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PubMed2000

Long-term follow-up of trauma patients with a vena caval filter.

BACKGROUND: Venous thromboembolism (VTE) is an important complication in blunt trauma patients. At our Level I trauma center, we had a deep venous thrombosis (DVT) rate of 3.2% from 1993 to 1997 despite an aggressive VTE prophylaxis program. During this time period, we placed vena caval filters (VCF) for both traditional and prophylactic indications. This project was developed to establish a VCF registry for trauma patients to determine the long-term complications of VCF placement. METHODS: A letter was sent to all trauma patients who had a VCF placed from 1993 through 1997. Patients were asked to return for a history and physical examination to detect signs and symptoms related to VTE, a duplex ultrasound of the inferior vena cava, and a plain abdominal radiograph to determine filter migration. RESULTS: There were 191 VCFs inserted in our trauma population from 1993 to 1997. There were 105 patients (75 male and 30 female) available for evaluation, with a mean follow-up of 28.9 months. Forty-one VCFs were placed in patients with DVT or pulmonary embolism, and 64 were placed in patients for prophylactic indications as per the guidelines developed by the Eastern Association for the Surgery of Trauma. There were no clinically identifiable complications related to insertion of the VCF. There were no pulmonary embolisms detected after VCF insertion. In follow-up, only one filter (0.95%) migrated, and this was minimal (1 cm cephalad). One (0.95%) vena cava was occluded, based on duplex ultrasonography, and 11 patients (10.4%) had signs or symptoms of leg swelling after hospital discharge. Twenty eight (44%) of the 64 patients with prophylactic VCFs developed a DVT after filter placement. CONCLUSION: VCFs placed in trauma patients have acceptable short- and long-term complication rates. Consideration should be given to prophylactic VCF placement in patients at high risk for VTE. Randomized controlled trials are needed to evaluate whether VCF insertion increases the risk for subsequent DVT.

Adolescent↗
PubMed1997

Electrocardiographic nature of restored sinus rhythm after Cox maze procedure in patients with chronic atrial fibrillation who also had other cardiac surgery.

OBJECTIVE: To characterise heart rate variability and high frequency components of restored sinus rhythm after the maze procedure. The maze procedure for chronic atrial fibrillation may prevent thrombotic events and improve the quality of life. However, the electrocardiographic nature of restored sinus rhythm after the maze procedure has not been fully elucidated. PATIENTS AND METHODS: Between March 1993 and August 1995, 104 consecutive patients undergoing the maze procedure in combination with other cardiac surgery were studied. There were 100 long-term survivors (78 with mitral valve disease, 9 with aortic valve disease, 8 with congenital heart disease, and 5 others). Twenty age-matched patients with mitral valve disease who were in normal sinus rhythm preoperatively were enrolled as a control group. 30 days after surgery, the presence of arrhythmias and the circadian changes of heart rate variability were estimated by ambulatory electrocardiographic monitoring and the filtered P duration was evaluated by signal-averaged electrocardiogram. RESULTS: Restoration of sinus rhythm was observed in 73 of 100 cases. Subjects were classified into three groups according to their postoperative ambulatory electro-cardiographic monitoring findings: patients in group 1 (n = 73) (1a: 58 regular sinus rhythm; 1b: 15 sinus rhythm with frequent premature atrial contractions (> 1000/day); patients in group 2 (n = 21) still had persistent atrial fibrillation; and patients in group 3 (n = 6) required permanent pacemaker implantation because of sick sinus syndrome. The success rate of restoration of sinus rhythm was 88.3% if left atrial diameter was small (< 65 mm). Circadian changes in the low frequency to high frequency power ratio in group 1a were significantly diminished compared with control group (P < 0.01). Furthermore, the filtered P duration in group 1a (150 (20) ms) and group 1b (158 (23) ms) were longer than in the control group (122 (11) ms) (P < 0.01). CONCLUSIONS: The maze procedure may result in a decreased sinus response and non-uniform transmission of impulses in the atrium.

Adult↗
PubMed2005

Usefulness of an intraoperative electrophysiological navigator system for subthalamic nucleus surgery in Parkinson's disease.

