Stability of neodymium:YAG laser posterior capsulotomy in eyes with capsular tension rings

·AIM: To evaluate the stability of neodymium(Nd):YAG laser posterior capsulotomy in eyes with capsular tension rings(CTRs).·METHODS: A total of 60 eyes that underwent cataract surgery and laser posterior capsulotomy postoperatively were included in this retrospective cohort study. To evaluate the safety and stability of capsulotomy, changes in the size of posterior capsulotomy and anterior chamber depth(ACD) in three groups: the group without CTR, the group with 12 mm CTRs, and the group with 13 mm CTRs, at 1wk, 3, 12, and 15mo after capsulotomy, were compared. ·RESULTS: In the group without CTR and the group with 12 mm CTR, there was no significant change in ACD at every post-laser follow-up. In the group with 13 mm CTR, the ACD change was significant until 3mo after capsulotomy. In all groups, there was a significant increase in the area of capsulotomy between 1wk and 3mo post-laser. Between 3 and 12mo post-laser, only the group with 13 mm CTR showed a significant increase in the area of capsulotomy(P<0.01). ·CONCLUSION: Laser posterior capsulotomy is safe in all three groups. The capsulotomy and ACD become stabilized and have not shown significant changes since 1y postlaser, even with larger CTRs. The maintenance of centrifugal capsular tension can last longer with larger CTRs, and the stability of the capsulotomy site can be reached about 12mo after capsulotomy in pseudophakic eyes with larger CTRs.

Early results of circularity and centration of capsulotomy prepared by three different methods

AIM:To compare the difference of capsulotomy produced by precision pulse capsulotomy(PPC),manual(M-CCC),and femtosecond laser assisted capsulotomy(FLAC)in relation to intraocular lens(IOL)centration,circularity and its effect on visual outcomes.METHODS:Prospective,non-randomized comparative study conducted at LV Prasad Eye Institute,Hyderabad,India.Sixty eyes of 52 patients were grouped into 3(FLAC,PPC and M-CCC)based on capsulotomy techniques used.Twenty consecutive eyes with uneventful phacoemulsification and with no comorbidities affecting the capsulotomy or visual outcome were included in each group.The main outcome measure was IOL centration in relation to capsulotomy and pupil.Secondary outcome measures were post-operative visual acuity,manifest refraction and aberration profile between groups.RESULTS:At 5 wk the visual,refractive outcomes and endothelial cell density were comparable between the 3 groups.The median circularity index of FLAC was statistically significantly different to M-CCC or PPC(1-10)groups(P<0.01)but PPC(11-20)was comparable to FLAC.Decentration of IOL center in relation to capsulotomy was seen only between the PPC(1-10)group and FLAC group(P=0.02).The IOL was well centered in relation to the pupil in all the groups(P=0.46).The quality of vision parameters like the higher order aberrations,spherical aberration,coma,trefoil,modular transfer function,and Strehl ratio were comparable between the groups.CONCLUSION:Our study shows that despite differences in the morphology of capsulotomy produced by PPC,M-CCC,FLAC a well-centered IOL can be achieved.The measured capsular morphology parameters do not affect visual outcomes.

Comparison of two Nd:YAG laser posterior capsulotomy: cruciate pattern vs circular pattern with vitreous strand cutting

