Most people are aware that cataracts occur when the crystalline lens in the eye becomes opaque. There are many different reasons and conditions that can cause cataracts, but the most prevalent is undoubtedly the natural ageing process.

That means that unsurprisingly, as the demographics of the population begin to shift toward an older, more long-lived populace, there is a corresponding increase in cases of cataracts.

Strangely, however, the most recent data from a study published by the US Department of Health and Human Services states there has been no corresponding increase in people becoming qualified ophthalmologists.

Indeed the study goes on to say that by 2025 there will be a deficit of ophthalmologists within the US, with demand for cataract surgery far outstripping the ability to supply the much needed medical intervention.

That being the case, it is more important than ever that ophthalmologists keep up to date with the latest medical advancements to ensure that they can increase their ability to perform cataracts surgery.

Procedure innovation

Recent studies suggest that the accuracy of toric lens alignment has been significantly improved with the introduction of the new alignment systems, which allow for toric intraocular lens (IOL) alignment and dispense with the need for either manually marking the eye on a slit lamp or freehand on the conjunctiva.

Further studies looking into the new alignment systems have found significant evidence that markerless alignment systems can reduce the number of post-operative astigmatisms common in some patients.

Additionally, Intraoperative Aberrometry (IA) can now assist with intraocular lens calculation so that ophthalmologists can now obtain exact axial length measurements which allows for more accurate lens planning.

Another recent advancement comes with the improved monofocal and multifocal IOL’s.

Monofocal lenses allow for the correction of patients suffering from a single focus impairment and are most often used to correct distance vision.

Multifocal IOL’s, on the other hand, have been specifically created to give patients near and intermediate vision but can additionally minimise problems with distance vision.

Multifocal IOL’s come in two different types; refractive multifocal lenses which have multiple refraction zones and rely heavily on pupil size to visualise both image and distance, and diffractive multifocal lenses which are designed to refract light entering at different points and allow for multifocality.

Patients have also been treated to another recent discovery in the form of a more blended option that allows ophthalmologists to provide a mild version of monovision to patients by implanting a different reading addition to non-dominant and dominant eyes.

This treatment has shown significant success in several studies done with small control groups and represents an exciting set of findings for ophthalmologists to study.

Advancements in IOL’s continue at pace as seen with the 2019 release of a new advanced monofocal lens that boasts a continuous change in power from the periphery to the centre of the anterior surface, that helps improve intermediate vision without detrimentally affecting distance vision.

Another new innovation with regards to IOL’s is the invention of the accommodating IOL that allows for improved near vision after implementation.

Lenses in development

Hopefully, in the near future, there will be even more improvements and advances in IOL’s as there are several exciting lenses currently in development.

Several of those IOL’s in development are being designed to be able to change shape via a complex system of pumps and shunts that move fluid around when it is implanted in the capsular bag.

Another eagerly awaited IOL is a lens that uses electrical impulses to control the refractive index via a liquid crystal. The lens is built with a monofocal IOL, that uses an aspheric central optic that helps improve both distance and intermediate vision.

Incredibly smart, the lens is touted to use microsensors to detect light changes that then cause the liquid crystal to change its focusing power.

Not only do recent advancements in cataracts lenses mean that the outcome for patients has drastically improved, but innovations and new surgical tools have also meant that the surgery itself has become safer, faster and has dramatically decreased complications.

Innovative approaches to anterior capsulotomy, for example, have included the nanoengineered Zepto device that uses precision pulses to create a perfectly round capsulotomy.

Similarly, the CAPSULaser uses a non-contact laser that delivers a continuous burst of energy that amazingly can create a circular capsulotomy in one second.

These recent developments and surgical advancements mean that patients can be assured that the treatment they receive is more accurate, more beneficial and crucially safer than ever before.

This is an important and crucial set of improvements for the future of cataracts surgery, because if the US Department of Health and Human Services are correct and within the next five years prospective patients end up outstripping ophthalmologists, then improvements in technology and surgical treatments are essential to ensure that demand can continue to be met.