OBJECTS: The characteristics and benefits are presented of an intraoperative neurophysiological navigator computerized system developed in our center (Columbus-Track 1.0) that helps the surgical team in neuronal identification and in strategy processes in subthalamic nucleus surgery for Parkinson's disease (PD). METHODS: The navigator consists of three assembled parts: (1) neuronal identification, based on wavelet processing, filtering and gaussian characteristics of the signal; (2) track identification, based on anatomical coincidence, somatomotor response and microstimulation quotient, and (3) strategy, coordinating correction for the next track. A retrospective comparative study was performed with 15 consecutive PD patients (30 targets) operated without the system and the next 15 consecutive patients operated with the aid of the system. With the aid of the computerized navigation system, a significant reduction in the number of tracks was observed (t = -2.503, p = 0.0015), with a mean difference of 1.2 tracks per hemisphere. A non-significant reduction in the total intervention time was also observed, with a mean difference of 20 min per hemisphere (t = -1.418, p = 0.161). CONCLUSIONS: The intraoperative computerized navigation system can aid the surgical team in better identifying the neuronal signal and in defining the optimal track to achieve the target.

Humans↗
PubMed1976

Bronchial cytologic changes during cardiopulmonary bypass: iron transport by histiocytes in low flow states.

We previously reported (1) that tracheobronchial secretions of patients in hemorrhagic shock contained significantly more iron laden histiocytes than secretions of matched controls and demonstrated by histiologic studies in rats bled to hemorrhagic shock that these animals' lungs contained significantly more iron laden histiocytes than those of a control group. Two explanations appeared plausible: 1) abnormal hemoglobin breakdown products of systemic hypoperfusion during shock (2, 3, 5) may have accumulated in the pulmonary circulation where they were phagocytozed by pulmonary histiocytes, or 2) circulating iron laden histiocytes may have been arrested in the lung, which is well known to act as a filter during low-flow states (4). The present study reports on assay of bronchial secretions of 12 open-heart surgery patients under cardiopulmonary bypass from specimens obtained 1) immediately after onset of anesthesia; 2) during; and 3) after termination of cardiopulmonary bypass. The percentage of iron laden histiocytes rose from 15.6+/-6.0 after intubation, to 49.6+/-6.8 after 1 hour on bypass with occluded pulmonary arteries (p less than 0.0025), remaining close to the latter value after pulmonary circulation was restored. Hypoperfusion, accumulation of metabolites, or falling pH at the tissue level are probable explanations for these findings.

Adult↗
PubMed1995

"Filtering effect" of cerebrospinal fluid on spinal somatosensory evoked potentials: case report.

A 31-year-old man presented complaining of radicular (L4) pain. MRI and myelo-TC of the thoraco-lumbar spine showed the presence of an extradural CSF cyst extending from Th6 to L2, posterior to the cord. The patient underwent a Th12 laminectomy, the cyst was opened and drained. A recording electrode was placed epidurally, dorsal to the cyst, at the level of the Th12 vertebral body, and the potentials evoked by stimulation of the tibial and saphenous nerves were monitored during surgery. After cyst drainage the epidural potentials were significantly larger (x5) in amplitude and more defined in shape than those recorded in the presence of the cyst. Our case demonstrates the "filtering effect" of CSF on spinal somatosensory evoked potentials.

Adult↗
PubMed2006

Update in the prevention and treatment of deep vein thrombosis and pulmonary embolism.

PURPOSE OF REVIEW: Thromboembolic events have a major impact on outcome of surgical and medical patients. This review is focused on standards and recent advances in antithrombotic strategies for prevention and therapy of venous thromboembolism and pulmonary embolism. RECENT FINDINGS: Alert programs improve prophylactic strategies to prevent venous thromboembolism. Evidenced-based guidelines are available on antithrombotic and thrombolytic therapy outweighing the benefits, risks, burdens and costs. Selective factor Xa and direct thrombin inhibitors are at least as effective as low-molecular-weight heparin in prevention of venous thromboembolism and treatment of pulmonary embolism, but have fewer side effects and will not need routine monitoring. In high-risk orthopaedic patients but not in general surgery patients fondaparinux is superior to low-molecular-weight heparin in the prevention of thromboembolic disease. Ximelagatran, the first oral direct thrombin inhibitor, is as effective and well tolerated as warfarin. Long-term treatment is uncertain, however, because of elevation in alanine transaminase levels. In high-risk patients with contraindication for anticoagulation, retrievable vena cava filters may be an option to prevent pulmonary embolism. Permanent cava filters do not improve long-term survival and are associated with relevant side effects. Thrombolytics should be reserved for deep venous thrombosis complicated by limb gangrene and for life threatening pulmonary embolism. SUMMARY: There is currently sufficient information based on guidelines available on preventive and therapeutic strategies for venous thromboembolism and pulmonary embolism. Antithrombotics are the therapeutic backbone. In high-risk orthopedic surgery and venous thromboembolism the new antithrombotics fondaparinux, idraparinux and ximelagatran are superior to standard treatment. Temporary caval filters may be a therapeutic option in high-risk patients with contraindication for antithrombotics.

