Water vapour thermal therapy  (marketed as Rezum) is a newer office procedure for removing prostate tissue using steam. Several studies including a four-year follow-up provided evidence for improvement of BPH symptoms, preserved sexual function, and low surgical retreatment rates. [ 12 ] [ 13 ]


Prostatic urethral lift  (marketed as Urolift) is a procedure for men with urinary symptoms caused by prostate enlargement. It consists of placing small hooks that compress the prostate tissue to open the urinary stream without cutting or removing tissue. This procedure likely improves quality of life without additional negative side effects when compared with a  sham surgery . [ 14 ]


Compared with  transurethral resection of the prostate , the standard surgery for treating benign prostatic hyperplasia, this procedure may be less effective in reducing urinary symptoms but may preserve ejaculation and have fewer unwanted effects on erections. [ 14 ]


Temporary implantable nitinol device (marketed as TIND and iTIND) is a device that is placed in the urethra that, when released, is expanded, reshaping the urethra and the bladder neck.


The  American Urological Association  (AUA) guidelines for the treatment of BPH from 2018 list minimally invasive therapies including TUMT - but not TUNA - as acceptable alternatives for certain patients with BPH. [ 11 ]  However, the  European Association of Urology  (EAU) has - as of 2019 - removed both TUMT and TUNA from its guidelines. [ 15 ]


The two most feared complications of prostate surgery are  erectile dysfunction  and  stress urinary incontinence . [ 16 ]  The type of complications depend on the treatment modality used:


The  National Institute for Health and Care Excellence  (NICE) of the UK in 2018 classified some novel methods as follows. [ 22 ]


Recommended:


Not recommended:


The success of  surgery for benign prostatic hyperplasia  (BPH) – as measured by a significant reduction of  lower urinary tract symptoms  (LUTS) – strongly depends on a reliable (unequivocal) pre-surgery diagnosis of bladder outlet obstruction (BOO). A pre-surgery diagnosis of other LUTS only, such as  overactive bladder  (OAB) with or without  urinary incontinence  predicts little or no success after surgery. [ 27 ]


If BOO is present or not can be determined by reliable non-invasive tests, such as the Penile cuff test (PCT). In this test, first published in 1997, a software-steered inflatable  cuff  (similar as in a  blood pressure meter ) is placed around the  penis  to measure the pressure of urinary flow. [ 28 ]  By applying this methode, a study of 2013 showed that 94% of the patients with the pre-surgery test result "Obstruction" had a successful surgery outcome. In contrast, 70% of the patients with the pre-surgery test result "No Obstruction" had a non-successful surgery outcome. [ 29 ] [ 27 ]


If BPH with obstruction additionally presents with overactive bladder (OAB), which is the case in about 50% of patients, [ 30 ]  this latter symptom (OAB) persists even post-surgery in about 20% of patients. However, this rate only applies to a period of a few years.  10–15 years after surgery 48 of 55 patients (87%)  with obstruction and OAB had kept their post-surgery reduction of obstruction, but their OAB symptoms had gone back to the pre-surgery status. [ 31 ]


The UNBLOCS trial compared using transurethral resection of the prostate (TURP) to the thulium laser transurethral vaporesection of the prostate (ThuVARP). Both methods led to similar improvements, number of complications and lengths of hospital stay. Both were effective as treatment but TURP resulted in a better  urinary flow rate . [ 32 ] [ 33 ]


Transrectal biopsy  is a  biopsy  procedure in which a sample of tissue is removed from the  prostate  using a thin needle that is inserted through the  rectum  and into the prostate. [ 1 ]   Transrectal ultrasound  (TRUS) is usually used to guide the needle. [ 2 ] [ 3 ]  The sample is examined under a  microscope  to see if it contains  cancer .


This article incorporates  public domain material  from  Dictionary of Cancer Terms .  U.S. National Cancer Institute .


This  oncology  article is a  stub . You can help Wikipedia by  expanding it .


Transurethral biopsy  is a  biopsy  procedure in which a sample of tissue is removed from the  prostate  for examination under a  microscope . A thin, lighted tube is inserted through the  urethra  into the prostate, and a small piece of tissue is removed with a  cutting loop .


Transurethral incision of the prostate  ( TUIP  or  TIP ) is a surgical procedure for treating  prostate  gland enlargement (benign  prostatic hyperplasia ). [ 1 ]


Transurethral incision of the prostate-—one or two small cuts in the prostate gland—can improve urine flow and correct other problems related to an enlarged prostate. [ citation needed ]


Compared with other surgical procedures for prostate gland enlargement, TUIP is simpler and generally has fewer complications. However, TUIP can only be used when the prostate is relatively small. [ citation needed ]


Transurethral needle ablation  (also called  TUNA  or  transurethral radiofrequency ablation ) is a technique that uses low  energy   radio frequency   delivered through two needles to  ablate  excess  prostate  tissue. A  cystoscope / catheter  deploys the needles toward the obstructing prostate tissue and is inserted into the  urethra  directly through the  penis  under  local anesthetic  before the procedure begins. The energy from the probe heats the abnormal prostate tissue without damaging the urethra. The resulting  scar tissue  later  atrophies , reducing the size of the prostate which in turn reduces the constriction of the urethra. It can be done with a  local anesthetic  on an  outpatient  basis. [ 1 ]  It takes about an hour to perform the procedure. [ 2 ]  It takes about 30 days for the ablated prostate tissue to  resorb . [ 3 ]


Transurethral  needle ablation can be used to treat  benign prostatic hyperplasia  (BPH). [ 4 ]


Some clinical studies have reported that TUNA is safe and effective, improving the  urine  flow with minimal side effects when compared with other procedures, such as  transurethral resection of the prostate  (TURP) and open  prostatectomy . [ 1 ] [ 5 ] [ 6 ]  However, other studies have reported that the procedure has a high failure rate, with the majority of patients requiring  retreatment . [ 7 ]  Some patients have reported long-term  inflammation  of their prostate after undergoing the TUNA process. This is known as chronic  prostatitis .


The TUNA system was pioneered by Stuart Denzil Edwards. The device was the main product for a startup company called Vidamed. Vidamed was founded in 1992 by Edwards along with Ron   G. Lax, Hugh Sharky and  Ingemar Lundquist , in  Menlo Park, California , before building an international global corporation headed up by Lyle   F. Brotherton. Vidamed was floated in an  IPO  on the US  NASDAQ  stock market in 1995 and then acquired by  Medtronic  in 2001. [ 10 ]
In 2011, Urologix, Inc. acquired the worldwide exclusive license to Prostiva radiofrequency therapy. [ 11 ]


Transurethral resection of the prostate  (commonly known as a  TURP , plural  TURPs , and rarely as a  transurethral prostatic resection ,  TUPR ) is a  urological  operation. It is used to treat  benign prostatic hyperplasia  (BPH). As the name indicates, it is performed by visualising the  prostate  through the  urethra  and removing tissue by  electrocautery  or sharp dissection. It has been the standard treatment for BPH for many years, but recently alternative, minimally invasive techniques have become available. [ 1 ]  This procedure is done with spinal or general anaesthetic. A triple lumen  catheter  is inserted through the urethra to irrigate and drain the bladder after the surgical procedure is complete. The outcome is considered excellent for 80–90% of BPH patients. The procedure carries minimal risk for  erectile dysfunction , moderate risk for bleeding, and a large risk for  retrograde ejaculation . [ 2 ]


BPH is normally initially treated medically through  alpha   antagonists  such as  tamsulosin , or  5-alpha-reductase inhibitors  such as  finasteride  and  dutasteride . If medical treatment does not reduce a patient's urinary symptoms, a TURP may be considered following a careful examination of the prostate or bladder through a  cystoscope . If TURP is contraindicated, a urologist may consider a simple  prostatectomy , in and out catheters, or a supra-pubic catheter to help a patient void urine effectively. [ 3 ]   As the medical management of BPH improves, the number of TURPs has been decreasing. [ citation needed ]


Traditionally, a  cystoscope  (a "resectoscope") has been used to perform TURP. The scope is passed through the  urethra  to the prostate where surrounding prostate tissue can then be excised. There are two types of modalities:


A 2019 Cochrane review of 59 studies including 8924 men with BPH urinary symptoms found that bipolar and monopolar TURP probably result in comparable improvements in urinary symptoms, as well as in similar  erectile function , incidence of urinary incontinence and need for retreatment. Bipolar surgery likely reduces the risk of  TUR syndrome  and the need for  blood transfusion . [ 4 ]


Another transurethral method utilizes laser energy to remove tissue. With laser prostate surgery a fiber optic cable pushed through the urethra is used to transmit lasers such as holmium-Nd:YAG high-powered "red" or potassium titanyl phosphate (KTP) "green" to vaporize the adenoma. More recently the KTP laser has been supplanted by a higher power laser source based on a lithium triborate crystal, though it is still commonly referred to as a "Greenlight" or KTP procedure. The specific advantages of utilizing laser energy rather than a traditional electrosurgical TURP is a decrease in the relative blood loss, elimination of the risk of post-TURP hyponatremia (TUR syndrome), the ability to treat larger glands, as well as treating patients who are actively being treated with anticoagulation therapy for unrelated diagnosis.


A further transurethal method utilizes a robotically-controlled waterjet to remove prostate tissue. Visualization is provided by a combination of cystoscope and transrectal ultrasound methods.  This procedure claims risk reduction advantages as a result of being heat free.


Because of bleeding risks associated with the procedure, TURP is not considered safe for many patients with cardiac problems. [ according to whom? ]


Postoperative complications include: [ 5 ]


In most cases, urinary incontinence and erectile dysfunction resolve on their own within 6 to 12 months post-TURP. Therefore, many doctors will postpone invasive treatment until a year after the surgery.


Additionally, transurethral resection of the prostate is associated with a low risk of mortality. [ according to whom? ]


The UNBLOCS trial compared using TURP to the thulium laser transurethral vaporesection of the prostate (ThuVARP). Both methods led to similar improvements, number of complications and lengths of hospital stay. Both were effective as treatment but TURP resulted in a better  urinary flow rate . [ 15 ] [ 16 ]


A  urethrectomy  is a  surgical procedure  to remove all or part of the male  urethra , a tube that connects the  urinary bladder  to the genitals for the removal of fluids out of the body. [ 1 ]
 [ 2 ]


Vasectomy  is an  elective surgical procedure  that results in male  sterilization , often as a means of permanent  contraception . During the procedure, the male  vasa deferentia  are cut and tied or sealed so as to prevent  sperm  from entering into the  urethra  and thereby prevent  fertilization  of a female through  sexual intercourse . Vasectomies are usually performed in a  physician 's office, medical clinic, or, when performed on a non-human  animal , in a  veterinary clinic .  Hospitalization  is not normally required as the procedure is not complicated, the incisions are small, and the necessary equipment routine.