If you suspect that you may be suffering from an eye disorder or worsening eye disease, it’s imperative that you get your eyes checked immediately. You can book an eye examination at your local optometrist or check out the highly skilled team over at London Cataract Centre – londoncataractcentre.co.uk

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The good news is that definition has changed with the introduction of new procedures such as microdiscectomy. The process is also known by other terms such as microdecompression or microdiskectomy. The procedure is minimally invasive and performed on patients with a herniated lumbar disc. The surgeon removes portions of the herniated disks and relieves pressure on the spinal nerve column.

When to go for this procedure

• Tests such as MRI that indicate the presence of a herniated disk.
• If one has leg pain that has been persistent for the last six weeks.
• When other treatments such as physical therapy and oral steroids are not helping in any way.
• When the patient is experiencing sciatica (leg pain) rather than lower back pain.

What is the success rate?

Recent research from the Spine Institute of San Diego shows that the procedure is up to 95 percent effective when it comes to the elimination of sciatica pain as a result of disc herniation. The compression of the nerve is the main cause of sciatica pain. The compression occurs when one has a herniated disk.

The damaged tissue tends to push into the spinal column while the hernia develops. The nerves become stressed and pain signals are sent to the brain. However, the brain interprets the pain to be coming from the legs. Such pains will go away on their own within a few weeks. However, if the sciatica pain lasts for more than 12 weeks, then a microdiscectomy will be a good solution.

The procedure

The main aim of this surgery is to remove the disc that is causing pressure on the nerves. There are main types of procedures that doctors use when they are performing a microdiscectomy:

Tubular

The surgeon will insert a small tube through a small incision. The tube will then be gently pushed through the back muscles until it reaches the spine. A series of expanding tubes will then be inserted one around the other. The tubes dilate or open up the area where the surgery will be performed. The surgeon will then use specialized equipment to remove the affected disks.

Mini-open

The procedure uses the same approach as open discectomy. The surgeon will use specialized equipment to view the affected areas through small incisions.

Endoscopic

The doctor will insert a small camera and get a view of the affected areas. The endoscope will be inserted through a tube and the doctor will then remove the affected discs with miniaturized instruments.

Microdiscectomy is usually done under general anesthesia. It thus means that the patient will be unconscious during the process and feel nothing until it is over. The patient will be required to sleep facing downwards.

Generally, the following steps will be followed:

• The doctor will do an incision of about 1 or one and a half inches over the affected disk.
• The surgeon will use a lighted microscope to view the affected area.
• The surgery may involve the removal of a small portion of the bone that usually protects the root nerve. The surgeon will then remove the herniated tissue and relieve pressure on the nerve.
• Sutures are used to close the incision.
• The discharge of the patient can be the same day.

How long does it take to recover?

The beauty of most minimally invasive surgeries is that they allow patients to go home within 24 hours. It is important to learn what it takes to make the recovery process successful. Finding resources from experts such as Randall Dryer on how to recover after microdiscectomy is very helpful to ensure that you have an easy time.

You may be required to interact with an occupational or physical therapist before you allowed to leave the facility. These therapists are tasked with guiding you on how to reduce bending, twisting, and lifting your back after the surgery. It is also their work to guide on the best exercises that will help improve the flexibility and strength of your back muscles.

What to avoid after the surgery

Going through the surgery does not heal yours instantly. You must readjust your lifestyle until such a time that you fully recover. Limit your sitting to shorter periods to allow your back to recover. You can have several breaks after like thirty minutes. This is not also the time to drive for many hours. Limit your driving hours or have someone drive you until your back gets back in shape.

You may not resume all your normal activities the next day. However, your lifestyle will not change a lot. You can reduce the nature of manual activities that you tackle for the first two to three weeks. This is also the time that you should avoid lifting heavy objects as your back is not yet strong. As a rule of thumb, you may need to avoid something above five pounds.

You have to limit your physical activities if you are a fitness freak. Going back to bodybuilding for the first six weeks might not be a good idea. You may have to do away with some of your hobbies such as bike riding. Give your body enough time to heal but also research some of the activities that will help you recover.

Are there any risks?