Anticoagulants↗
PubMed1983

Surgical management of chronic glaucoma in aphakia.

The surgical management of glaucoma in aphakia has been limited by poor success in the control of intraocular pressure and serious postoperative complications that threaten vision. A consecutive series of trabeculectomy filtering procedures in aphakic eyes with a mean preoperative intraocular pressure of 38 mmHg was followed for an average of 26 months and revealed a 62% control of intraocular pressure at 21 mmHg or less. Five additional patients (24%) had pressures lower than 21 mmHg following digital massage. The complication of decreased visual acuity following surgery was significant but not directly related to the surgical procedure. Another patient population with glaucoma and aphakia with a mean preoperative pressure of 25 mmHg was treated with laser trabeculoplasty. In 12 of 15 patients (80%) intraocular pressure was lower than 22 mmHg for an average of eight months and did not require glaucoma surgery. There were no significant complications following this therapy and all patients retained preoperative level of visual acuity. In aphakic patients who have uncontrolled glaucoma on maximal medical therapy, surgery is indicated. We recommend the following approach to surgical management: (1) Laser treatment to the trabecular meshwork if the angle is open; (2) if this fails, or the angle is extensively closed, a trabeculectomy filtering procedure is suggested; (3) cyclocryotherapy has been effective in controlling pressure but the unpredictable loss of vision has prompted caution in seeing eyes; (4) cyclodialysis; and (5) transpupillary or transscleral treatment of the ciliary processes are additional modes of therapy. Improved results of surgical treatment for glaucoma and aphakia have been encouraging and should be used when maximal medical therapy is ineffective.

Adult↗
PubMed1989

[Investigation of Limulus test during and after cardiopulmonary bypass--analysis of Limulus positive substance and particles in the cardiopulmonary bypass circuit].

Patients undergoing heart surgery with cardiopulmonary bypass (CPB) frequently have positive Limulus test without any remarkable signs of endotoxemia. CPB circuit could be one of the possible causes of this phenomenon, but the exact mechanism has not been studied. Accordingly, a prospective study was made in 41 patients undergoing heart surgery with CPB. Limulus test were performed on the samples of priming fluids of CPB including the plasma and urine of those patients during and after surgery. Besides the Limulus test, the CPB fluids were analysed by the false positive test. Microscopic examinations were carried out on the priming fluids before and after using a 40 microns filter during recirculation without washing the CPB circuit and the fluid from a 4 microns filter been washed by 2000 ml of Martose-10 in order to find out the presence of any foreign particles in the CPB circuit. The size and the number of particles were measured by coulter counter. The studies revealed the following facts, 1) Limulus test; most of the samples from priming fluids (31/35), plasma circulating the CPB (36/36), urine during CPB (22/25) and plasma (34/35) and urine (21/30) just after the surgery revealed positive. However, only 4 samples from plasma at 3POD and 2 samples from urine at 2POD revealed positive, 2) false positive test of the samples from priming fluids was negative meaning the Limulus positive substances are not endotoxin, 3) under microscopic analysis and coulter counter, there were about 40 particles over 50 microns per ml of priming fluids before washing the CPB circuit.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2004

Does leucocyte depletion during cardiopulmonary bypass improve oxygenation indices in patients with mild lung dysfunction?

BACKGROUND: Leucocyte-depleting arterial line filters have not dramatically improved lung function after cardiopulmonary bypass (CPB), but patients with pre-existing lung dysfunction may benefit from their use. METHODS: We randomized 32 patients with mild lung dysfunction having elective first-time coronary revascularization to either a leucocyte depleting or a standard 40-mm arterial line filter during CPB. The alveolar arterial oxygenation index was calculated before and 5 min after CPB, then at 1, 2, 4, 8, and 18 h after surgery. Time to extubation on the ITU was recorded. Preoperative, immediate postoperative, and 24 h postoperative chest x-rays were scored for extravascular lung water. RESULTS: Postoperative alveolar-arterial oxygenation indices were better in the patients who received leucocyte depletion during CPB (1.65+/-0.96 in the study group vs 2.90+/-1.72 in the control group, P<0.05). The duration of postoperative mechanical ventilation was less in the leucocyte-depleted group (4.8+/-2.1 vs 8.3+/-4.7 h in the control group, P<0.05). The extravascular lung water scores immediately postoperatively were 13.0+/-8.6 in the study group vs 19.6+/-10.8 in the control group (P=0.04), and at 24 h postoperatively, 9.7+/-7.7 vs 15.2+/-9.9 for controls. CONCLUSIONS: For patients with mild lung dysfunction, a leucocyte-depleting arterial line filter improves postoperative oxygenation, reduces extravascular lung water accumulation, and reduces time on artificial ventilator after CPB. There may be an economic argument for the routine use of leucocyte-depleting filters for every patient during CPB.