There are several methods by which a surgeon might complete a vasectomy procedure, all of which occlude (i.e., "seal") at least one side of each vas deferens. To help reduce  anxiety and increase patient comfort, those who have an aversion to needles may consider a " no-needle " application of anesthesia while the ' no-scalpel ' or 'open-ended' techniques help to accelerate recovery times and increase the chance of healthy recovery. [ 4 ]


Due to the simplicity of the surgery, a vasectomy usually takes less than 30 minutes to complete. After a short recovery at the doctor's office (usually less than an hour), the patient is sent home to rest. Because the procedure is minimally invasive, many vasectomy patients find that they can resume their typical sexual behavior within a week, and do so with little or no discomfort.


Because the procedure is considered a permanent method of contraception and is not easily reversed, patients are frequently counseled and advised to consider how the long-term outcome of a vasectomy might affect them both emotionally and physically. The procedure is not typically encouraged for young single childless people as their risk of later regret is higher as chances of biological parenthood are thereby permanently reduced, often completely. [ citation needed ]
A vasectomy without the patient's consent or knowledge is considered  forced sterilization.


A vasectomy is done to prevent fertility in males. It ensures that in most cases the person will be  sterile  after confirmation of success following surgery. The procedure is regarded as permanent because  vasectomy reversal  is costly and often does not restore the male's sperm count or sperm motility to prevasectomy levels. Those with vasectomies have a very small (nearly zero) chance of successfully impregnating someone, but a vasectomy does not protect against  sexually transmitted infections  (STIs). [ 5 ]


After vasectomy, the testes remain in the scrotum where  Leydig cells  continue to produce  testosterone  and other male hormones that continue to be secreted into the bloodstream.


When the vasectomy is complete, sperm cannot exit the body through the  penis . Sperm is still produced by the testicles but is broken down and absorbed by the body. Much fluid content is absorbed by membranes in the  epididymis , and much solid content is broken down by the responding  macrophages  and reabsorbed via the bloodstream. [ citation needed ]  After vasectomy, the membranes must increase in size to absorb and store more fluid; this triggering of the immune system causes more macrophages to be recruited to break down and reabsorb more solid content. [ citation needed ]  Within one year after vasectomy, sixty to seventy percent of those vasectomized develop  antisperm antibodies . [ 6 ]  In some cases,  vasitis nodosa , a benign proliferation of the ductular epithelium, can also result. [ 7 ] [ 8 ]  The accumulation of sperm increases pressure in the vas deferens and epididymis. The entry of the sperm into the scrotum can cause  sperm granulomas  to be formed by the body to contain and absorb the sperm which the body will treat as a foreign biological substance (much like a virus or bacterium). [ 9 ]


Vasectomy is the most effective permanent form of contraception available to males. (Removing the entire vas deferens would very likely be more effective, but it is not something that is regularly done. [ 13 ] ) In nearly every way that vasectomy can be compared to  tubal ligation  it has a more positive outlook. Vasectomy is more cost effective, less invasive, has techniques that are emerging that may facilitate easier reversal, and has a much lower risk of postoperative complications.


Early failure rates, i.e. pregnancy within a few months after vasectomy, typically result from unprotected  sexual intercourse  too soon after the procedure while some sperm continue to pass through the vasa deferentia. Most physicians and surgeons who perform vasectomies recommend one (sometimes two) postprocedural semen specimens to verify a successful vasectomy; however, many people fail to return for verification tests citing inconvenience, embarrassment, forgetfulness, or certainty of sterility. [ 14 ]  In January 2008, the FDA cleared a home test called SpermCheck Vasectomy that allows patients to perform postvasectomy confirmation tests themselves; [ 15 ]  however, compliance for postvasectomy semen analysis in general remains low.


Late failure, i.e. pregnancy following spontaneous recanalization of the vasa deferentia, has also been documented. [ 16 ]  This occurs because the  epithelium  of the vas deferens (similar to the epithelium of some other human body parts) is capable of regenerating and creating a new tube if the vas deferens is damaged and/or severed. [ 17 ]  Even when as much as five centimeters (or two inches) of the vas deferens is removed, the vas deferens can still grow back together and become reattached—thus allowing sperm to once again pass and flow through the vas deferens, restoring one's fertility. [ 17 ]


The  Royal College of Obstetricians and Gynaecologists  states there is a generally agreed-upon rate of late failure of about one in 2000 vasectomies—better than  tubal ligations  for which the failure rate is one in every 200 to 300 cases. [ 18 ]  A 2005 review including both early and late failures described a total of 183 recanalizations from 43,642 vasectomies (0.4%), and 60 pregnancies after 92,184 vasectomies (0.07%). [ 10 ]


Short-term possible complications include  infection ,  bruising  and  bleeding  into the scrotum resulting in a collection of blood known as a  hematoma . [ 19 ]  A study in 2012 demonstrated an infection rate of 2.5% postvasectomy. [ 11 ]  The  stitches  on the small incisions required are prone to irritation, though this can be minimized by covering them with gauze or small  adhesive bandages . The primary long-term complications are chronic pain conditions or syndromes that can affect any of the scrotal, pelvic or lower-abdominal regions, collectively known as  post-vasectomy pain syndrome . Though vasectomy results in increases in circulating immune complexes, these increases are transient. Data based on animal and human studies indicate these changes do not result in increased incidence of  atherosclerosis .


Complications not withstanding, many men express concerns regarding potential adverse effects of vasectomy, including Cancer.  The risk of testicular cancer is not affected by vasectomy. [ 20 ]  In 2014 the AUA reaffirmed that vasectomy is not a risk factor for prostate cancer and that it is not necessary for physicians to routinely discuss prostate cancer in their preoperative counseling of vasectomy patients. [ 21 ]  There remains ongoing debate regarding whether vasectomy is associated with prostate cancer. A 2017 meta-analysis found no statistically significant increase in risk. [ 22 ]  A 2019 study of 2.1 million Danish males found that vasectomy increased their incidence of prostate cancer by 15%. [ 23 ]  A 2020 meta-analysis found that vasectomy increased the incidence by 9%. [ 24 ]  Other recent studies agree on the 15% increase in risk of developing prostate cancer, but found that people who get a vasectomy are not more likely to die from prostate cancer than those without a vasectomy. [ 25 ] [ 26 ]


A vasectomy will not Impact sexual performance: A vasectomy does not affect libido or masculinity aside from its contraceptive effect. Some men have even reported increased sexual satisfaction post-vasectomy.
It won't cause permanent damage to sexual organs: The risk of injury to the testicles, penis, or other reproductive organs during surgery is minimal. Although extremely rare, damage to the blood supply could potentially lead to testicular loss, but this occurrence is unlikely with a skilled surgeon.


It won't increase the risk of heart disease: There is no established connection between vasectomy and heart-related issues.


Vasectomy will not result in severe pain: While minor discomfort such as pulling or tugging sensations may occur during the procedure, severe pain is uncommon. Post-surgery, most men experience minor pain that typically resolves within a few days. In rare cases, some men report chronic post surgery pain, Post Vasectomy Pain Syndrome.


Post-vasectomy pain syndrome is a chronic and sometimes debilitating condition that may develop immediately or several years after vasectomy. [ 27 ]  The most robust study of post-vasectomy pain, according to the American Urology Association's Vasectomy Guidelines 2012 (amended 2015) [ 28 ]  surveyed people just before their vasectomy and again seven months later. Of those that responded and who said they did not have any scrotal pain prior to vasectomy, 7% had scrotal pain seven months later which they described as "Mild, a bit of a nuisance", 1.6% had pain that was "Moderate, require painkillers" and 0.9% had pain that was "quite severe and noticeably affecting their quality of life". [ 12 ]  Post-vasectomy pain can be constant  orchialgia  or epididymal pain ( epididymitis ), or it can be pain that occurs only at particular times such as with sexual intercourse, ejaculation, or physical exertion. [ 9 ]


Approximately 90% are generally reported in reviews as being satisfied with having had a vasectomy, [ 29 ]  while 7–10% of people regret their decision. [ 30 ]  For those in relationships, regret was less common when both people in the relationship agreed on the procedure. [ 31 ]


Younger people who receive a vasectomy are significantly more likely to regret and seek a reversal of their vasectomy, with one study showing people in their twenties being 12.5 times more likely to undergo a vasectomy reversal later in life (and including some who chose sterilization at a young age). Pre-vasectomy counseling is often emphasised for younger patients. [ 32 ] [ 33 ]


An association between vasectomy and  primary progressive aphasia , a rare variety of frontotemporal dementia, was reported. [ 31 ]  However, it is doubtful that there is a causal relationship. [ 34 ]  The putative mechanism is a cross-reactivity between brain and sperm, including the shared presence of neural surface antigens. [ 35 ]   In addition, the cytoskeletal  tau protein  has been found only to exist outside of the CNS in the  manchette  of sperm. [ 35 ]


The traditional incision approach of vasectomy involves numbing of the scrotum with local anesthetic (although some people's physiology may make access to the vas deferens more difficult in which case general anesthesia may be recommended) after which a  scalpel  is used to make two small incisions, one on each side of the scrotum at a location that allows the surgeon to bring each vas deferens to the surface for excision. The vasa deferentia are cut (sometimes a section may be removed altogether), separated, and then at least one side is sealed by ligating ( suturing ),  cauterizing   ( electrocauterization ), or clamping. [ 36 ]  There are several variations to this method that may improve healing, effectiveness, and which help mitigate long-term pain such as post-vasectomy pain syndrome or  epididymitis , however the data supporting one over another are limited. [ 37 ]


The following vasectomy methods have purportedly had a better chance of later reversal but have seen less use by virtue of known higher failure rates (i.e., recanalization). An earlier clip device, the VasClip, is no longer on the market, due to unacceptably high failure rates. [ 46 ] [ 47 ] [ 48 ] [ unreliable medical source? ]


The VasClip method, though considered reversible, has had a higher cost and resulted in lower success rates. Also, because the vasa deferentia are not cut or tied with this method, it could technically be classified as other than a vasectomy. Vasectomy reversal (and the success thereof) was conjectured to be higher as it only required removing the Vas-Clip device. This method achieved limited use, and scant reversal data are available. [ 48 ]


Both vas occlusion techniques require the same basic patient setup: local anesthesia, puncturing of the scrotal sac for access of the vas, and then plug or injected plug occlusion. The success of the aforementioned vas occlusion techniques is not clear and data are still limited.  Studies have shown, however, that the time to achieve sterility is longer than the more prominent techniques mentioned in the beginning of this article. The satisfaction rate of patients undergoing IVD techniques has a high rate of satisfaction with regard to the surgery experience itself. [ 51 ]


Sexual intercourse can usually be resumed in about a week (depending on recovery); however, pregnancy is still possible as long as the  sperm count  is above zero. Another method of contraception must be relied upon until a sperm count is performed either two months after the vasectomy or after 10–20 ejaculations have occurred. [ 52 ]