Dealing with the spine is always a delicate procedure. A simple mistake can alter the entire nervous system. A cerebrospinal fluid leak or dural tear is the most common risk associated with this procedure. The good news is that it occurs in 1-7% of the procedures done. The leak will not usually affect the surgery when it happens. However, the patient may be requested to lie down for two to three days to allow the sealing of the leakage. Some of the other risks associated with microdiscectomy include:

• Infection
• Bleeding
• Nerve root damage
• Bladder/ bowel incontinence
• Pain that persists after the surgery
• Deep vein thrombosis (occurs when blood clots in the legs)
• Possibility of fluid building up in the lungs

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The ETZ (Elisabeth-TweeSteden Ziekenhuis) is one of the eleven trauma centers in the Netherlands. As the only center in the country with trauma surgeons on location 24 hours a day, it serves as the main location for emergency patients in North Brabant. 3D printing has already been used to visualize bone fractures, but pioneering researchers believe it can also be used to help treat trauma patients.

Mike Bemelman, MD, trauma surgeon at the ETZ, had already seen the potential of 3D printing back in 2016. Together with Lars Brouwers, MD, PhD-candidate, and Koen Lansink, MD, trauma surgeon, they have started conducting research into the benefits and effectiveness of 3D printing, compared to traditional and other new technologies. Their idea is to 3D print scanned bone fractures in order to give both surgeons and patients a clear understanding of each situation, before operating.

Before 3D printing

In order to prepare for an operation, surgeons will analyze CT scans of the patient. Getting an exact idea of each situation is challenging, even for an experienced surgeon. CT scans are converted into a 3D reconstruction, enabling surgeons to examine it virtually on a computer screen. While this has improved the ease of understanding each situation, it has limitations: surgeons sometimes find it difficult to orient the model, and 3D reconstructions are viewed on a 2D screen, lacking a realistic sense of depth.

3D printing fractured bones

Lars started using the Ultimaker to print fractured bone structures, allowing surgeons to analyze a fracture not only by looking at it, but also touching and rotating it, which gives important added value to the operation planning process. Using water-soluble PVA support material, complex, organic geometries can be accurately reproduced with small cavities and important details included.

Adapting 3D Printing to the process

One challenge of adopting 3D printing was finding a simple and efficient way to convert DICOM files—the proprietary file format of CT scans—into 3D printable STL files. Using Philips IntelliSpace Portal, Lars is able to directly export a 3D model of the scan, which he can prepare in Ultimaker Cura, and send to the Ultimaker 3.

Benefits for the patient

After the patient is in a stable condition, a CT scan is produced so that doctors can make a diagnosis. CT scan information is immediately available to Lars in the 3D print studio, where he can begin printing the fractured bone structure of the patient. The 3D print will be ready within a day, and is used by surgeons to plan the operation and explain the process to the patient before it happens.

Results of Lars’ research

When a patient has a fracture, doctors will analyze the x-rays or 2DCT scans and decide on an appropriate treatment. The better the understanding of the situation, the more accurately the right procedure can be determined. Surgeons will reach a solution using an agreement scoring system, known as the kappa score. On average, surgeons with little experience have a kappa score around 0.2, using traditional 2DCT images. Surgeons with more years of experience have a kappa score around 0.4. Lars researched the agreement score when surgeons used other techniques such as 3DCT, 3D printing and VR visualization. Using a 3D printed model, both new and experienced surgeons scored a kappa of between 0.6 up to 0.7, which is the highest score of all methods.

The increased kappa score demonstrates the added value of 3D printing to the decision-making process. By conducting this research, Lars hopes to prove that 3D printing can be of added value to patient satisfaction, surgical satisfaction, operation time, and health-related quality of life for the patient.

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Communication Challenge

The rapid evolution of technology, not least robotics, is inspiring the next generation of ergonomic design to better understand the human / technology interaction. Within the OR, the development of 3D imagery, precise robotics, even protective garments with in-built air supply, are changing not only the type of procedures that can be considered but also the processes and the need for effective interaction between multi-skilled teams. From situational awareness to decision making, teamwork and coping with stress, in an increasingly technology dominated OR, team members’ cognitive and social skills are recognised to contribute to safe and efficient task performance.