Adolescent↗
PubMed2000

Leukocyte-depleted blood cardioplegia reduces cardiac troponin T release in patients undergoing coronary artery bypass grafting.

OBJECTIVE: Activated neutrophils have been implicated in reperfusion injury of the myocardium. Leukocyte depletion at reperfusion may contribute to better myocardial protection during cardiac surgery. We tested the efficacy of leukocyte-depleted blood cardioplegia in reducing myocardial injury during coronary artery bypass grafting. METHODS: Subjects were 27 patients undergoing elective coronary artery bypass grafting divided into controls (perfused with nonfiltered blood cardioplegia, n = 12) and those undergoing leukocyte-depleted blood cardioplegia (n = 15). Oxygenated blood mixed with a potassium crystalloid cardioplegic solution was delivered through the aortic root at every 30 minutes during cardiac arrest and terminal warm blood was administered before aortic declamping in both groups. In leukocyte depletion, blood was filtered prior to the mixture with crystalloid solution in the cardioplegic reservoir. RESULTS: Patient profiles did not differ significantly between groups, nor did systemic leukocyte count during or after surgery despite more than 81% removal of leukocytes in cardioplegic delivery. No consistent differences between groups in creatine kinase or creatine kinase-MB were seen up to 18 hours after surgery. Peak troponin T levels were significantly lower in the leukocyte-depleted blood cardioplegia group (0.52 +/- 0.13 ng/ml), however, than in controls (3.85 +/- 0.85 ng/ml). CONCLUSION: We concluded that leukocyte-depleted blood cardioplegia reduces the release of cardiac troponin T in patients undergoing elective coronary artery bypass grafting and may produce better myocardial protection in patients with impaired cardiac function or a damaged myocardium.

Aged↗
PubMed2005

Sestamibi scans are not all created equally.

HYPOTHESIS: The sensitivity of sestamibi scanning techniques used for preoperative localization in primary hyperparathyroidism is a function of the parameters of image acquisition and processing. DESIGN: Criterion standard vs optimized technique. SETTING: Tertiary referral center. PATIENTS: One hundred forty-eight consecutive patients with primary hyperthyroidism were analyzed. Under the initial protocol, 97 patients underwent a preexisting standard sestamibi--single-photon emission computed tomographic scan and surgical exploration. The scanning technique was modified and in the revised protocol, 51 patients underwent imaging and surgical exploration. INTERVENTION: Image acquisition and processing revisions as follows: patient positioning standardized, collimator resolution adjusted, radioactive tracer delay extended, visualization field broadened, data extraction refined, and image processing filter modified. MAIN OUTCOME MEASURES: concordance among the scan and operative localization, lateralization, and cure rate. RESULTS: Initial protocol: 97 patients underwent surgery for primary hyperthyroidism with the initial sestamibi design. Eighty-one patients (83%) had a positive result, that is, at least 1 gland was identified; 77 patients (79%) had correct lateralization; and 49 patients (52%) had precise localization. Revised protocol: 51 patients underwent imaging under the optimized protocol. Forty-nine patients (96) had a positive result; 47 patients (92%) had correct lateralization; and 36 patients (70%) had precise localization. These improvements were significant, with P<.05 for localization and P<.01 for lateralization. Cure rates were 96% in both groups, confirmed by laboratory and pathologic findings. CONCLUSIONS: Sestamibi optimization in primary hyperparathyroidism can improve scan sensitivity. This may permit a focused minimally invasive operation.

Chi-Square Distribution↗
PubMed1997

Cells are present in the smoke created during laparoscopic surgery.