After a vasectomy, contraceptive precautions must be continued until  azoospermia  is confirmed. Usually two semen analyses at three and four months are necessary to confirm azoospermia. The British Andrological Society has recommended that a single semen analysis confirming azoospermia after sixteen weeks is sufficient. [ 53 ]


Post-vasectomy, testicles will continue to produce sperm cells. As before vasectomy, unused sperm are reabsorbed by the body. [ 54 ]


In order to allow the possibility of reproduction via  artificial insemination  after vasectomy, some opt for  cryopreservation of sperm  before sterilization. Dr Allan Pacey, senior lecturer in andrology at  Sheffield University  and secretary of the British Fertility Society, notes that those he sees for a vasectomy reversal which has not worked express wishing they had known they could have stored sperm. Pacey notes, "The problem is you're asking a man to foresee a future where he might not necessarily be with his current partner—and that may be quite hard to do when she's sitting next to you." [ 55 ]


The cost of cryo-preservation (sperm banking) may also be substantially less than alternative vaso-vasectomy procedures, compared to the costs of  in-vitro fertilization  (IVF) which usually run from $12,000 to $25,000. [ 56 ]


Sperm can be aspirated from the testicles or the epididymides, and while there is not enough for successful artificial insemination, there is enough to fertilize an ovum by  intracytoplasmic sperm injection . This avoids the problem of  antisperm antibodies  and may result in a faster pregnancy. IVF may be less costly per cycle than reversal in some health-care systems, but a single IVF cycle is often insufficient for conception. Disadvantages include the need for procedures on the woman, and the standard potential side-effects of IVF for both the mother and the child. [ 57 ]


Vasectomies are not always reversible. There is a surgical procedure to reverse vasectomies using  vasovasostomy  (a form of  microsurgery  first performed by Earl Owen in 1971 [ 58 ] [ 59 ] ). Vasovasostomy is effective at achieving pregnancy in a variable percentage of cases, and total out-of-pocket costs in the United States are often upwards of $10,000. [ 60 ]  The typical success rate of pregnancy following a vasectomy reversal is around 55% if performed within 10 years, and drops to around 25% if performed after 10 years. [ 61 ]  After reversal, sperm counts and motility are usually much lower than pre-vasectomy levels. There is evidence that those who had a vasectomy may produce more abnormal sperm, which may explain why even a mechanically successful reversal does not always restore fertility. [ 62 ] [ 63 ]  The higher rates of  aneuploidy  and  diploidy  in the sperm cells of those who have undergone vasectomy reversal may lead to a higher rate of birth defects. [ 62 ]


Approximately 2% of men who have undergone vasectomy will undergo a reversal within 10 years of the procedure. [ 33 ]  A small number of vasectomy reversals are also performed in attempts to relieve post-vasectomy pain syndrome. [ 64 ]


Internationally, vasectomy rates are vastly different. [ 65 ]  While female sterilisation is the most widely used method worldwide, with 223 million women relying on it, only 28 million women rely on their partner's vasectomy. [ 66 ]  In the world's 69 least developed countries less than 0.1% of males use vasectomies on average. Of 54 African countries, only ten report measurable vasectomy use and only Eswatini, Botswana, and South Africa exceed 0.1% prevalence. [ 65 ]


In North America and Europe vasectomy usage is on the order of 10% with some countries reaching 20%. [ 65 ]  Despite its high efficacy, in the United States, vasectomy is utilized less than half the rate of the alternative female  tubal ligation . [ 67 ]  According to the research, vasectomy in the US is least utilized among black and Latino populations, the groups that have the highest rates of female sterilization. [ 67 ]


New Zealand, in contrast, has higher levels of vasectomy than tubal ligation; 18% of all males, and 25% of all married males, have had a vasectomy. The age cohort with the highest level of vasectomy was 40–49, where 57% of males had taken it up. [ 68 ]  Canada, the UK, Bhutan and the Netherlands all have similar levels of uptake. [ 69 ]


The first human vasectomies were performed in the late 19th century. The procedure was initially used mainly as a treatment for  prostate enlargement  and as a  eugenic  method for sterilizing "degenerates". [ 70 ]  Vasectomy as a method of voluntary birth control began during the Second World War. [ 71 ]


The first recorded vasectomy was performed on a dog in 1823. [ 71 ]  The first human vasectomies were performed to treat  benign prostatic hyperplasia , or enlargement of the prostate.  Castration  had sometimes been used as a treatment for this condition in the 1880s, but, given the serious side effects, doctors sought alternative treatments. The first to suggest vasectomy as an alternative to castration may have been  James Ewing Mears  (in 1890), or  Jean Casimir Félix Guyon . [ 70 ]
The first human vasectomy is thought to have been performed by  Reginald Harrison . [ 71 ] [ additional citation(s) needed ]  By 1900, Harrison reported that he had performed more than 100 vasectomies with no adverse outcomes. [ 70 ]


In the late 1890s, vasectomy also came to be proposed as a eugenic measure for the sterilization of men considered unfit to reproduce. The first case report of vasectomy in the United States was in 1897, by A. J. Ochsner, a surgeon in Chicago, in a paper titled, "Surgical treatment of habitual criminals". He believed vasectomy to be a simple, effective means for stemming the tide of  racial degeneration  widely believed to be occurring. [ 72 ] [ 73 ]  In 1902,  Harry C. Sharp , the surgeon at the Indiana Reformatory, reported that he had sterilized 42 inmates in an effort to both reduce criminal behavior in those individuals and prevent the birth of future criminals. [ 74 ]


Eugen Steinach  (1861–1944), an Austrian physician, believed that a unilateral vasectomy (severing only one of the two vasa deferentia) in older individuals could restore general vigor and  sexual potency , shrink  enlarged prostates , and cure various ailments by somehow boosting the hormonal output of the vasectomized testicle. [ 75 ]  This surgery, which became very popular in the 1920s, was undertaken by many wealthy individuals, including  Sigmund Freud  and  W. B. Yeats . [ 76 ]   Since these operations lacked rigorous controlled trials, any rejuvenating effect was likely due to the  placebo effect , and with the later development of synthetic injectable hormones, this operation fell out of vogue. [ 75 ] [ 77 ]


Vasectomy began to be regarded as a method of consensual  birth control  during the  Second World War . [ 71 ]  The first vasectomy program on a national scale was launched in 1954 in  India . [ 78 ]  In the 1970s, India enacted a  coercive sterilization campaign  which resulted in millions of vasectomies. Today, India's  sterilization program  focuses on coercing poor women.


The procedure is seldom performed on dogs, with  castration  remaining the preferred reproductive control option for canines. It is regularly performed on bulls. [ 79 ]


Vasectomy costs are (or may be) covered in different countries, as a method of both contraception or population control, with some offering it as a part of a national health insurance. The procedure was generally considered illegal in  France  until 2001, due to provisions in the  Napoleonic Code  forbidding "self-mutilation". No French law specifically mentioned vasectomy until a 2001 law on contraception and infanticide permitted the procedure. [ 80 ]


The U.S.  Affordable Care Act  (signed into law in 2010) does not cover vasectomies, [ 81 ]  although eight states require state- health insurance  plans to cover the cost. These include:  Illinois ,  Maryland ,  New Jersey ,  New Mexico ,  New York ,  Oregon ,  Vermont  and  Washington . [ 82 ]


In 2014, the Iranian parliament voted for a bill that would ban the procedure. [ 83 ]


An analysis of medical records of 217 million people in the U.S. compared  tubal sterilization  and vasectomy rates in the last six months of 2021 with rates in the last six months of 2022—just after the  Dobbs  ruling (i.e. the overturning of  Roe vs Wade ) in June 2022. Although the effect of Dobbs was different in various social groups, it had a strong impact on those under age 30 with their vasectomy rates increasing by 59%, and tubal sterilization rates increasing by 29%. [ 84 ]


Medical tourism, where a patient travels to a less-developed location where a procedure is cheaper to save money and combine convalescence with a vacation, is infrequently used for vasectomy due to its low cost, but is more likely to be used for vasectomy reversal. Many hospitals list vasectomy as being available. Medical tourism has been scrutinized by some governments for quality of care and postoperative care issues. [ 85 ]


In 1990,  Andrew Rynne , chairperson of the  Irish Family Planning Association , and the  Republic of Ireland 's first vasectomy specialist, [ 86 ]  was shot by a former client, but he survived. The incident is the subject of a short film,  The Vasectomy Doctor , by Paul Webster. [ 87 ]


Vasectomy reversal  is a term used for surgical procedures that reconnect the  male reproductive tract  after interruption by a  vasectomy . Two procedures are possible at the time of vasectomy reversal:  vasovasostomy  ( vas deferens  to vas deferens connection) and  vasoepididymostomy  ( epididymis  to vas deferens connection). Although vasectomy is considered a permanent form of contraception, advances in microsurgery have improved the success of vasectomy reversal procedures. The procedures remain technically demanding and may not restore the pre-vasectomy condition. [ 1 ]


A general or regional  anesthetic  is most commonly used, as this offers the least interruption by patient movement for microsurgery. Local  anesthesia , with or without  sedation , can also be used. The procedure is generally done on a “come and go” basis. The actual operating time can range from 1–4 hours, depending on the anatomical complexity, skill of the surgeon and the kind of procedure performed. [ citation needed ]


After anesthesia and scrubbing the  scrotum  with soap and water, the vas deferens is exposed through a small, 1–2 cm incision in the upper scrotum on each side. The vas deferens is cut sharply in half, both above and below the  vasectomy  site. A special bipolar microcautery is used to judiciously control any bleeding. One end of the vas deferens, termed the abdominal end, is inspected and flushed with salt solution to ensure that it is not blocked as it courses from the scrotum to the  prostate  (a “saline vasogram”). In order to assess for the presence of possible obstruction above the vasectomy site the testicular end of the vas deferens can be compressed and inspected for fluid. This fluid is examined with a microscope for color, consistency and for sperm. This information is used by some surgeons to decide whether or not a secondary epididymal obstruction is present [ citation needed ]  (see Table below).


If sperm are found at the testicular end of the vas deferens, then it is assumed that a secondary epididymal obstruction has not occurred and a vas deferens-to-vas deferens reconnection ( vasovasostomy ) is planned. If sperm are not found, then some surgeon consider this to be prime facie evidence that an epididymal obstruction is present and that an epididymis to vas deferens connection (vasoepididymostomy) should be considered to restore sperm flow. Other, more subtle findings that can be observed in the fluid—including the presence of sperm fragments and clear, good quality fluid without any sperm—require surgical decision-making to successfully treat. There are however, no large randomised prospective controlled trials comparing patency or pregnancy rates following the decision to perform either microsurgical vasovasostomy to microsurgical vasoepididymosty as determined by this paradigm.