AIM: To investigate the effects and safety of neodymium: yttrium-aluminium-garnet(Nd:YAG) laser posterior capsulotomy with vitreous strand cuttingMETHODS: A total of 40 eyes of 37 patients with symptomatic posterior capsular opacity(PCO) were included in this prospective randomized study and were randomly subjected to either cruciate pattern or round pattern Nd:YAG posterior capsulotomy with vitreous strand cutting(modified round pattern). The best corrected visual acuity(BCVA), intraocular pressure(IOP), refractive error, endothelial cell count(ECC), anterior segment parameters, including anterior chamber depth(ACD) and anterior chamber angle(ACA) were measured before and 1 mo after the laser posterior capsulotomy. RESULTS: In both groups, the BCVA improved significantly(P<0.001 for the modified round pattern group, P=0.001 for the cruciate pattern group); the IOP and ECC did not significantly change. The ACD significantly decreased(P<0.001 for both) and the ACA significantly increased(P=0.001 for the modified round pattern group and P=0.034 for the cruciate group). The extent of changes in these parameters was not significantly different between the groups.CONCLUSION: Modified round pattern Nd:YAG laser posterior capsulotomy is an effective and safe method for the treatment of PCO. This method significantly changes the ACD and ACA, but the change in refraction is not significant. Modified round pattern Nd:YAG laser posterior capsulotomy can be considered a good alternative procedure in patients with symptomatic PCO.

Femtosecond laser capsulotomy versus manual capsulotomy： a Meta-analysis

AIM:To perform a Meta-analysis on the precision and safety of femtosecond laser(FSL) capsulotomy compared with manual continuous curvilinear capsulotomy(CCC).· METHODS:We searched PubMed,EMBASE,Web of Science,the Cochrane Library databases,and Clinical Trials.gov that maintained our inclusion criteria.Reference lists of retrieved articles were also reviewed.The effects of morphology of capsulorhexis and the tears of anterior capsule were calculated by using randomeffect models.· RESULTS:We identified 4 randomized and 7nonrandomized studies involving 2941 eyes.The diameter of capsulotomy and the rates of anterior capsule tear showed no statistically difference between FSL group and manual group(MD=0.03;95%CI,-0.03 to0.09,P=0.31),and(OR=1.40;95%CI,0.28 to 6.97,P=0.68) respectively.In terms of the circularity of capsulotomy,FSL group had a more significant advantage than the manual CCC group(MD=0.09;95%CI,0.05 to 0.12,P<0.001).· CONCLUSION:Our Meta-analysis shows that FSL can perform a capsulotomy with more precision and higher reliability than manual CCC.The results in diameter of capsulotomy and the rate of anterior capsule tears was no significant difference between FSL and manual CCC groups.However in terms of circularity,the FSL was superior to the manual procedure.

A new technique for Nd:YAG laser posterior capsulotomy

AIM:To investigate the effects of a new opening pattern in neodymium:yttrium-aluminum-garnet(Nd:YAG)laser posterior capsulotomy on visual function.METHODS:This technique was conducted along a circular pattern.The energy ranged between 0.8 and1.2 mJ/pulse was consumed and mean total energy levels were 74±21 mJ(mean±standard deviation:SD,from 40 to167)and laser shots aimed at 150μm away behind a datum point and went along an imaginary line which extends 0.5 mm inside from optic margin and into the circular en bloc pattern.Vitreous stands were attached with fragment and then they were cut off by the laser after circular application.The circular fragment was completely separated from vitreous,and then this fragment was quickly sunk in intravitreal space.RESULTS:The follow-up period ranges from at least a week to 40mo,making 15.8mo on average.The procedural outcome showed 96%(74 eyes out of the 77eyes)enhancement in patients'visual acuity.Cystoid macular edema or retinal detachment was not observed in any of the patients during follow-up periods.CONCLUSION:This new technique is expected to improve the weaknesses that the conventional procedures have by adding the process to cut off vitreous stands attached with the fragment by the laser to the circular application.

