complications

Complications after cataract surgery are relatively uncommon.

Some people can develop a posterior capsular opacification (also called an after-cataract). As a physiological change expected after cataract surgery, the posterior capsular cells undergo hyperplasia and cellular migration, showing up as a thickening, opacification and clouding of the posterior lens capsule (which is left behind when the cataract was removed, for placement of the IOL). This may compromise visual acuity and the ophthalmologist can use a device to correct this situation. It can be safely and painlessly corrected using a laser device to make small holes in the posterior lens capsule of the crystalline. It usually is a quick outpatient procedure that uses a Nd-YAG laserposterior capsulotomy). This creates a clear central visual axis for improving visual acuity. . In very thick opacified posterior capsules, a surgical (manual) capsulectomy is the surgical procedure performed. (neodymium-yttrium-aluminum-garnet) to disrupt and clear the central portion of the opacified posterior lens capsule (

Posterior capsular tear may be a complication during cataract surgery. The rate of posterior capsular tear among skilled surgeons is around 2% to 5%. It refers to a rupture of the posterior capsule of the natural lens. Surgical management may involve anterior vitrectomy and, occasionally, alternative planning for implanting the intraocular lens, either in the ciliary sulcus, in the anterior chamber (in front of the iris), or, less commonly, sutured to the sclera.

Retinal detachment is an uncommon complication of cataract surgery, which may occur weeks, months, or even years later.

Toxic Anterior Segment Syndrome or TASS is a non-infectious inflammatory condition that may occur following cataract surgery. It is usually treated with topical corticosteroids in high dosage and frequency.

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CAD Treatment: Bypass Surgery

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CAD Treatment: Bypass Surgery

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Treatment is most often used to mean a process of modifying or altering something, and depending on context may be used in an unqualified form to refer to any of the following:

A type of therapy used to remedy a health problem

Experimental treatment, the levels of treatment factor(s) (variables controlled by the experimenter) applied

Water treatment

Sewage treatment

Surface treatment or surface finishing, processes used to improve the surface of a manufactured item

National treatment, economic term for the principle that foreigners and domestic nationals are treated equally.

Treatment

Currently, there is no cure for psoriasis. However, there are many treatment options that can clear psoriasis for a period of time. Each treatment has advantages and disadvantages, and what works for one patient may not be effective for another. Board-certified dermatologists have the medical training and experience needed to determine the most appropriate treatments for each patient.

Diagnosis

There are several forms of psoriasis, and each form has unique characteristics that allow dermatologists to visually identify psoriasis to determine what type, or types, of psoriasis is present. Sometimes a skin biopsy will be performed to confirm the diagnosis.

It may also refer to

A film treatment is prose telling of a story intended to be turned into a screenplay

A Dutch metalcore band

A legendary political tactic that Senate Majority Leader, and later President Lyndon Baines Johnson used to get Congress to support certain policy initiatives, notably Medicare, the Civil Rights Act of 1964 and the Voting Rights Act of 1965.

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Psychic Surgery – Conclusion

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Psychic Surgery – Conclusion

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Psychic surgery

Psychic surgery is a procedure typically involving the apparent creation of an incision using only the bare hands, the apparent removal of pathological matter, and the seemingly spontaneous healing of the incision.

Psychic surgery has been condemned in many countries as a form of medical fraud. It has been denounced by the US Federal Trade Commission as a “total hoax “and the American Cancer Society maintains that psychic surgery may cause needless death by keeping the ill away from life-saving medical care.Medical professionals and skeptics consider it sleight of hand and any positive results a placebo effect.

It first appeared in the Spiritualist communities of the Philippines and Brazil in the mid-1900s, and it has taken different paths in those two countries.

Procedure

Although psychic surgery varies by region and practitioner, it usually follows some common lines. Without the use of a surgical instrument, a practitioner will press the tips of his/her fingers against the patient’s skin in the area to be treated. The practitioner’s hands appear to penetrate into the patient’s body painlessly and blood seems to flow. The practitioner will then show organic matter or foreign objects apparently removed from the patient’s body, clean the area, and then end the procedure with the patient’s skin showing no wounds or scars.