For a  vasovasostomy , two microsurgical approaches are most commonly used. Neither has proven superior to the other. [ 2 ]  What has been shown to be important, however, is that the surgeon use optical magnification to perform the vasectomy reversal. One approach is the modified 1-layer vasovasostomy and the other is a formal, 2-layer vasovasostomy. [ citation needed ]


A  vasoepididymostomy  involves a connection of the  vas deferens  to the  epididymis . This is necessary when there is no sperm present in the vas deferens.


With vasectomy reversal surgery, there are two typical measures of success: patency rate, or return of some moving sperm to the ejaculate after vasectomy reversal, and  pregnancy  rates. In one study [ 3 ]  95% of men with a vasovasostomy were found to have motile sperm in the ejaculate within 1 year after vasectomy reversal. Almost 80% of these men achieved sperm motility within 3 months of vasectomy reversal. The case for vasoepididymostomy is different. Fewer men will eventually achieve motile sperm counts and the time to achieve motile sperm counts is longer.


Additional information:


Another issue to consider is the likelihood of vasoepididymostomy at the time of vasectomy reversal, as this technique is generally associated with lower patency and pregnancy rates than vasovasostomy. Web-based, computer models and calculations have been proposed and published that described the chance of needing an vasoepididymostomy at reversal surgery. [ 5 ]


The pregnancy rate is often seen as a more reliable way of measuring the success of a vasectomy reversal than the patency rates, as they measure the real-life success of whether the man succeeds in the aim of having a new child.


It is important to appreciate that female age is the single most powerful factor determining the pregnancy rate following any fertility treatment and vasectomy reversal is no exception. No large studies have stratified the results of vasectomy reversal by female age and hence assessing outcomes is confounded by this issue.


Pregnancy rates range widely in published series, with a large study in 1991 observing the best outcome of 76% pregnancy success rate with vasectomy reversals performed within 3 years or less of the original vasectomy, dropping to 53% for reversals 3–8 years out from the vasectomy, 44% for reversals 9–14 years out from the vasectomy, and 30% for reversals 15 or more years after the vasectomy. [ 6 ]  BPAS cites the average pregnancy success rate of a vasectomy reversal is around 55% if performed within 10 years, and drops to 25% if performed over 10 years. [ 7 ]  Higher success rates are found with reversal of  vasovasostomy than those with a vasoepididymostomy, and factors such as  antisperm antibodies  and epididymal dysfunction are also implicated in success rates. [ 8 ]


The current measure of success in vasectomy reversal surgery is achievement of a pregnancy. There are several reasons why a vasectomy reversal may fail to achieve this:


In general, vasectomy reversal is a safe procedure and complication rates are low. There are small chances of infection or bleeding, the latter of which can result in a  hematoma  or blood clot in the scrotum that needs surgical drainage. If there is significant scar tissue encountered during the vasectomy reversal, fluid other than blood ( seroma ) can also accumulate in a small number of cases.  Painful  granulomas , caused by leaking sperm, can develop near the surgical site in some cases. Very rare complications include  compartment syndrome  or deep  venous thrombosis  from prolonged positioning, testis atrophy due to damaged blood supply, and reactions to  anesthesia .


Assisted reproduction  uses “ test tube baby ” technology (also called  in vitro fertilization , IVF) for the female partner along with sperm retrieval techniques for the male partner to help build a family. This technology, including  intracytoplasmic sperm injection  (ICSI), has been available since 1992 and became available as an alternative to vasectomy reversal soon after. This alternative should be discussed with couples during a consultation for vasectomy reversal.


Procedure to extract sperm for IVF include  percutaneous epididymal sperm aspiration  (PESA procedure),  testicular sperm extraction  (TESE procedure) and open testicular biopsy. Needle aspiration in a PESA procedure invariably causes trauma to the epididymal tubule and TESE procedures may damage the intra testicular collecting system (rete testis). Both potentially compromise the prospect of successful vasectomy reversal. Conversely, because in most circumstances vasectomy reversal leads to the restoration of sperm in the semen, it reduces the need for sperm retrieval procedures in association with IVF.


Published research attempts to identify the issues that matter most as couples decide between IVF-ICSI and vasectomy reversal, two very different approaches to family building. This  research has generally taken the form of cost-effectiveness or cost-benefit analyses [ 14 ]  and decision analyses [ 15 ]  and Markov modeling. [ 16 ]  Since it is difficult to perform randomized, blinded prospective trials on couples in this situation, analytic modeling can help uncover what variables affect outcomes the most. From this body of work, it has been observed that vasectomy reversal can be the most cost-effective way to build a family if: (a) the female partner is reproductively healthy, and (b) the surgeon can achieve good vasectomy reversal outcomes. If the surgeon can achieve high “patency” rates (moving sperm in the ejaculate) after vasectomy reversal, then vasectomy reversal is competitive with IVF-ICSI. [ 15 ]  In the special instance of couples with  advanced maternal age  (defined as a female partner > 38 years old), case series’ have reported that pregnancy rates with vasectomy reversal are competitive with IVF-ICSI. [ 17 ]  When Markov modeling was applied to probe the issue of pregnancy rates after reversal surgery in more depth, the results revealed that female reproductive health is far more important than: (a) the age of the vasectomy, (b) the age of the man, or (c) the vasectomy reversal patency rate. Ultimately the decision to pursue a vasectomy reversal is a personal one for each couple.


Every patient who is considering vasectomy reversal should undergo a screening visit before the procedure to learn as much as possible about his current  fertility  potential. At this visit, the patient can decide whether he is a good candidate for vasectomy reversal and assess if it is right for him. Issues to be discussed at this visit include:


Immediately before the procedure, the following information is important for patients:


After the procedure, patients should perform the following tasks:


Sperm  are produced in the male sex gland or  testicle . From there they travel through tubes (efferent tubules), exit the  testes  and enter a “storage site” or  epididymis . The epididymis is a single, 18-foot-long (5.5 m), tightly coiled, small tube, within which sperm mature to the point where they can move, swim and fertilize eggs. Testicular sperm are not able to fertilize eggs naturally (but can if they are injected directly into the egg in the laboratory), as the ability to fertilize eggs is developed slowly over several months of storage in the epididymis. From the epididymis, a 14-inch, 3 mm-thick muscular tube called the  vas deferens  carries the sperm to the  urethra  near the base of the penis. The urethra then carries the sperm through the  penis  during  ejaculation . A vasectomy interrupts sperm flow within the vas deferens. After a vasectomy, the testes still make sperm, but because the exit is blocked, the sperm die and eventually are reabsorbed by the body.


A problem in the delicate tubes of epididymis can develop over time after vasectomy. [ 6 ]   The longer the time since the vasectomy, the greater the “back-pressure” behind the vasectomy. This “back-pressure” may cause a “blowout” in the delicate epididymal tubule, the weakest point in the system. The blowout may or may not cause symptoms, but will probably scar the epididymal tubule, thus blocking sperm flow at second point. To summarize, with time, a man with a vasectomy can develop a second obstruction deeper in the  reproductive tract  that can make the vasectomy more difficult to reverse. Having the skill to detect and fix this problem during vasectomy reversal is the essence of a skilled surgeon. If the surgeon simply reconnects the two freshened ends of the vas deferens without examining for a second, deeper obstruction, then the procedure can fail, as sperm-containing fluids are still unable to flow to the place of the connection. In this case, the vas deferens must be connected to the epididymis in front of the second blockage, to bypass both blockages and allow the sperm to reenter the urethra in the  ejaculate . Since the epididymal tubule is much smaller (0.3 mm diameter) than the vas deferens (3 mm diameter, 10-fold larger), epididymal surgery is far more complicated and precise than the simple vas deferens-to-vas deferens connection.


Vasectomy is a common method of  contraception  worldwide, with an estimated 40-60 million individuals having the procedure and 5-10% of couples choosing it as a  birth control  method. [ 18 ]  In the USA, about 2% of men later go on to have a vasectomy reversal afterwards. [ 19 ]  However the number of men inquiring about vasectomy reversals is significantly higher - from 3% to 8% [ 16 ]  - with many "put off" by the high costs of the procedure and pregnancy success rates (as opposed to "patency rates") only being around 55%. [ 20 ]  90% of men are satisfied with having had the procedure. [ 21 ]


While there are a number of reasons that men seek a vasectomy reversal, some of these include wanting a family with a new partner following a relationship breakdown / divorce, their original wife/partner dying and subsequently going on re-partner and to want children, the unexpected death of a child (or children - such as by car accident), or a long-standing couple changing their mind some time later often by situations such as improved finances or existing children approaching the age of school or leaving home. [ 22 ]  Patients often comment that they never anticipated such situations as a relationship breakdown or death (of their partner or child) may affect their situation. A small number of vasectomy reversals are also performed in attempts to relieve  post-vasectomy pain syndrome .


In the UK, 16% of all men under 70 have had a vasectomy, and with remarriages accounting for 40% of all marriages, there are a significant proportion of men finding themselves in a new relationship and regretting their decision to have a vasectomy. [ 22 ]  Combined with longer life histories, the rate of divorce and remarriage is thought to be driving the increase in vasectomy reversals and inquiries for vasectomy reversals in recent times. [ 22 ]


Technical advances in vasectomy reversal mirror those in  microsurgery  over the past 100 years.  As a discipline, microsurgery was first performed by Carl Nylen in Sweden for middle ear surgery in 1910, [ 23 ]  but grew most rapidly as a discipline in the 20th century stimulated by its success in microvascular reconstruction of war-injured soldiers. The first microsurgical vasectomy reversal was performed by  Earl Owen  in 1971. [ 24 ]


Vasectomy: A Delicate Matter  is a 1986 film directed by Robert Burge and starring  Paul Sorvino , Cassandra Edwards,  Abe Vigoda ,  Ina Balin , and  Lorne Greene . [ 1 ]


After his wife gives birth to their eighth child, a bank executive reluctantly consents to undergo vasectomy.


This film article about a 1980s comedy film is a  stub . You can help Wikipedia by  expanding it .


This article related to an American film of the 1980s is a  stub . You can help Wikipedia by  expanding it .


Vasoepididymostomy  or  epididymovasostomy  is a surgery by which  vasectomies  are reversed. It involves connection of the severed  vas deferens  to the  epididymis  and is more technically demanding than the  vasovasostomy . [ citation needed ]


For a vasectomy reversal that involves a vasoepididymostomy, there are two microsurgical approaches. The procedure involves a similar surgical incision as  vasovasostomy ; however, unlike with a vasovasostomy, the testis is usually delivered into the field for this more complex microsurgery. After the findings from the vasal fluid are reviewed showing epididymal obstruction, the epididymis is exposed by opening the outer testis covering ( tunica vaginalis ). The epididymis is inspected and an individual tubule is selected to enter and connect to the vas deferens. From this point on, one of two epididymovasostomy techniques is taken. In the  mucosa -to-mucosa, end to side method, [ 1 ]  an opened epididymal tubule is connected to the cut end of the vas deferens with 4 to 6 small (10-0) simple sutures placed around the circumference of each. This "inner" layer is supported with an "outer" layer of radially placed 9-0 sutures to strengthen the connection. Recently, an " invagination " vasoepididymostomy was described as an alternative to the mucosa-to-mucosa method. [ 2 ]  With this technique, one, two or three "vest" sutures of 10-0 suture should be placed near the opening of the epididymal tubule to allow the epididymal tubule to "invaginate" into the vas deferens, theoretically creating a connection, that, based on studies in animal models, has an improved watertight seal and possibly a higher chance for success. Once the vas-deferens-epididymis connection is completed, the covering around the testis is replaced.