Pediatric Nd:YAG laser capsulotomy in the operating room: review of 87 cases

AIM: To report a large series of children having Nd:YAG laser capsulotomy in the operating room using the lateral decubitus position. METHODS: Medical records of children who underwent Nd:YAG laser capsulotomy in the operating room at Ann & Robert H. Lurie Children's Hospital of Chicago between September 2008 and April 2017 were reviewed. Induction of general anesthesia and intubation was performed in the supine position after which the patient was placed in lateral decubitus position. The Nd:YAG laser capsulotomy was performed using a standard protocol. At the completion of the procedure, the patient was turned back into the supine position and extubated. RESULTS: This study included 87 eyes of 60 patients. Patient's age ranged from 1 to 18 y(mean 6.4±4.1 y). In most cases(84/87, 97%), the procedure was performed under general anesthesia. In all cases, good focus on the membrane was achieved, and the procedure was performed successfully. There were no intraoperative ocular or anesthesia-related complications. CONCLUSION: When performing Nd:YAG laser capsulotomy in the operating room, the lateral decubitus position allowsan easy and safe approach without the risk of potentially devastating complications that have been associated with the previously described sitting and prone positions.

Surgical stress and cytoskeletal changes in lens epithelial cells following manual and femtosecond laser-assisted capsulotomy

AIM:To study the effect of mechanical stress on the cytoskeleton in lens epithelial cells following conventional phacoemulsification surgery(CPS)and femtosecond laserassisted cataract surgery(FLACS).METHODS:The cytoskeleton of the epithelial cells of the anterior lens capsules(ALC)removed by CPS and FLACS was examined by immunohistochemistry.Expression of the intermediate filament,glial fibrillary acidic protein(GFAP),and glutamine synthetase(GS)immunoreactivity were detected.In order to map the actin network of cells,fluorescently labeled phalloidin was used.The samples were examined using confocal laser scanning microscopy.RESULTS:GFAP expression was visible in a larger number of the epithelial cells after CPS compared to FLACS.In CPS sample’s epithelial cells,GFAP immunoreactivity indicated robust morphological change.Regarding the actin filaments,the presence of tubular elements connecting epithelial cells,regular actin pattern and marked cortical network after CPS were found.Following FLACS,the actin cytoskeleton of the epithelial cells remained densely structured,and the tubular elements were undetectable,however,the above-mentioned regular actin pattern and the marked cortical network were visible.CONCLUSION:The conventional removal of the ALC induces more robust changes of the cytoskeleton of the lens epithelial cells.

A randomized controlled trial of peeling and aspiration of Elschnig pearls and neodymium: yttrium-aluminiumgarnet laser capsulotomy

AIM: To compare surgical peeling and aspiration and neodymium yttrium garnet laser capsulotomy for pearl form of posterior capsule opacification(PCO).METHODS: A prospective, randomized, double blind,study was done at Rotary Eye Hospital, Maranda,Palampur, India, Santosh Medical College Hospital,Ghaziabad, India and Laser Eye Clinic, Noida India.Consecutive patients with pearl form of PCO following surgery, phacoemulsification, manual small incision cataract surgery and conventional extracapsular cataract extraction(ECCE) for age related cataract, were randomized to have peeling and aspiration or neodymium yttrium garnet laser capsulotomy. Corrected distance visual acuity(CDVA), intra-operative and postoperative complications were compared.RESULTS: A total of 634 patients participated in the study, and 314(49.5%) patients were randomized to surgical peeling and aspiration group and 320(50.5%) to the Nd:YAG laser group. The mean pre-procedural log MAR CDVA in peeling and neodymium: yttrium-aluminium-garnet(Nd:YAG) laser group was 0.80 ±0.25 and 0.86 ±0.22, respectively. The mean final CDVA in peeling group(0.22 ±0.23) was comparable to Nd:YAG group(0.24 ±0.28; t-test, P =0.240). There was a significant improvement in vision after both the procedures(P <0.001). A slightly higher percentage of patients in Nd:YAG laser group(283/88.3%) than in peeling group(262/83.4%) had a CDVA of 0.5(20/63) or better at 9mo(P <0.001). On the contrary, patients havingCDVA worse than 1.00(20/200) was also significantly higher in Nd:YAG laser group as compared to peeling group(25/7.7% vs 15/4.7%, respectively). On application of ANCOVA, there was less than 0.001% risk that PCO thickness and total laser energy had no effect on rate of complications in Nd:YAG laser group and less than 0.001% risk that PCO thickness had no effect on complications in peeling group respectively. Sum of square analysis suggests that in the Nd:YAG laser group,thick PCO had a stronger impact on complications(Fischer test probability, P r <0.0001) than thin PCO and total laser energy(Fischer test probability, P r <0.002),respectively; similarly, in peeling group, thick PCO and preoperative vision had a stronger effect on complications than thin PCO, respectively(Fischer test probability, P r <0.001). The rate of complications like uveitis(P =0.527) and cystoid macular edema(P =0.068),did not differ significantly between both the groups.However, intraocular pressure spikes(P =0.046) and retinal detachment(P<0.001) were significantly higher in Nd:YAG laser group as compared to peeling group.Retinal detachment was more common in patients having degenerative myopia(7/87.5%, P <0.001). Recurrence of pearls was the most common cause of reduction of vision in the peeling group(24/7.6%, P <0.001).CONCLUSION: There is no alternative to Nd:YAG laser capsulotomy for fibrous subtype of PCO. For pearl form of PCO, both techniques are comparable with regard to visual outcomes. Nd:YAG laser capsulotomy has a higher incidence of IOP spikes and retinal detachment whereas recurrence of pearls may occur after successful peeling and aspiration. When posterior capsulotomy is needed in patients with retinal degenerations,retinopathies and pre-existing retinal breaks, the clinician should be cautious about increased risks of possible complications of Nd:YAG laser capsulotomy.