BACKGROUND: The application of laparoscopy for malignancy has been halted in many centres because of a growing number of reports of metastases arising in port sites. The smoke created by coagulation during laparoscopic surgery appears to contain particles visible to the naked eye. This study tested the hypothesis that whole cells can be carried as an aerosol in the pneumoperitoneum during laparoscopy. METHODS: Nine patients undergoing laparoscopic surgery for benign and metastatic disease were studied. Throughout the procedure the gas of the pneumoperitoneum was allowed to escape through a filter. The filters and tubing were washed, and washing solution was centrifuged and stained immunohistochemically to identify the cells. Three of the filters were also examined with an electron microscope. RESULTS: Six of the nine samples contained cells. Clumps of whole cells were identified as mesothelial in origin; the electron micrographs showed many other cells stuck to the filter, which appeared to be blood and mesothelial cells but were not analysed further. CONCLUSION: The presence of whole identifiable cells carried in the pneumoperitoneum raises concerns for operating staff and could be a mechanism for tumour implantation. No malignant cells were found, but ethical considerations prevented intentional coagulation of malignant tissue.

Aerosols↗
PubMed2001

Cephalometric image analysis and measurement for orthognathic surgery.

Automatic identification of landmarks in cephalometry is very important and useful for orthognathic surgery. A computerised automatic cephalometric analysis system (CACAS), based on image processing, is presented. For an original X-ray image, median filtering and histogram equalisation are used to improve image quality. The edge of an X-ray image is detected by a wavelet transform and Canny filter. Seventeen landmarks in cephalometry are successfully identified by knowledge-based edge tracing and changeable templates. Seventy-three measurements based on distances, angles and ratios between landmarks are computed automatically. The reliability of the landmarks and the validity of the measurements are compared for automatic and manual operation. The values of measurements obtained by CACAS are more precise and reliable: the mean error for linear measurements is less than 0.9mm; the mean error for angular measurements is less than 1.2 degrees. The rate of validity is over 80%, even if the image quality is poor. For an image with a high signal-to-noise ratio, the rate of validity of landmarking and measurements using the CACAS system is over 90%.

Cephalometry↗
PubMed2026

The diagnostic potential of combined quantitative polymerase chain reaction and next-generation sequencing using the same primers for periprosthetic joint infection.

Next-generation sequencing (NGS) enables the detection of specific pathogens unidentifiable by conventional cultures, but its application in orthopedics remains inconsistent due to background contamination and irreproducible findings. This study evaluated the diagnostic performance of a novel workflow combining broad-range 16S rRNA gene quantitative PCR (qPCR) screening with downstream NGS, focusing on bacterial biomass thresholds. The qPCR assay demonstrated excellent intrarater reliability, with an intraclass correlation coefficient (ICC) of 0.961 (95% confidence interval, 0.881 to 0.997). Based on serially diluted positive controls, a quantitative threshold of 10&#x2075; CFU/mL was established as the minimum concentration required for the consistent detection of fastidious taxa, such as Escherichia coli. When evaluated against conventional cultures using 95 sonicate fluid and 276 pre/intraoperative tissue samples, the qPCR assay achieved a sensitivity of 80% and a specificity of 72%. Subsequent NGS sequencing of 26 clinical samples and 9 controls showed concordance in 4 of 6 culture-positive infected cases with NGS taxonomy, whereas the remaining discrepancies were likely attributable to culture-based phenotypic misidentification. Notably, among the qPCR-positive cases, three were culture-negative, including two hip prosthesis loosening cases exhibiting polymicrobial profiles, and one post-traumatic osteoarthritis case harboring low-level Staphylococcus. Crucially, this post-traumatic patient developed delayed periprosthetic joint infection (PJI) 2 years post-surgery, with cultures identifying Staphylococcus previously detected by the initial NGS analysis. Integrating qPCR screening with targeted NGS effectively refines pathogen identification, filters environmental artifacts, and overcomes the diagnostic limitations of culture-negative infections in orthopedic practice.IMPORTANCENext-generation sequencing (NGS) enables the detection of specific pathogens in clinical samples that are not identifiable by conventional methods. However, NGS applications in orthopedics have not been quantitatively evaluated, and findings have been inconsistent owing to contaminants and the presence of non-credible causative organisms. These factors primarily stem from the failure to evaluate low-biomass samples and the absence of proper controls, such as negative controls or mock community DNA samples. This study demonstrates that interpreting results from low-biomass samples requires careful consideration because NGS relies on relative bacterial abundances; distinguishing likely pathogens from contaminants is particularly challenging when bacterial loads are low. We demonstrated that combining NGS with quantitative PCR (qPCR) and applying a Cq cutoff can reduce false positives.