Vasoepididymostomy  is often considered one of the most technically challenging operations in the field of urology. The procedure requires anastomosis of a single epididymal tubule (luminal diameter 0.15–0.25 mm) to the lumen of the vas deferens (diameter 0.3–0.4 mm), and is reserved for patients with congenital or acquired epididymal obstruction, or patients who have failed previous attempts at surgical reconstruction of the vas deferens. This surgery attaches the vas deferens directly to the epididymis, the coiled tube on the back of each testicle where sperm matures. A vasectomy can cause blockages or a break in the vas deferens or the epididymis. This surgery is used when a vasovasostomy won't work because sperm flow is blocked. The vas deferens is connected to the epididymis above the point of blockage.


Vasovasostomy  (literally connection of the  vas  to the vas) is a surgery by which  vasectomies  are partially reversed. Another surgery for  vasectomy reversal  is  vasoepididymostomy . [ citation needed ]


Vasovasostomy is a form of microsurgery first performed by Australian surgeon Dr. Earl Owen (1934–2014) in 1971. [ 1 ]


In most cases the  vas deferens  can be reattached but, in many cases, fertility is not achieved. There are several reasons for this, including blockages in the vas deferens, and the presence of  autoantibodies  which disrupt normal  sperm  activity. If blockage at the level of the  epididymis  is suspected, a  vasoepididymostomy  can be performed.


Return of sperm to the ejaculate depends greatly on the length of time from the vasectomy and the skill of the surgeon. Generally, the shorter the interval, the higher the chance of success. The likelihood of pregnancy can depend on female partner factors.


Over half of men who have undergone a vasectomy develop anti-sperm antibodies. The effects of anti-sperm antibodies continue to be debated in the medical literature, but there is agreement that antibodies may reduce sperm  motility .


Only two conditions must be satisfied for sperm to be returned to a patient's  semen  with vasectomy reversal by vasovasostomy. First, the patient must have sperm available to pass through at least one reconnection. The second condition is that each reconnection must be as watertight as possible. The surgeon's goal is to achieve a very precise circumferential reconnection of the sperm canal edges by using meticulously placed microsurgical sutures. [ citation needed ]


Vasovasostomy can be performed in the convoluted or straight portion of the vas deferens. [ 2 ]


Vasovasostomy is typically an out-patient procedure (patient goes home the same day).


The procedure is typically performed by  urologists . Most urologists specializing in the field of male infertility perform vasovasostomies using an operative microscope for magnification, under general or regional  anesthesia .


If sperm were seen in one or both vas contents at the time of surgery, or sperm reached the patient's semen only transiently after the reversal, microsurgical vasovasostomy may be successful. Unfortunately, surgeons performing only an occasional vasectomy reversal often neglect examining the vas contents for presence or absence of sperm. A surgeon cannot determine sperm presence or absence by the naked eye. The most common cause for failed vasectomy reversals is the inappropriate non-microsurgical technique using sutures that are too large to achieve watertight reconnections. The failure of a competently performed microsurgical vasovasostomy following the absence of any sperm in the contents of each vas usually is due to “blowouts” in the epididymides. Under these circumstances an operation should be performed only by a micro-surgeon with proven  vasoepididymostomy  expertise, bypassing the blowouts.


The prognosis for each patient should be determined by a  pre-operative examination of the vasectomy sites and consideration of the time interval since vasectomy.


The rate of pregnancy depends on such factors as the method used for the vasectomy and the length of time that has passed since the vasectomy was performed. The reversal procedures are frequently impermanent, with occlusion of the vas recurring two or more years after the operation.


The presence of  sperm granulomas  improves the likelihood of restoring sperm to the semen with a vasovasotomy. A local urologist can easily determine whether a patient has 0, 1, or 2  sperm granuloma  by a painless examination of each vasectomy site. If the interval since the vasectomy is less than fifteen years, the prognosis will be 70% or better and this local examination is probably not needed. [ citation needed ]
A sperm granuloma develops from post-vasectomy sperm leakage and somehow it behaves like a safety valve preventing internal pressure build up and ruptures of the delicate epididymis tubules with subsequent obstructive scarring.


Vasovasostomy can be effective regardless of how long it's been since the original vasectomy. However, if more than 15 years have passed since the original vasectomy, one may have a lower chance of having enough healthy sperm in one's own semen to father a child. Also, the longer the obstructive interval, the more likely it is that a  vasoepididymostomy  will be required.


Typical cost of one vasovasostomy is US$5,000–15,000 (one side).


World Vasectomy Day  (WVD) is an annual event to raise global awareness of  vasectomy  as a male-oriented solution to prevent unintended pregnancies. The goal is for doctors all over the world to perform vasectomies, connected to the event via  Skype  and  social media  platforms.


WVD was founded in 2012 by the American film-maker  Jonathan Stack  while he was working on a documentary about the decision of having a vasectomy. [ 1 ]  The underlying goal was to involve men in family planning decisions and educate them about vasectomies as a simple way of taking responsibility for birth control.


In 2013, prolific vasectomist Dr  Douglas Stein  was scheduled to perform vasectomies in front of an audience at the  Royal Institution of Australia (RiAus)  to launch the inaugural World Vasectomy Day with the world’s first  live-streamed  vasectomy. Stein answered questions from a live audience in  Australia  and an international online audience. [ 2 ]


The event's third edition was hosted by Indonesia in 2015; [ 3 ]  the fourth edition was centered in Kenya and featured a vasectomy broadcast live on Facebook. [ 4 ]


On 17 November 2017, at its fifth anniversary, more than 1,200 vasectomists in more than 50 countries joined the event, making it the largest male-focused family planning event in history. [ 5 ]  The 2017 event's headquarter was located in Mexico. [ 6 ]


Ocular surgery may be performed under  topical ,  local  or  general anesthesia . Local anaesthesia is more preferred because it is economical, easy to perform and the risk involved is less. Local anaesthesia has a rapid onset of action and provides a dilated  pupil  with low  intraocular pressure .


Susruta Samhita  has evidences of use of anaesthesia for ocular surgeries. Inhalational anaesthesia was used for this purpose. [ citation needed ]  Egyptian surgeons used carotid compression to produce transient  ischemia  during eye surgery to reduce the perception of pain. [ citation needed ]  In 1884,  Karl Koller  used  cocaine  for ocular surgery. [ citation needed ]  The same year,  Herman Knapp  used cocaine for retrobulbar block. [ citation needed ]  In 1914, van Lint achieved  orbicularis  akinesia by local injection. [ citation needed ]


Surface anaesthesia is given by instillation of 2.5 ml  xylocaine . One drop of xylocaine instilled four times after every 4 minutes will produce conjunctival and corneal anaesthesia.  Paracaine ,  tetracaine ,  bupivacaine ,  lidocaine  etc. may also be used in place of xylocaine. [ 1 ]  Cataract surgery by  phacoemulsification  is frequently performed under surface anaesthesia.  Facial nerve , which supplies the orbicularis oculi muscle, is blocked in addition for intraocular surgeries. Topical anaesthesia is known to cause endothelial and epithelial toxicity, allergy and surface keratopathy. [ citation needed ]


There are four types of facial block : van Lint's block, Atkinson block, O' Brien block and Nadbath block.


This technique was first practiced by  Herman Knapp  in 1884. Here, 2% xylocaine is introduced into the muscle cone behind the eyeball. The injection is usually given through the inferior fornix of the skin of the outer part of the lower lid when the eye is in primary gaze. The  ciliary nerves ,  ciliary ganglion ,  oculomotor nerve  and  abducens nerve  are anesthetized in retrobulbar block. [ 2 ]  As a result, global akinesia, anaesthesia and analgesia are produced. The  superior oblique muscle , which is outside the muscle cone, is not usually paralyzed. The complications of retrobulbar block are globe perforation,  optic nerve  injury, retrobulbar  haemorrhage  and extraocular muscle palsy. Retrobulbar anaesthesia is contraindicated in posterior  staphyloma , high axial  myopia  and  enophthalmos . [ 4 ]


This technique was first applied by Davis. In peribulbar block, local anaesthetic is injected to the peripheral spaces of the orbit. The anaesthetic diffuses into the muscle cone and  eyelids , causing global and orbicularis akinesia and anaesthesia. After injection, orbital compression is applied for around 15 minutes. [ clarification needed ] [ 4 ]


Nearly all ocular surgeries  viz   keratoplasty ,  cataract extraction ,  glaucoma surgery ,   iridectomy ,  strabismus , [ 5 ]  retinal detachment surgery etc. can be done under regional anaesthesia.  Conjunctiva ,  globe  and orbicularis can be paralysed using a combination of surface anaesthesia, facial anaesthesia and retrobulbar block. [ 1 ]  The advantage is that it produces less post-operative restlessness. It has less post-operative lung complications and less bleeding. [ 2 ]


General anaesthesia is preferred for ocular surgeries in anxious adults, psychiatric patients, infants and children. [ 5 ]  It is also indicated in perforating ocular injuries and major surgeries like exenteration. During the surgery, it has to be ensured that no carbon dioxide retention occurs. If this occurs, the  choroid  swells up and ocular contents may prolapse as soon as the eye is opened. The advantages of general anaesthesia is that it produces complete akinesia, controlled  intraocular pressure  and safe operating environment. It is the safest option for bilateral surgery. The complications of general anaesthesia are  laryngospasm ,  hypotension ,  hypercarbia , respiratory depression and  cardiac arrhythmia .


Anterior chamber paracentesis  ( ACP ) is a surgical procedure done to reduce  intraocular pressure  (IOP) of the eye. The procedure is used in management of  glaucoma  and  uveitis . It is also used for clinical diagnosis of infectious uveitis.