Cell death and survival following manual and femtosecond laser-assisted capsulotomy in age-related cataract

AIM: To study molecular and morphological changes in lens epithelial cells following femtosecond laser-assisted and manually performed continuous curvilinear capsulotomy(CCC) in order to get information about these methods regarding their potential role in the induction of development of secondary cataract. METHODS: Anterior lens capsules(ALC) were removed from 40 patients with age-related cataract by manual CCC and by femtosecond laser-assisted capsulotomy(FLAC). Samples removed by manual CCC were assorted in group 1, FLAC samples were classified in group 2. Morphology of lens epithelial cells was examined with light and electron microscopes. Following capsulotomy, expressions of p53, Bcl-2 and cyclin D1 genes were analyzed with reverse transcriptase polymerase chain reaction. Immunohistochemistry was used to detect the pro-apoptotic p53 in the epithelial cells. RESULTS: Light and electron microscopic examination showed that ALC of group 1 contained more degenerating cells following manual CCC than after FLAC. The expression level of p53 was higher after manual than laser-assisted surgery. Immunocytochemistry indicated significantly higher number of cells containing p53 protein in the manual CCC group than following FLAC. Bcl-2 and cyclin D1 gene expression levels were slightly lower following manual CCC than after FLAC, but the difference was not significant. CONCLUSION: Manually removed ALC shows slightly, but not significantly larger damage due to the mechanical stretching and pulling of the capsule than those removed using FLAC.

Featuring the Nd:YAG laser capsulotomy in the operating room

Dear Editor,We read with interest the article of Kinori et al[1]titled’Pediatric Nd:YAG laser capsulotomy in the operating room:review of 87 cases’.Facilities for laser capsulotomy under general anesthesia are essential for young children and uncooperative patients undergoing cataract surgery.