Humans↗
PubMed2002

The effect of universal leukodepletion of packed red blood cells on postoperative infections in high-risk patients undergoing abdominal aortic surgery.

UNLABELLED: We evaluated, by using a before-and-after study, the influence of leukoreduction by filtration on postoperative infections and adverse outcomes in patients undergoing elective major aortic surgery. From January 1995 to October 2000, all patients who underwent elective abdominal aortic surgery were included in the analysis. Before the introduction of systematic leukodepletion of packed red blood cells (RBCs), on April 1, 1998, 192 patients received standard or buffy-coat-depleted packed RBCs. Then, 195 patients were transfused with exclusively filtered leukodepleted packed RBCs. No major significant difference was observed between the groups of patients with regard to preoperative cardiac and pulmonary status, anesthetic and surgical techniques, or transfusion policy. No significant difference in mortality was observed between the two groups. The incidence of postoperative infections was 31% (95% confidence interval, 25%--38%) in the Control group versus 27% (95% confidence interval, 21%--33%) in the Leukodepleted group; severe infectious complications and pneumonia were not significantly different between the two groups of patients. Cardiovascular and respiratory outcomes were not significantly different between the groups. Data from this study suggest that the effect of using leukodepleted RBC on postoperative infections is not of obvious importance. IMPLICATIONS: We evaluated the influence of leukocyte reduction by filtration of packed red blood cells (RBC) on postoperative infections and adverse outcomes in patients undergoing elective major aortic surgery by comparing two epochs with and without filtration. Data from this study suggest that the effect of using filtered RBC on postoperative infections is not of obvious importance.

Adult↗
PubMed2000

Preliminary report: Dynamic stereopsis in patients with impaired binocular function.

In this study, 46 strabismic patients aged between 9 and 58 years were tested for dynamic stereopsis in the peripheral visual field with up to 20 degrees eccentricity. Squint angles ranged from +30 to -36 degrees. The effect of surgical realignment of the visual axes on dynamic stereopsis was tested before and after surgery in 40 of these patients. Of the 46 patients, 23 had esotropia and 23 exotropia. A test device was used which presented two projected squares in polarized light (each square being perceived monocularly through a polarization filter) in horizontal motion, thus creating a three-dimensional impression. Patients were tested qualitatively for dynamically stereoactive fields of vision and quantitatively for the threshold value needed to create a three-dimensional impression. We found residual dynamic stereopsis in 30% of patients who had no central static stereopsis. 56% of the patients improved after surgery, either through a significant (p < 0.01) gain of stereoactive fields or through a decrease in threshold values. This emphasizes the necessity of creating a test device suitable for everyday clinical use. Strabismus surgery is especially beneficial in connection with traffic and sports medicine, regardless of the effect on classical tests.

Adolescent↗
PubMed1997

Technical aspects of insertion and removal of an inferior vena cava IVC filter for prophylactic treatment of pulmonary embolus.

We report the successful insertion and subsequent retrieval of a Gunther-Tulip vena cava filter in a patient with an anomalous left-sided inferior vena cava, who developed a right ilio-femoral venous thrombosis prior to planned surgical resection of a right femoral osteosarcoma. The indication was for short-term prophylaxis against pulmonary embolism during manipulative leg surgery.

Catheterization, Central Venous↗
PubMed1981

Iridectomy with scleral cautery.

I have described modifications that have evolved over the years in doing iridectomy with cautery and have reviewed some of my experiences with the method. All filtering operations leave a great deal to be desired. Each technique has certain advantages and disadvantages. A great advantage of the cautery procedure is its safety and simplicity. It is as effective in lowering pressure as most other procedures. Even if the operation fails to control pressure, little harm is done to the eye, and it can be repeated. One of the great advances in management of open-angle glaucoma in recent years has been the adoption of stringent indications for surgery. Surgery should not be advised until a thorough trial of maximal medical therapy has been made. In many instances, however, the pendulum has been allowed to swing too far. When medical treatment has failed, and the patient is faced with progressive loss of vision if control of pressure is not achieved, the ophthalmic surgeon should resist the temptation to procrastinate. Surgery should be done promptly and deterioration should not be allowed to occur. Should a cataract occur, it can be removed. Endophthalmitis can be prevented or cured by antibiotic therapy. Although filtering operations leave a great deal to be desired, when effective, they will preserve a functioning optic nerve.

Cautery↗