Anterior chamber paracentesis is used in the management of  acute angle closure glaucoma , and uveitis. [ 1 ] [ 2 ]  It can also prevent a raise in IOP after  intravitreal injections . [ 3 ]  Aqueous humor collected using anterior chamber paracentesis may be used for clinical diagnosis of infectious uveitis. [ 4 ]


In this procedure  aqueous humor  from the  anterior chamber of eyeball  is drained out by using a tuberculin syringe, with or without a plunger attached to a hypodermic needle or a paracentesis incision. [ 1 ]  Eye is anesthetized using  proparacaine  or  tetracaine   eye drops  prior to ACP. [ 5 ]   Paracentesis  is performed through the clear cornea adjacent to the  limbus . [ 5 ]


Pain, traumatic injuries of the  iris ,  corneal  abscess, inadvertent  lens  touch, occurrence of Anterior chamber  fibrin ,  Intraocular hemorrhage , decompression  retinopathy ,  hyphaema , ocular hypotension due to leakage and exogenous  endophthalmitis  are complication of ACP. [ 1 ] [ 3 ] [ 6 ]   Traumatic cataract  may occur secondary to lens trauma. [ 5 ]


This  ophthalmology  article is a  stub . You can help Wikipedia by  expanding it .


Hermenegildo Arruga Liró, 1st Count of Arruga  (March 15, 1886 – May 17, 1972) was a Spanish ophthalmologist known for refining several eye surgeries. He devised one of the early procedures to address  retinal detachment , and he received the  Gonin Medal  from the  International Council of Ophthalmology  in 1950.


Arruga was the second of three generations of eye surgeons. He and his father, ophthalmologist Eduardo Arruga, were both born in Barcelona. He entered medical studies at 16 and graduated in 1908, leaving Spain for a while for further study in France and Germany. His mentors included  Edmund Landolt ,  Julius Hirschberg  and  Félix de Lapersonne . He returned to Barcelona, spending the rest of his life seeing patients there, with the exception of a move to South America during the  Spanish Civil War . Arruga lived above his clinic in Barcelona, where patients and physicians from all over the world came to see him. [ 1 ]


One of the first surgeons to promote  intracapsular cataract extraction , Arruga also suggested technical improvements to several other eye surgeries. [ 2 ]  Arruga introduced a procedure for treating  retinal detachment  that became known as Arruga's  suture . In this surgery, a band was made around the  sclera  using Supramid, a synthetic suture material, but the technique caused some problems with  scleral  erosion. Even after the procedure could be performed with  silicone  bands, there were still problems with  ischemia  of the  anterior segment  of the eye, and the procedure was ultimately replaced by newer techniques. [ 3 ]


Arruga was close friends with  Jules Gonin , the Swiss ophthalmologist who devised the first retinal detachment repair surgery. Arruga wrote two influential books:  Retinal Detachment  (1936) and  Ocular Surgery  (1946); for the latter, his son, ophthalmologist Alfredo Arruga-Forgas, wrote a chapter of the third English edition (1962). [ 1 ]


In 1950, Arruga won the  Gonin Medal . [ 4 ]  He was recognized with the  Order of Isabella the Catholic  in 1956. [ 5 ]  He received honorary doctorates from the  University of Barcelona  and  Heidelberg University . [ 6 ] [ 7 ]  Arruga was named an honorary fellow of the  Royal College of Surgeons of Edinburgh . He was created  Count of Arruga  (Spanish:  Conde de Arruga ), in 18 July 1950. [ 8 ]


Arruga enjoyed chess and was a skilled artist. He engaged in mountain climbing, reaching the summit of the  Jungfrau  in the  Bernese Alps  when he was 70 years old. [ 1 ]


He died of  heart disease  in 1972. [ 9 ]  He was preceded in death by his wife, Teresa Forgas, the mother of his four children; she died following an automobile accident. [ 1 ]


Blepharoplasty  ( Greek :  blepharon , "eyelid" +  plassein  "to form") is the  plastic surgery  operation for correcting defects, deformities, and disfigurations of the  eyelids ; and for aesthetically modifying the eye region of the face. With the excision and the removal, or the repositioning (or both) of excess tissues, such as  skin  and  adipocyte fat , and the reinforcement of the corresponding  muscle  and  tendon  tissues, the blepharoplasty procedure resolves functional and cosmetic problems of the  periorbita , which is the area from the eyebrow to the upper portion of the cheek. The procedure is more common among women, who accounted for approximately 85% of blepharoplasty procedures in 2014 in the US and 88% of such procedures in the UK. [ 1 ] [ 2 ]


The operative goals of a blepharoplastic procedure are the restoration of the correct functioning to the affected eyelid(s) and the restoration of the aesthetics of the eye-region of the face, which are achieved by eliminating excess skin from the eyelid(s), smoothing the underlying eye muscles, tightening the supporting structures, and resecting and re-draping the excess fat of the retroseptal area of the eye, in order to produce a smooth anatomic transition from the lower eyelid to the cheek.


In an eye surgery procedure, the usual correction or modification (or both) is of the upper and the lower eyelids, and of the surrounding tissues of the eyebrows, the upper nasal-bridge area, and the upper portions of the cheeks, which are achieved by modifying the  periosteal coverings  of the facial bones that form the  orbit  (eye socket). The periosteum comprises two-layer connective tissues that cover the bones of the human body:


The  East Asian blepharoplasty  procedure differs from the classic blepharoplasty. In younger patients, the goal of the surgery is to create a supratarsal fold ("double eyelid surgery") whereas in older patients the goals are to create or elevate the supratarsal fold and to resect surplus eyelid skin ("Asian blepharoplasty"). [ 3 ] [ 4 ]


The thorough pre-operative  medical  and surgical histories, and the physical examination of the patient's  periorbital area  (eyebrow-to-cheek-to-nose), determine if the patient can safely undergo a blepharoplasty procedure to feasibly resolve (correct or modify, or both) the functional and aesthetic indications presented by the patient. Sequentially, lower eyelid blepharoplasty can successfully address the anatomic matters of excess eyelid skin, slackness of the eye-muscles and of the  orbital septum  (palpebral ligament), excess orbital fat, malposition of the lower eyelid, and prominence of the nasojugal groove, where the orbit (eye socket) meets the slope of the nose. [ 5 ]


Concerning the upper eyelid, a blepharoplasty procedure can resolve the loss of  peripheral vision , caused by the slackness of the upper-eyelid skin draping over the eyelashes; the outer and the upper portions of the field of vision of the patient are affected and cause him or her difficulty in performing mundane activities such as driving an automobile and reading a book. [ 6 ]


In many East Asian countries, double eyelid surgery is the most popular surgery, especially in South Korea. Depending on the methods, directing doctors' experience, and the difficulty of the individual case, this surgery can cost between about  US$ 2,000 to $4,000. The procedure is famous for producing double-eyelid for patients for the long-term. [ citation needed ]  This kind of operation normally takes about 30 minutes to an hour, and patients are not required to stay hospitalized afterward. Stitches are removed 5 to 7 days after surgery. Many foreigners go to South Korea each year for blepharoplasty. [ 7 ]


A blepharoplasty procedure usually is performed through external surgical incisions made along the natural skin lines (creases) of the upper and the lower eyelids, which then hide the surgical  scars  from view, especially when affected by the skin creases below the  eyelashes  of the lower eyelid. The incisions can also be made from the  conjunctiva , the interior surface of the lower eyelid, as in the case of a transconjunctival blepharoplasty. [ 9 ]


Transconjunctival lower blepharoplasty technique was pioneered by Clinical Professor of Surgery at the University of Chicago Medicine, [ 10 ]  Dr. Anthony J. Geroulis [ 11 ]  and introduced to medical trial in 1998. Transconjunctival Technique has become the norm in the plastic surgery field with most surgeons preferring it over the external surgical incisions. This technique is particularly useful for patients with darker skin tones where standard external incision often leaves a visible white scar.


Transconjunctival blepharoplasty technique permits the excision (cutting and removal) of the lower-eyelid  adipose tissue  without leaving a visible scar, but the technique does not allow the removal of excess eyelid-skin. [ 6 ]


A blepharoplasty operation usually requires 1–3 hours to complete. Post-operatively, swelling and bruising is expected and will usually resolve without further intervention; application of cold compresses can help to reduce the duration and discomfort. [ 12 ]  There are no standardized outcome measures for upper or lower blepharoplasty. [ 12 ]  Blepharoplasty is generally a relatively safe surgery, but possible complications include hematoma/ecchymosis, lagophthalmos (incomplete or abnormal closure of the eyelids), ptosis (drooping of the upper eyelid), scarring, dry eyes, orbital hematoma/compartment syndrome, lymphedema, and ocular motility disorders. [ 13 ]


After the procedure, a type of stitch known as a canthopexy is placed near the outer corner of the lower eyelid, which is inside the tissue. This allows the eyelid's position to remain fixed during the healing process. The canthopexy is dissolved after four to six weeks of use. For particular patients, a mid-face elevation may be required to rejuvenate the lower eyelid-cheek complex. [ 14 ] [ unreliable source? ]


The anatomic condition of the eyelids, the "wear-and-tear" quality of the patient's skin, age, and the general condition of the adjacent tissues affect the functional and aesthetic results achieved. Additional to the anatomic conditions of the eye region of the patient, the possible occurrence of  medical complications  is determined by factors including: [ medical citation needed ]


As techniques began developing the ancient Greeks and Romans began writing down and collecting everything they knew involving these procedures.  Aulus Cornelius Celsus , a first-century Roman, described making an excision in the skin to relax the eyelids in his book  De Medicina . [ 15 ]


Karl Ferdinand von Gräfe  coined the phrase blepharoplasty in 1818 when the technique was used for repairing deformities caused by cancer in the eyelids. [ 16 ] [ 17 ]


Laser blepharoplasty is the performance of eyelid  surgery using a laser  instead of a scalpel. Laser blepharoplasty is often combined with laser eyelid rejuvenation, as the two procedures can be performed in conjunction.


A  CO 2  laser  blepharoplasty offers many benefits over a blepharoplasty performed using a scalpel. Some of these benefits include less bleeding, shortened surgical time, better intraoperative visibility, less bruising and swelling, less pain or discomfort, and smoother healing. [ 18 ]


Historically there has been some contention as to the categorization of laser treatment on upper or lower eyelids as blepharoplasty, which is itself by definition surgical. The statutory definition of surgery and that supported by the American College of Surgeons states that surgery is the "treatment ... by any instrument causing localized alteration or transportation of live human tissue, which include lasers...". [ 19 ]


Boston keratoprosthesis  ( Boston KPro ) is a collar button design  keratoprosthesis  or  artificial cornea . [ 1 ]  It is composed of a front plate with a stem, which houses the optical portion of the device, a back plate and a titanium locking c-ring. [ 2 ]  It is available in type I and type II formats. The type I design is used much more frequently than the type II which is reserved for severe end stage dry eye conditions and is similar to the type I except it has a 2 mm anterior nub designed to penetrate through a tarsorrhaphy. The type I format will be discussed here as it is more commonly used.