Effect of Anterior Capsule Polishing on the Need for Laser Capsulotomy

Purpose: To determine the effect of anterior capsule polishing (APC) on the rate of posterior capsule opacification (PCO) as assessed by the need for laser posterior capsulotomy. Setting: University-based clinical practice, Jules Stein Eye Institute, Los Angles, California, USA. Methods: This study involved a retrospective review of eyes that underwent phacoemulsification and intraocular lens implantation between September 1991 and June 1999. Lens epithelial cells in the 763 study eyes were mechanically debrided or polished from the inside surface of the anterior capsules using a pair of Shepherd-Rentsch (Morning STAAR Inc.) capsule polishers. The 484 control eyes that had surgery earlier in the series were not polished. The rate of laser capsulotomy in the ACP and the non-ACP groups was compared using a Kaplan-Meier survival analysis. Multivariate regression was performed to determine if variables other than ACP influenced the need for laser posterior capsulotomy. Results: We identified 763 eyes that had ACP and 484 that did not. At the 24-month follow-up interval, 26.6% of the eyes in the ACP group had received a capsulotomy versus 19.50% in the non-APC. Next, a separate study was done using only one eye per patient, taking the patient as the unit of analysis. Again the capsulotomy rate was higher in the ACP group compared to the non-ACP (1.02 per 100 person-months of follow-up vs. 0.74 per 100 person-months of follow-up). Finally, a third Kaplan-Meier analysis was done on 52 patients that had one eye treated with the ACP procedure and the other eye with the non-ACP procedure. Although the log-rank test showed the statistical significant of this analysis to be borderline, the results again favored the non-ACP group with a lower capsulotomy rate. Multivariate analysis showed very similar results to the above univariate studies. The mean time to capsulotomy was 46 months for the polished group and 70 months for the unpolished group. The severity of cataract (p = 0.46) and the type of haptics (p = 0.86) did not influence the rate of capsulotomy. Plate haptic IOLS had a higher rate of capsulotomy than loop haptic IOLS (p = 0.001). Conclusions: Polishing of the anterior capsule with Shepherd-Rentsch polishers may unexpectedly increase the rate of posterior capsule opacification in eyes with round-edge silicone lenses.

COMPARISON OF THE EFFECTIVENESS BETWEEN ANTERIOR CAPSULOTOMY WITH Nd:YAG LASER AND WITH BENT NEEDLE IN PATIENTS WITH CONGENITAL CATARACT

The effectiveness of capsulotomy with Nd:YAG laser and with bent needle were compared in 50 patients(66 eyes) with congenital cataract. There were 24 patients(32 eyes) in the laser group and 26 patients(34 eyes) in the needle group. There were not significant differences in sex, age, pre-operative visual acuity and intraocular pressures, and classification of cataract between the two groups. The results show that patients in the laser group have better post-operative visual acuity. The reason is YAG las...

Cumulative probability and risk analysis for Nd:YAG laser capsulotomy

AIM: To estimate the cumulative probability of Nd:YAG capsulotomy at a teaching institution and evaluate secondary risk factors.METHODS: The records of all patients who underwent phacoemulsification with intraocular lens(IOL) placement between 2005-2010 were retrospectively reviewed. The cumulative probability of Nd:YAG capsulotomy(capsulotomy) was calculated using KaplanMeier survival analysis and secondary risk factors were evaluated using the Cox proportional hazards regression model. RESULTS: One thousand three hundred and fifty four charts were reviewed. A total of 70 capsulotomies wereperformed. The mean follow-up was 19.4 mo(standard deviation 17 mo). The cumulative probability of capsulotomy was 4% at 1 year, 5% at 2 year, and 9% at 3 year. Multivariate analysis demonstrated an increased risk with younger age(HR = 1.03, CI 1.01-1.05, P = 0.007), placement of sulcus IOL(HR = 2.57, CI 1.32-4.99, P = 0.005), ocular trauma(HR = 2.34, CI 1.13-4.83, P = 0.02), and phacoemulsification by a more experienced surgeon(HR = 4.32, CI 1.89-9.87, P = 0.001).CONCLUSION: Cumulative probability of capsulotomy was lower than previously reported. Posterior capsule opacification was strongly associated with younger age and factors associated with high-risk cataract surgery. Surgeon awareness to the risk factors that correlate with posterior capsulotomy may allow for more thorough pre-operative disclosure and enhance patient satisfaction.