Most cases do not involve actual surgery although some practitioners make real incisions. The practitioners are using sleight of hand techniques to produce blood or blood-like fluids, animal tissue or substitutes, and/or various foreign objects from folds of skin of the patient as part of a confidence game for financial benefit of the practitioner.

Two psychic surgery practitioners provided testimony in an Federal Trade Commission trial that, to their knowledge, the organic matter apparently removed from the patients usually consists of animal tissue and clotted blood. In regions of the world where belief in evil spirits is prevalent, practitioners will sometimes exhibit objects, such as glass, explaining that the foreign bodies were placed in the patient’s body by evil spirits.

History

Accounts of psychic surgery started to appear in the Spiritualist communities of the Philippines and Brazil in the mid-1900s.

Philippines

In the Philippines, the procedure was first noticed in the 1940s, when performed routinely by Eleuterio Terte. Terte and his pupil Tony Agpaoa, who was apparently associated with the Union Espiritista Christiana de Filipinas (The Christian Spiritist Union of the Philippines), trained others in this procedure.

In 1959, the procedure came to the attention of the U. S. public after the publication of Into the Strange Unknown by Ron Ormond and Ormond McGill. The authors called the practice “fourth dimensional surgery,” and wrote “[we] still don’t know what to think; but we have motion pictures to show it wasn’t the work of any normal magician, and could very well be just what the Filipinos said it was — a miracle of God performed by a fourth dimensional surgeon.”

Alex Orbito, who became well-known in the U. S. through his association with actress Shirley MacLainewas one said practitioner of the procedure. On June 14, 2005, Orbito was arrested by Canadian authorities and indicted for fraud.

Psychic surgery made U.S. tabloid headlines in March 1984 when comedian Andy Kaufman, diagnosed with large cell carcinoma (a rare lung cancer), traveled to the Philippines for a six-week course of psychic surgery. Practitioner Jun Labo claimed to have removed large cancerous tumors and Kaufman declared to believe the cancer had been removed. Kaufman died from renal failure as consequence of a metastatic lung cancer, on May 16, 1984.

Brazil

The origins of the practice in Brazil are obscure; but by the late 1950s several “spiritual healers” were practicing in the country. Many of them were associated with Kardecism, a major spiritualistic movement in Brazil[, and claimed to be performing their operations merely as channels for spirits of deceased medical doctors. Others were following practices and rituals known as “Umbanda”, a shamanic ritualistic religion with mediumistic overtones inherited from the African slaves brought to the country in colonial times.

Medical and legal criticism

In 1975, the Federal Trade Commission declared that “‘psychic surgery’ “is nothing but a total hoax”.” Judge Daniel H. Hanscom, when granting the FTC an injunction against travel agencies promoting psychic surgery tours, declared: “Psychic surgery is pure and unmitigated fakery. The ‘surgical operations’ of psychic surgeons … with their bare hands are simply phony.”

In 1990, the American Cancer Society stated that it found no evidence that “psychic surgery” results in objective benefit in the treatment of any medical condition, and strongly urged individuals who are ill not to seek treatment by psychic surgery.

The British Columbia Cancer Agency “strongly urges individuals who are ill not to seek treatment by psychic surgeon.”

While not directly hazardous to the patient, the belief in the alleged benefits of psychic surgery may carry considerable risk for individuals with diagnosed medical conditions, as they may delay or forgo conventional medical help, sometimes with fatal consequences.

Accusations of fraud

According to stage magician James Randi, psychic surgery is a sleight-of-hand confidence trick. He has said that in personal observations of the procedure, and in movies showing the procedures, he can spot sleight-of-hand moves that are evident to experienced stage magicians, but might deceive a casual observer. Randi has replicated the appearance of psychic surgery himself through the use of sleight-of-hand. Professional magicians Milbourne Christopher and Robert Gurtler have also observed psychic surgeons at work, and claimed to have spotted the use of sleight-of-hand. On his A&E show Mindfreak in the episode “Sucker,” illusionist Criss Angel performed “Psychic Surgery,” showing first-hand how it may be done (fake blood, plastic bags and chicken livers were used).

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