However, as surgical teams are increasingly reporting, while the innovation is compelling, technology led procedures are raising challenges – not least with the quality and timing of essential team communication. With a growing reliance on data, imagery, graphics and cameras, individuals are rarely looking at each other or even directly at the patient. Indeed, many individuals are moving around within, but also in and out of, the OR. Not only are they blind to the progress of the procedure, but they can also struggle to share essential information with the rest of the team. Furthermore, as technology takes an increasingly dominant role, there is a risk that clinical teams feel they have only a supportive role and potentially lose engagement.

For many Trusts, additional challenges are created in medical environments that are still in transition between paper based and electronic records, a situation that is proven to create new problems that can lead to mistakes.  From the ability to verify information to fostering teamwork, ensuring people share the right information at the right time and reinforcing situational awareness, effective communication is essential to the safe utilisation of technology innovation.

Effective Human Machine Interaction

To create and retain a calm, stress free environment, growing numbers of surgical teams are now exploring the value of high quality wireless headsets that enable every team member to be part of the procedure from beginning to end. Using one channel, the lightweight headsets provide simple, effective communication where every team member is part of the process and can quietly comment, provide essential insight from the imagery or data, or request information when required.

Linking up every team member via headsets, from the initial pre-op discussion to the end of the procedure, fosters an essential level of collaboration.  It enables effective, unambiguous speech between multiple specialists during a highly complex procedure. It supports training by empowering junior doctors, for example, to ask questions without feeling they are interrupting the procedure. And it can be used to keep everyone engaged during the routine, increasingly high-throughput procedures, such as joint replacement.

Evolving Ergonomics

The quality of communication has a direct implication on risk, safety and patient well-being – but it also provides a vital platform for successful utilisation of technology. Overcoming communication barriers is the foundation for ORs to embrace the evolution in human / technology interaction – including the maximising the social and personal skills including situation awareness, decision making, teamwork and coping with stress. When the communication works, the rest of the new OR ergonomics can fall into place.

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Prehab (Preventative Rehabilitation) is a familiar phrase in the sports world as it is widely acknowledged that it makes sense to train the muscles you need for your chosen speciality and strengthen them appropriately to try and reduce the incidence of injury. Top tennis player Roger Federer is the perfect example of this as he incorporates regular prehab into his training regime and most of us accept that in order to run a marathon we would spend a dedicated amount of time training for it.

However, it is a relatively unknown concept in the world of surgery yet surely it makes sense to be as fit as possible before undergoing any surgery? After all most people have heard of rehab which has long been used to help people to recover from everything from a stroke to operations to replace an arthritic hip or knee. Yet there is much less discussion about prehab despite evidence that preparing patients in advance of surgery improves outcomes and also enhances recovery.

What is Prehab?

There are a number of differing definitions of prehabilitation when applying it in surgical terms.  In the Orthopaedic world the idea that increasing someone’s fitness and muscle strength prior to an operation is likely to produce better outcomes, reduced complications and reduced spend is not new but still not widely used. A paper reviewing the effect of prehabilitation to improve patients with severe disability from hip or knee osteoarthritis reported on patients having benefited from the programme which included exercise and specific education prior to their orthopaedic surgery (DesmeulesF, Hall J, Woodhouse L. Physiother Can. 2013;65.) This idea has spread into other areas of medicine especially with oncology and major surgical interventions with the premise that it would be beneficial not only for surgical interventions but also for ongoing treatment.

PREPARE             

The Imperial College Healthcare Trust’s PREPARE for Surgery programme, trains patients for surgery based on their individual needs. It looks at different factors that are important to focus on before and after a procedure, including physical activity, diet, psychological wellbeing and medication management. The outcomes collected are a significant reduction in the average post-operative hospital stay, reduced complications, less incidence of pneumonia, improved physical function and an improvement in self-confidence.

In Southampton, the Trust has piloted a Prehab programme for rectal cancer patients. Their conclusions were that prehab resulted in significant improvements in fitness and augmented pathological tumour regression. (Exercise prehabilitation may lead to augmented tumour regression following neoadjuvant chemoradiotherapy in locally advanced rectal cancer West et al Acta Oncol 2019 Feb 6:1-8). There is currently an ongoing trial called the Wessex Fit-4-Cancer Surgery Trial (WesFit) based at University of Southampton looking further into the outcomes of prehabilitation.