Management of femoral neck fractures in the young patient: A critical analysis review

Femoral neck fractures account for nearly half of all hip fractures with the vast majority occurring in elderly patients after simple falls.Currently there may be sufficient evidence to support the routine use of hip replacement surgery for low demand elderly patients in all but non-displaced and valgus impacted femoral neck fractures.However for the physiologically young patients,preservation of the natural hip anatomy and mechanics is a priority in management because of their high functional demands.The biomechanical challenges of femoral neck fixation and the vulnerability of the femoral head blood supply lead to a high incidence of non-union and osteonecrosis of the femoral head after internal fixation of displaced femoral neck fractures.Anatomic reduction and stable internal fixation are essentials in achieving the goals of treatment in this young patient population.Furthermore,other management variables such as surgical timing,the role of capsulotomy and the choice of implant for fixation remaincontroversial.This review will focus both on the demographics and injury profile of the young patient with femoral neck fractures and the current evidence behind the surgical management of these injuries as well as their major secondary complications.

Effect of four different intraocular lenses on posterior capsule opacification

AIM: To evaluate the impact of 4 different intraocular lenses(IOLs) on posterior capsule opacification(PCO) by comparing the neodymium: yttrium-aluminum-garnet(Nd:YAG) laser capsulotomy rates.METHODS: This retrospective study included 4970 eyes of 4013 cataract patients who underwent phacoemulsification and IOL implantation between January 2000 and January 2008 by the same surgeon at one clinic. Four different IOLs were assessed. The outcome parameter was the incidence of Nd:YAG laser posterior capsulotomies.· RESULTS: An Nd:YAG laser posterior capsulotomy was performed in 153(3.07%) of the 4970 eyes. The mean follow-up time was 84 mo for all of the IOL groups. The percentage of eyes developing PCO was significantly greater for the acrylic hydrophilic IOLs than for the hydrophobic IOLs, although eyes with acrylic hydrophilic IOLs did not require Nd:YAG laser capsulotomy as soon as eyes with acrylic hydrophobic IOLs. There was no difference between the long-term PCO rates when 1-and 3-piece acrylic hydrophobic IOLs were compared or when IOLs made of the same material but with different haptic angles were compared.· CONCLUSION: In this study, eyes with acrylic hydrophilic IOLs were more likely to develop PCO than those with acrylic hydrophobic IOLs. The lens design(1-piece versus 3-piece and varying haptic angles) did not affect the PCO rate.

Effect of different lens status on intraocular pressure elevation in patients treated with anti-vascular endothelial growth factor injections

AIM: To assess the effect of lens status on sustained intraocular pressure(IOP) elevation in patients treated intravitreally with anti-vascular endothelial growth factor(VEGF) agents. METHODS: Data were retrospectively collected for all patients treated with intravitreal injections of anti-VEGF medication at a tertiary medical center in July 2015. Findings were analyzed by lens status during 6 months' follow-up. The main outcome measure was a sustained increase in IOP(≥21 mm Hg or change of ≥6 mm Hg from baseline on ≥2 consecutive visits, or addition of a new IOPlowering medication during follow-up). RESULTS: A total of 119 eyes of 100 patients met the study criteria: 40 phakic, 40 pseudophakic, and 39 pseudophakic after Nd:YAG capsulotomy. The rate of sustained IOP elevation was significantly higher in the postcapsulotomy group(23.1%) than in the phakic/pseudophakic groups(8.1%;P=0.032), with no statistically significant differences among the 3 groups in mean number of injections, either total(P=0.82) or by type of anti-VEGF mediation(bevacizumab: P=0.19;ranibizumab: P=0.13), or mean follow-up time(P=0.70). CONCLUSION: Nd:YAG capsulotomy appears to be a risk factor for sustained IOP elevation in patients receiving intravitreal anti-VEGF injections. This finding has important implications given the growing use of anti-VEGF treatment and the irreversible effects of elevated IOP.