The type I Kpro is available in single standard pseudophakic power or customized  aphakic  optic with an 8.5 mm diameter adult size or 7.0 mm diameter pediatric size back plate. The device is currently machined from medical grade  polymethylmethacrylate (PMMA)  in  Wilmington, Massachusetts  in the  United States . [ 3 ]  During implantation of the device, the device is assembled with a donor corneal graft positioned between the front and back plate which is then sutured into place in a similar fashion to  penetrating keratoplasty (corneal transplantation) . [ 4 ]


The Boston KPro is a treatment option for corneal disorders not amenable to standard  penetrating keratoplasty (corneal transplantation)  or corneal transplant. The Boston KPro is a proven primary treatment option for repeat graft failure, [ 5 ]  herpetic keratitis, [ 6 ]   aniridia [ 7 ]  and many pediatric congenital corneal opacities including Peter's anomaly. [ 8 ]  The device is also used to treat  cicatrizing  conditions including  Stevens–Johnson syndrome [ 9 ]  and  ocular cicatricial pemphigoid , and also  ocular burns . [ 10 ] [ 11 ]


Most common postoperative complications in order of decreasing prevalence include retroprosthetic membrane (RPM), elevated intraocular pressure/glaucoma, infectious endophthalmitis, sterile vitritis, retina detachment (rare) and vitreous hemorrhage (rare). [ 12 ] [ 13 ] [ 14 ] [ 15 ]


Four major studies have been completed to date showing outcomes with the type I Boston KPro:


Boston ophthalmologist Swedish origins  Claes Henrik Dohlman  began developing the Boston keratoprosthesis in 1965, [ 19 ]  and refined it over the next decades. [ 20 ]  It was approved by the U.S.  Food and Drug Administration  in 1992. [ 20 ]  Fewer than 50 of the devices had been implanted before 2002, when popularity began increasing. [ 21 ]  1,161 had been placed by 2009, [ 21 ]  8,000 by 2012, [ 22 ]  9,000 by 2014. [ 21 ]  and 16,000 by 2020. [ 23 ]


The design of the device has evolved over its history. In 1996, eight holes were added in the back plate. [ 21 ]  The holes allow the  aqueous humour  fluids of the eye to provide nutrients to  the donor graft  stroma  and  keratocytes . [ 24 ]  The device is now available with either eight or 16 holes. [ 21 ]  In 2004, a  titanium  locking c-ring was added to prevent intraocular unscrewing of the device. [ 2 ]  In 2007, a threadless design replaced the previous screw-type one, simplifying assembly and reducing damage to the donor graft when the device is assembled during the surgical procedure. [ 24 ]  The back plate was changed to titanium in 2012, due to  titanium's biocompatibility . [ 21 ]


Canthotomy  (also called  lateral canthotomy  and  canthotomy with cantholysis ) is a surgical procedure where the lateral  canthus , or corner, of the  eye  is cut to relieve the  fluid pressure  inside or behind the eye, known as  intraocular pressure  (IOC). [ 1 ]  The procedure is typically done in emergency situations when the intraocular pressure becomes too high, which can damage the  optic nerve  and lead to blindness if left untreated. [ 2 ]


The most common cause of elevated intraocular pressure is orbital  compartment syndrome  (OCS) caused by trauma,  retrobulbar hemorrhage , infections, tumors, or prolonged  hypoxemia . [ 3 ]   Absolute contraindications  to canthotomy include  globe rupture . Complications include bleeding, infections, cosmetic deformities, and functional impairment of eyelids. [ 3 ]  Lateral canthotomy further specifies that the lateral canthus is being cut. Canthotomy with cantholysis includes cutting the  lateral palpebral ligament , also known as the canthal tendon.


The first case of orbital compartment syndrome causing monocular blindness was published in 1950 due to a complication of a  zygomatic fracture  repair. [ 4 ]  In 1953, the first surgical orbital decompression was performed. Two incisions below and above the external canthus were made and  surgical drains  were put in place. [ 5 ]  In 1990, the first lateral canthotomy procedure as presently performed was completed. [ 6 ]  In 1994, lateral canthotomy was first published in a review of procedures that emergency physicians can perform.  [ 7 ]  Today, a canthotomy is almost always performed with cantholysis of the inferior canthal tendon as this provides the best decompression of intraocular pressure. [ 8 ]


A canthotomy is often used as a last resort to decompress orbital compartment syndrome. Orbital compartment syndrome can be caused by trauma, infections, tumors, retrobulbar hemorrhage, or prolonged hypoxemia. [ 9 ]  Orbital compartment syndrome can be recognized by elevated intraocular pressure, globe compressibility,  afferent pupillary defect ,  proptosis , decreased visual acuity, and decreased  extraocular muscle  movements.


Studies in animals have demonstrated irreversible vision loss within 90 to 120 minutes, further indicating the emergent nature of this procedure.  [ 8 ]


In an unconscious patient who is unable to comply with a physical exam, an intraocular pressure greater than 40 indicates emergent canthotomy. [ 2 ]


The foremost absolute contraindication to canthotomy is  globe rupture , sometimes referred to as an open globe injury. [ 9 ]  Globe rupture can be recognized by these symptoms or physical exam features:


Due to the emergent nature of this procedure and the possibility of restoring or preventing vision loss, globe rupture is the only absolute contraindication.


Due to portions of the procedure having poor visualization of anatomical structures, and the overall rarity and difficulty of the procedure,  iatrogenic  globe injury is an immediate complication that can occur. Other complications include infections, bleeding, cosmetic deformities, and functional impairment of eyelids. [ 3 ]


Due to the infrequency and difficulty of canthotomy,  emergency medicine physicians  defer more than 50 percent of canthotomies to a consulting physician, [ 10 ]  which in turn can increase time to treatment. In an effort to decrease difficulty and improve patient outcomes, vertical lid split or paracanthal "one-snip" procedures have been studied. This is performed by making a full-thickness vertical incision a few millimeters medial from the lateral canthus in both the upper and lower eyelids. [ 11 ]


Capsulotomy  (BrE /kæpsjuː'lɒtəmi/, AmE /kæpsuː'lɑːtəmi/) [ 1 ]  is a type of eye surgery in which an incision is made into the  capsule  of the  crystalline lens  of the eye. In modern  cataract  operations, the lens capsule is usually not removed. The most common forms of  cataract surgery  remove nearly all of the crystalline lens but do not remove the crystalline lens capsule (the outer "bag" layer of the crystalline lens). The crystalline lens capsule is retained and used to contain and position the  intraocular lens implant  (IOL).


The removal of the central part of the anterior lens capsule during cataract surgery is known as anterior capsulotomy. It gives the surgeon access to the lens inside so that it can be removed. The remaining part of the capsule is left in place and provides a barrier between the anterior and posterior chambers that prevents leakage of the vitreous into the anterior chamber, and provides a natural support for an implanted intraocular lens in the optimum position. [ 2 ]


Can opener capsulotomy is done by making a circular opening of 5–6 mm diameter in the anterior capsule, by series of small cuts or tears made with a  cystitome . [ 2 ]   Jacques Daviel  invented this technique in 1752. [ 2 ]  This technique was commonly done during extracapsular cataract extraction (ECCE). It often leaves stress raisers at the junction between cuts, which predisposes the edge to further tearing under stress.


Manual capsulorhexis and particularly the commonly used technique known as  continuous curvilinear capsulorhexis  (CCC), is used to remove the anterior part of the capsule of the lens by  shear  and tensile forces. In effect, by controlled tearing, as opposed to cutting. A well constructed capsulorhexis using the method has good circularity and no stress raisers along the edge of the tear The method can efficiently create different sizes of smooth and circular capsulotomy with a smooth, strong edge that resists tearing during cortical removal and lens implantation. [ 3 ]


Envelope capsulotomy is done by making a linear incision in upper one-third of anterior capsule, after which the nucleus is extracted and cortical matter arpirated. After cataract removal cuts are started at the ends of the incision and the opening for implantation is formed by tearing as in CCC. There is a lower risk of radial tearing than with the can-opener method. [ 2 ]
Sourdilla and Baikuff suggested this technique in 1979. [ 2 ]


This technique uses a  femtosecond laser  to do capsulotomy. The laser produces a precisely spaced row of adjacent perforations through the capsule, and can produce uniformly circular, accurately centred cuts compared with manual CCC, but the edges are relatively rough and this can reduce tear strength due to stress concentrations, though statistically the incidence of tears is low. The equipment is also expensive, and the method is associated with higher incidence of  capsular block syndrome . [ 2 ]


Plasma blade capsulotomy uses plasma technology to make a circular incision through the anterior capsule. The energy destroys the molecular structure, and caused transient microscopic plasma and cavitation bubbles in the tissue. The power output and heating effects are small, it does not cause bleeding, and when used correctly there is no collateral tissue damage. There is no tearing stress applied to the capsule during the cut, and the tip cuts along the line of contact with the capsule, as guided by the surgeon. The cut edge may not be as strong as the edge produced by manual CCC. [ 2 ]


Precision Pulse Capsulotomy is a non laser capsulotomy procedure performed using a device with a soft collapsible tip and circular  Nitinol  cutting element that is connected to a control console. The Nitinol tip can be collapsed sufficiently to pass through an incision of about 2.2 mm, after which it springs back into circular shape inside the anterior chamber. The device is moved into contact with the anterior capsule, held in position by suction, and uses 4 millisecond electrical pulses to make a circular incision of exact size and shape, without overheating the chamber. The edge of the incision is smooth, but care must be taken to ensure a complete cut. [ 2 ]


Months or years after the  cataract operation , the remaining posterior lens capsule can become opaque and vision will be reduced in about 20–25% of eyes. [ 4 ]  This is known as posterior capsule opacification (PCO). PCO is best treated by posterior capsulotomy using  YAG laser . [ 4 ]


Retinal detachment ,  ocular hypertension  and  IOL  dislocation are the major complications of posterior capsulotomy. [ clarification needed ] [ 5 ]


Clear lens extraction , also known as  refractive lensectomy ,  custom lens replacement  or  refractive lens exchange  is a surgical procedure in which clear  lens  of the human eye is removed. Unlike  cataract surgery , where the cloudy lens is removed to treat a  cataract , clear lens extraction is done to surgically correct  refractive errors  such as high  myopia . It can also be done in  hyperopic  or  presbyopic  patients who wish to have a  multifocal IOL  implanted to avoid wearing glasses. It is also used as a treatment for diseases such as  angle closure glaucoma .