Personal & Relevant

It appears to be generally accepted that it is important for the programme to be individualised for the particular patient and potentially include a multimodal approach which could include psychological support. The baseline health needs to be assessed and comorbidities and risk factors to exercise considered, such as cardiovascular disease. Patients will also require ongoing support whether by hospital-based programmes, community led or phone support.

Delivery of Care

We obviously need future studies looking at more innovative delivery of care as most have been based in community or hospital. However remote monitoring for encouragement and to increase adherence seems a sensible route to take to gain the maximum from prehabilitation.

For example, leading research has found that video consultations are as effective as face-to-face appointments and our experience, at PhysioFastOnline (PFO), is that three in four people can be triaged, assessed and supported online without any need for physical treatment. This means that our service is accessible to anyone with a screen and an internet connection from the comfort of their home, workplace or even overseas. Appointments are booked online, in real-time, and are generally available same day to swiftly start the process of treatment. For me there is no doubt that our kind of service has an important role to play in the future and will perfectly complement traditional physiotherapy.

Conclusion

Reviewing the literature leads us to recognise that further assessment is required to confirm that it is cost effective particularly in times where there is restricted expenditure and healthcare is rationed.  But with an ever increasing sedentary and an ageing population there really seems no reason for the concept of prehabilitation not to be embraced in all aspects of healthcare.

This ageing population is resulting in more and more complex surgery and treatment and it is vital that we help patients to prepare with programmes that are personalised and relevant. This will, in its simplest terms, involve physical activity and all the known benefits associated with that such as improved bone density, joint mobility, heart and lung health and also a positive impact on mood and mental health. Some of the prehabilitation can also address specific muscle strengthening programmes which can be targeted depending on presentation or treatment to be undertaken.

For me, prehab is a proactive approach that encourages patients to participate and be involved in their care and the benefits of empowering them makes complete sense from both a physical and psychological aspect.

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St George’s University Hospitals NHS Foundation Trust is the latest London hospital to adopt the VR and haptic simulation system for spine and orthopaedic training. The simulation system has been installed within the GAPS Centre (St George’s Advanced Patient Simulation and Skills Centre) and was used in a recent South London Deanery training day on hip arthroplasty.

“We are thrilled to have integrated Fundamental Surgery into the GAPS Centre and to have also had the group of orthopaedic trainees go through the program, experiencing the Posterior Approach Total Hip Relacement (PTHR) on the machine for the first time,” said Omar Sabri, consultant at St George’s University Hospitals NHS Foundation Trust and lead consultant on the integration into the program. “Through this integration, trainees can now demonstrate the skills they’ve learned by using this technology and have it reflected in their educational portfolio and Intercollegiate Surgical Curriculum Project. This along with the Royal College approval are just the start for Fundamental Surgery’s platform and the team’s effort to integrate it into all surgical training programs across the country.”

With the integration, the trainees at St George’s University Hospitals NHS Foundation Trust can now utilize the Fundamental Surgery platform to test and hone their skills. Through the platform’s live dashboard, the trainees and their professors can review their performances and scores achieved, allowing both parties to visualize their progression with all aspects of the training module.

“We are thrilled to be working with such a prestigious teaching hospital. Our education platform has tremendous long-term potential for enhancing surgical training throughout the NHS, in the pursuit of better patient outcomes,” said Richard Vincent, CEO at FundamentalVR. “The implementation is further proof that our haptic simulations provide a virtual environment that can help provides access and aid training development.”

Named as one of the best inventions of 2018 by Time magazine, the Fundamental Surgery platform was launched in August 2018. It combines virtual reality (VR) with cutting-edge haptics to create a scalable ‘flight simulator’ experience for trainee and qualified surgeons, allowing them to experience and navigate the same visuals, sounds and feelings they would during a real surgical procedure.

What sets Fundamental Surgery apart from other solutions is that it is designed to be equipment agnostic, compatible with any laptop, VR headset or haptic device enabling it to be delivered at a fraction of the cost.

Furthermore its remote data analytics and data dashboard covering surgical skills and knowledge provide invaluable insight into surgical capability and education progression.