Hydrophobic versus hydrophilic acrylic intraocular lens on posterior capsule opacification: a Meta-analysis

AIM: To conduct a Meta-analysis pooling randomized controlled trials(RCTs) to compare hydrophobic with hydrophilic acrylic intraocular lenses in terms of posterior capsule opacification(PCO) development.METHODS: Electronic databases including PubMed,Embase, and the Cochrane Library were queried from their starting till January 2020. RCTs investigating the impact of hydrophobic versus hydrophilic acrylic intraocular lenses on PCO were considered eligible in this study. The pooled effect estimates were calculated using the random-effects model.RESULTS: Thirteen RCTs comprising of 939 patients(1263 eyes) were covered in this study. Patients with hydrophobic acrylic intraocular lenses had a lower PCO score than those with a hydrophilic acrylic intraocular lenses [standard mean difference:-1.80;95% confidence interval(CI):-2.62 to-0.98;P<0.001]. Moreover, the frequency of neodymium-doped yttrium aluminum garnet(Nd:YAG)capsulotomy in patients with hydrophobic acrylic intraocular lenses was significantly lower than patients with hydrophilic acrylic intraocular lenses(relative risk: 0.38;95%CI: 0.20-0.71;P=0.003).CONCLUSION: These findings suggest that hydrophobic acrylic intraocular lenses are superior to hydrophilic acrylic intraocular lenses in patients after cataract surgery due to lower PCO score and reduced Nd:YAG capsulotomy. While similar studies are conducted by other researchers, the present study conducted subgroup analyses that show superior results with hydrophobic lenses in trials conducted in western countries.

Ophthalmic surgery teaching

The outcomes of modern ophthalmic surgery,especially cataract surgery,continue to improve and patients now realistically expect an excellent and speedy outcome with good vision and few complications.Social and regulatory demands for greater transparency and accountability in medicine have increased,highlighting a fundamental ethical tension in medical education-balancing the needs of trainees(who have not yet mastered the technique)to gain experience by performing surgery,with patient safety and the needs of the public to be protected from risk.Patient safety and well-being are the paramount considerations in any training program and must be the first consideration in program design.A variety of different educational strategies,each implemented with the aim of improving operative skills assessment and teaching,has recently been described in the literature.Effective use of these educational tools,combined with a structured approach to teaching and providing meaningful feedback,could improve outcomes,decrease complications and improve the quality and efficiency of surgical training in ophthalmology.Supervisors must assess their teaching style and communication,as being a good surgeon does not necessarily make a good trainer.Open disclosure must be given to patients about who will be performing the surgery,and communication during surgery between supervisors and trainees must be clear,respectful and appropriate.

Deep brain stimulation for Tourette’s syndrome

Tourette syndrome(TS)is a childhood-onset neuropsychiatric disorder characterized by the presence of multiple motor and vocal tics.TS usually co-occurs with one or multiple psychiatric disorders.Although behavioral and pharmacological treatments for TS are available,some patients do not respond to the available treatments.For these patients,TS is a severe,chronic,and disabling disorder.In recent years,deep brain stimulation(DBS)of basal ganglia-thalamocortical networks has emerged as a promising intervention for refractory TS with or without psychiatric comorbidities.Three major challenges need to be addressed to move the field of DBS treatment for TS forward:(1)patient and DBS target selection,(2)ethical concerns with treating pediatric patients,and(3)DBS treatment optimization and improvement of individual patient outcomes(motor and phonic tics,as well as functioning and quality of life).The Tourette Association of America and the American Academy of Neurology have recently released their recommendations regarding surgical treatment for refractory TS.Here,we describe the challenges,advancements,and promises of the use of DBS in the treatment of TS.We summarize the results of clinical studies and discuss the ethical issues involved in treating pediatric patients.Our aim is to provide a better understanding of the feasibility,safety,selection process,and clinical effectiveness of DBS treatment for select cases of severe and medically intractable TS.