As opposed to procedures that use lasers to make corrections to the corneal surface, such as  LASIK , the clear lens extraction procedure uses the same procedures as cataract surgery. [ 1 ]


Clear lens extraction can be done in patients with severe refractive error and/or presbyopia who wish to avoid spectacles. [ 2 ] [ 3 ]  It is often necessary in patients with severe refractive error who cannot undergo other  refractive procedures  such as LASIK or  photorefractive keratectomy . [ 2 ]


Clear lens extraction is also used as a treatment of choice in patients with diseases such as  angle closure glaucoma . [ 4 ]  A study also found that CLE is even more effective than laser peripheral  iridotomy  in patients with angle closure glaucoma. [ 5 ] [ 6 ]  A systematic review comparing lens extraction and laser peripheral  iridotomy  for treating acute primary angle closure found that lens extraction potentially provides better  intraocular pressure  control and reduces medication needs over time. However, it remains uncertain if it significantly lowers the risk of  recurrent episodes  or reduces the need for additional  surgeries . [ 7 ]


Procedure is similar to  cataract surgery , most commonly followed by an  intraocular lens  implantation. In patients requiring only distance vision correction, a conventional mono-focal intraocular lens is placed in both eyes after the clear lens is removed. [ 1 ]  While distance vision is fine in this,  reading glasses  are required for near vision. [ 1 ]  Another method is to correct one eye only for distance vision and the other eye for near vision only. [ 1 ]  The best way to achieve both distance vision and near vision is to place  multifocal IOLs  or  accommodating IOLs  in both eyes. [ 1 ] [ 8 ]


The intraocular lens power calculations for clear lens extraction is similar to calculations used for conventional cataract surgery. [ 8 ]


Under topical anesthesia, through a 2.2 mm  corneal  incision, the lens  nucleus  and cortex are removed by irrigation and aspiration technique using a  phaco  machine. [ 9 ]  After removal of lens material, the viscoelastic solution initially instilled is removed from the  anterior chamber , intraocular lens is inserted and the corneal wound is closed by  stromal  hydration method. [ 9 ]  In some people with very high myopia, the eye may be left  aphakic , without intraocular lens implantation. [ 10 ]


In addition to the common complications of cataract surgery, clear lens extraction may also cause premature posterior  vitreous detachment  and  retinal detachment , [ 2 ]  particularly in patients with high Myopia. However, modern surgical techniques and advanced lens technology have significantly reduced the likelihood of this and other complications. The procedure is generally safe and effective when performed by experienced surgeons, with most patients experiencing improved vision post-surgery without major complications.  [ 11 ]


As opposed to the more commonly performed cataract treatment, the idea of removing the lens exclusively for refractive purposes first emerged in the 18th century. [ 12 ]  French ophthalmologist Abbé Desmonceaux may be the first to suggest such an operation in 1776 for a patient with high myopia. [ 12 ]  He recommended the operation to Baron Michael Johann de Wenzel, although it is not known whether he ever performed the operation. [ 13 ]


The first systematic work on clear lens extraction was carried out by Polish ophthalmologist  Vincenz Fukala  in Vienna. Fucala advised clear lens extraction in young high myopic (−13 diopters or more) patients with poor vision and inability to work. [ 12 ]


A  conformer  is a clear  acrylic  shell fitted after an  enucleation of the eye [ 1 ]  if the final artificial eye is not available at the time of surgery, to hold the shape of the  eye socket  and allow the eyelids to blink over the shell without rubbing the  suture  line.
The conformer shell holds the shape ready for the artificial eye, and is worn for six to eight weeks after surgery.
Some  ocularists  will make a temporary artificial eye which can be worn as the conformer shell. [ citation needed ]


A  corneal button  is a replacement  cornea  to be transplanted in the place of a damaged, diseased or  opacified  cornea, normally approximately 8.5–9.0mm in diameter. [ 1 ]  It is used in a  corneal transplantation  procedure (also corneal grafting) whereby the whole, or part, of a cornea is replaced. [ 2 ]  The donor tissue can now be held for days to even weeks of the donor's death and is normally a small, rounded shape. [ 3 ]  The main use of the corneal button is during procedures where the entirety of the cornea needs to be replaced, also known as penetrating keratoplasty. [ 2 ]


Greek physician  Galen  is said to have first consider the possibility of corneal transplantation [ 4 ]  however, there is no evidence that he actually attempted the procedure. [ 5 ]  It was only until the 18th century that early surgical proposals for keratoplasty would arise and the 19th century for experimentation in the field to begin. [ 6 ]


In 1813, Karl Himley suggested that opaque animal corneas can be replaced by transplanting corneas from other animals; with his student Franz Reisenger commencing experimentation in 1818. [ 5 ]


In 1844, Edward Kissam undertook the first ever recorded attempt of a xenograft on a human; the donor was a pig and was ultimately unsuccessful. [ 6 ]  Henry Power made a suggestion in 1867 that using human tissue rather than animal tissue for transplantation would be more effective however, it would not be until 1905 for the first successful human corneal transplant by MD,  Eduard Zirm . [ 6 ]


Since 1905, various techniques and procedures have been developed to increase the effect of the transplantation and success rate. Traditionally, the most common procedure for corneal transplantation was penetrating keratoplasty whereby an entire corneal button is replaced. [ 6 ]  Recently however, procedures such as anterior and posterior lamellar techniques where only diseased or damaged layers of the cornea are selectively replaced have become increasingly popular. [ 6 ]


After the death of the donor, the cornea must be retrieved within a few hours and will be screened for diseases and assessed for its viability to be used for a corneal transplantation by assessing its health. If passed, the cornea will be stored in a nutrient solution at an  eye bank  until needed for an operation. [ 1 ]  In most cases, the corneal button is removed from the donor cornea prior to storage as this extends its possible storage time. [ 3 ]


For the operation procedure, the patient is anaesthetised and the damaged or diseased corneal button will be removed using a bladed instrument called a  trephine  (approximately 8.0–8.5mm in diameter). [ 7 ]  A corneal button of matching size is then put in place of the removed tissue and stitched in place. Usually, twelve clock-hour nylon stitches are used with a continuous band nylon stitch. [ 1 ]


The procedure takes approximately 60–90 minutes however, a few months will be required for vision to return to what it was like preceding the operation; and continue to improve from then on.  Approximately 12–18 months after the operation, all stitches will be removed. During this time,  anti-rejection  drops will be needed to minimise inflammation; the dosage of which is carefully monitored by a corneal surgeon. [ 1 ]


Due to the swelling, it is impossible to predict the quality of vision without removing the stitches. A few months after the stitches are removed, measurements are made of the shape of the cornea and  refractive error . If the shape of the cornea is fairly regular and refractive error is similar to that of the other eye, it is usually possible to fix any error with  glasses ; if not, a hard lens may be necessary to correct vision. [ 1 ]


One of the largest causes for issue in penetrating keratoplasty is the natural  immune rejection  of a transplanted corneal button which can cause reversible or irreversible damage to the grafted cornea. The types corneal rejection include epithelial rejection, chronic rejection, hyperacute rejection and endothelial rejection and these can occur individually, or in some cases in conjunction. [ 8 ]


There are however, two main preventative methods to reduce the possibility of immune rejection; prevention and management. Prevention involves increasing compatibility of the donor tissue with that of the patient and suppressing host  immune response . These analyses of donor corneas are done during a screening phase soon after receiving the donation. The management aspect mainly involves early detection and therapy with  corticosteroids  along with  Immunosuppressive therapy . [ 8 ]


There are two main storage methods used in the storage of the corneal button. They are stored using a hypothermic storage method or an organ culture method in a  tissue culture  medium. Corneal buttons cannot be reliably frozen as a storage method. [ 3 ]


Usually, the corneal button is removed from the entire globe before storage as this extends the possible storage time. [ 3 ]


The hypothermic storage method was first introduced in 1974 [ 9 ]  and it requires no complex equipment. It is stored in a refrigerator, usually 2–6 °C, in commercially available storage solutions. Factors such as the temperature, maximal storage time, expiry date, etc. should be maintained according to the storage solution manufacturer's recommendations and can vary depending on the solution. Also, provided donor screening permits are available, the corneal tissue can be used immediately after leaving storage for surgery. Inspection of tissue can however be performed in a closed system under a  slit lamp  or specular microscope. [ 3 ]


The organ culture method, first introduced in 1976, [ 10 ]  is however quite complicated. The corneal button is stored in an incubator approximately 30–37 °C in a tissue culture medium into which either fetal or new-born calf serum,  antibiotics  and  antimycotics  are added. The corneal cells are also injected with dehydrating  macromolecules  to maintain hydration, this causes the corneal button to swell to approximately twice its original thickness during storage. During storage, the medium must be replaced within every 10–14 days. When it is required for surgery, the swollen tissue is placed in a  dextrin  containing storage medium which brings down the swelling and must also be inspected under strict aseptic conditions. [ 3 ]


There are rigorous criteria for donor selection as it is essential to minimise possibility of disease transmission. These criteria focuse on medial medical records and post-mortem  serological tests  which aim not to eliminate risk, but to limit risk to a reasonable level, a balance between safety and availability. [ 11 ]


A health history report is usually used, however, death certificate reports and data from family and acquaintances are also acceptable substitutions. The donation is rejected if no information can be found. [ 11 ]


Donations can be rejected or limited if some specific diseases are found in a donor's medical history. Diseases transmissible via corneal transplantation include  bacterial infection  and  fungal infection , [ 12 ]   rabies , [ 13 ]   Hepatitis B [ 14 ]  and  retinoblastoma . [ 15 ]  Diseases likely to be transmissible via corneal transplantations include  HIV ,  Herpes simplex virus  and  Prion disease . [ 16 ]  There are also many other diseases which may result in rejection of donations. [ 16 ]


Corneal cross-linking  ( CXL ) with  riboflavin  (vitamin B 2 ) and  UV-A  light is a surgical treatment for corneal ectasia such as  keratoconus ,  PMD , and  post-LASIK ectasia .


It is used in an attempt to make the cornea stronger. According to a 2015 Cochrane review, there is insufficient evidence to determine if it is useful in  keratoconus . [ 2 ]  In 2016, the  US Food and Drug Administration  approved riboflavin ophthalmic solution crosslinking based on three 12-month clinical trials. [ 3 ]


A 2015  Cochrane review  found that the evidence on corneal cross-linking was insufficient to determine if it is an effective procedure for the treatment of  keratoconus . [ 2 ]


Among those with keratoconus who worsen, CXL may be used. In this group, the most common side effects are haziness of the cornea, punctate keratitis, corneal striae, corneal epithelium defect, and eye pain. [ 4 ]  In those who use it after  post-LASIK ectasia , the most common side effects are haziness of the cornea, corneal epithelium defect, corneal striae, dry eye, eye pain, punctate keratitis, and sensitivity to bright lights. [ 5 ]


There are no long-term studies about crosslinking effect on pregnancy and lactation. According to a manufacturer crosslinking should not be performed on pregnant women. [ 5 ]


People undergoing crosslinking should not rub their eyes for the first five days after the procedure. [ 5 ]


Corneal cross-linking involves application of  riboflavin  solution to the eye that is activated by illumination with  UV-A  light for approximately 30 or fewer minutes. The riboflavin causes new bonds to form across adjacent collagen strands and proteoglycans in the stromal layer of the  cornea , which recovers and preserves some of the cornea's mechanical strength. The corneal epithelial layer is generally removed to increase penetration of the riboflavin into the  stroma , a procedure known as the Dresden protocol. [ 7 ]