While other simulations are limited to visual and audio interactions, Fundamental Surgery takes it to a new level with HapticVRTM, its proprietary technology that adds a real-time sense of touch. Surgical trainees can feel the movement and interaction of tissue, muscle and bone as they would in an actual procedure within a submillimeter of accuracy of resistance.

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Northwell Health – New York State’s largest health care provider with 23 hospitals – has already used Formlabs’ standalone Form 2 3D printers in its 3D printing lab, but looks to increase production with the Form Cell, an automated 3D print production solution. Personalized models provide surgeons with more effective preparation, offering a hands-on opportunity to get a feel for patient anatomy, and pre-fit equipment before entering the operating room. During orthopedic or oncologic procedures, surgeons are now able to use patient-specific, 3D-printed surgical guides, which help with precise excisions of tumors or drill depths for optimal screw insertions.

The benefits of the partnership are evident to Barnaby Goberdhan, whose son, Isaiah Onassis Goberdhan, age 7, recently utilized a 3D printed model of the youngster’s palate to physically visualize the procedure and talk through the surgery. Mr. Goberdhan visited a Northwell Health physician because his son had trouble breathing through one of his nostrils. The checkup revealed an aggressive tumor in his palate and nasal cavity. Isaiah needed surgery to remove the tumor, so the family met with Neha A. Patel, MD, a pediatric otolaryngologist at Cohen Children’s Medical Center in New Hyde Park, NY.

“Having a 3D printed depiction of my son was really helpful when talking with the doctor about his surgery,” said Mr. Goberdhan. “The doctor was able to do more than talk me through what they were going to do – Dr. Patel showed me. There is almost nothing more frightening and stressful than having your child go through surgery. There were several options Dr. Patel walked us through for the best way to preserve Isaiah’s teeth and prevent additional cuts within his mouth. I wanted all of my questions answered so I could be less fearful and more prepared to talk my son through what he was about to face. I wanted Isaiah to feel prepared. With the 3D model, we both felt more at ease.”

Dr. Patel worked with Todd Goldstein, PhD, and his 3D Design and Innovation Center to develop the 3D model for Isaiah. From Isaiah’s CT and MRI scans, Dr. Goldstein was able to create a personalized 3D rendering of his mouth and nasal cavity. Dr. Goldstein used Formlabs industry-leading 3D printing technology to print an anatomical model with the tumor in place as well as removed.

A recent study based on Northwell Health data shows the use of 3D printed models or surgical guides for complex cases can reduce time in the operating room by at least 10 percent. This shows significant savings, for instance, assuming 10-15 percent of select surgical cases could use a 3D printed model or guide, the annual operating room cost avoidance for 1,150 annual cases would be approximately $1,750,000. Based on these findings, within four years models printed on the Form Cell could save Northwell Health approximately $7 million in operating room time alone.

“As a part of Northwell’s multidisciplinary team, I had the opportunity to work with Dr. Dev Kamdar from Head and Neck Surgery, Dr. Ken Kurtz from Prosthodontics, and Dr. Korgan Koral from Neuroradiology to formulate a treatment strategy for Isaiah,” said Dr. Patel. “It wasn’t until we worked with Dr. Goldstein’s team that we were able to incorporate 3D printing into our surgery and really bring Isaiah’s family into the shared decision making process. The 3D models help me explain surgery to patients and plan for surgery. In Isaiah’s case, I wanted to be able to visualize where the tumor was and to determine whether we could preserve key structures in the area. The palate and nasal cavity is a delicate area, close to the orbit and dentition. Precision is key and the 3D-printed model helped us get very accurate.”

Dr. Patel and Dr. Kamdar conducted the surgery in April 18. Today, Isaiah is healed and doing well. Isaiah can now breathe out of both nostrils, allowing him to run and play like other children.

“Before the surgery, I had trouble breathing in and out of my nose, which made it hard for me to keep up with my family and friends at school,” said Isaiah Onassis Goberdhan. “The surgery was fine and now I’m able to breathe so much better.”

Now with the Formlabs Form Cell, Northwell will be able to scale production of anatomical models and surgical guides, bringing this pre-planning and explanation capability to even more patients.

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