Longitudinal rates of postoperative adverse outcomes after glaucoma surgery among medicare beneficiaries 1994 to 2005

Early Endophthalmitis Rates and Risk Factors After Corneal Transplant Surgeries in Medicare Beneficiaries From 2016 to 2019

PURPOSE

The aims of this study were to determine rates of early postkeratoplasty endophthalmitis and identify sociodemographic and medical risk factors in the Medicare population.

METHODS

Using a retrospective cohort design, patients aged 65 years and older undergoing penetrating keratoplasty (PK), endothelial keratoplasty (EK), and anterior lamellar keratoplasty (ALK) from 2016 to 2019 among 100% Medicare Fee-or-Service database were included. Rates of early endophthalmitis within 42 days of keratoplasty were determined using the International Classification of Diseases, 10th Revision-Clinical Modification diagnostic codes. Patient and physician characteristics were compared using x2 tests, and a multivariable logistic regression model was used to evaluate factors associated with endophthalmitis.

RESULTS

The overall early endophthalmitis rate after keratoplasty was 0.39% (n = 216/54,822) with a median time to diagnosis of 14 (interquartile range: 5-25) days. Rates by keratoplasty types were 1.31% for cataract surgery combined with PK, 1.13% for PK, and 0.22% for EK. On multivariable analysis, the odds of endophthalmitis were higher for PK [odds ratio (OR): 5.46, 95% confidence interval (CI), 3.98-7.49] and ALK (OR: 5.45, 95% CI, 2.59-11.49) relative to EK. Patients with a Charlson Comorbidity Index (CCI) ≥3 had higher odds of endophthalmitis (OR: 1.82; 95% CI, 1.28-2.58) relative to patients with a CCI of 0. Practices located in the Midwest (OR: 0.59, 95% CI, 0.36-0.96), West (OR 0.57; 95% CI, 0.35-0.93), and Northeast (OR: 0.59 95% CI, 0.35-0.99) had lower odds of reporting endophthalmitis when compared to the South.

CONCLUSIONS

Patients undergoing PK and ALK and those with a CCI ≥3 had higher odds of endophthalmitis relative to EK and patients without comorbidities, respectively. Practices in the West, Midwest, and Northeast had lower odds of endophthalmitis relative to the South.

Endophthalmitis rates and risk factors following intraocular surgeries in the medicare population from 2016 to 2019

AIMS

To determine endophthalmitis rates and risk factors following intraocular surgeries in the Medicare population.

METHODS

Retrospective, cross-sectional study from 2016 to 2019 in Medicare fee-for-service and Medicare Advantage beneficiaries. 100% Medicare claims were used to identify eyes that underwent intraocular surgery. Exclusion criteria included eyes that had intraocular surgery 42 days before or after and eyes in patients with a history of endophthalmitis within 12 months.

RESULTS

9 744 400 intraocular surgeries were performed among Medicare beneficiaries from 2016 to 2019. A 42-day postoperative endophthalmitis rate was 0.09%. Endophthalmitis rate by surgery type was 0.43% for corneal transplant, 0.36% for secondary intraocular lens (IOL), 0.24% for retina, 0.16% for glaucoma, 0.11% for cataract combined with other procedures and 0.08% for cataract surgeries alone. On multivariable analysis, the risk of endophthalmitis was increased for all intraocular surgery types when compared with cataract surgeries; adjusted OR (aOR) 5.30 (p<0.01) for corneal transplant, aOR 4.50 (p<0.01) for secondary IOL, aOR 3.00 (p<0.01) for retina, aOR 1.93 (p<0.01) for glaucoma, aOR 1.45 (p<0.01) for combined cataract surgeries. Increased risk of developing endophthalmitis was associated with older age (≥85 vs 65-75 years: aOR 1.36; p<0.01), male sex (aOR 1.20; p<0.001) and greater Charlson Comorbidity Index (≥7 vs 0: aOR 1.79; p<0.01).

CONCLUSIONS

Postoperative endophthalmitis rate after intraocular surgeries was 0.09% between 2016 and 2019 for Medicare beneficiaries. Endophthalmitis rates were highest for corneal transplant surgeries followed by secondary IOL surgeries and lowest for cataract surgeries. Older age, male gender and higher comorbidity index were associated with risk of endophthalmitis.

Postoperative Complications in the Primary Tube Versus Trabeculectomy Study During 5 Years of Follow-up

PURPOSE

To describe postoperative complications encountered in the Primary Tube Versus Trabeculectomy (PTVT) Study during 5 years of follow-up.

DESIGN

Multicenter randomized clinical trial.

PARTICIPANTS

A total of 242 eyes of 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery, including 125 patients in the tube group and 117 patients in the trabeculectomy group.

METHODS

Patients were enrolled at 16 clinical centers and randomly assigned to treatment with a tube shunt (350-mm2 Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC, 0.4 mg/ml for 2 minutes).

MAIN OUTCOME MEASURES

Surgical complications, reoperations for complications, visual acuity, and cataract progression.

RESULTS

Early postoperative complications occurred in 24 patients (19%) in the tube group and 40 patients (34%) in the trabeculectomy group (P = 0.013). Late postoperative complications developed in 27 patients (22%) in the tube group and 32 patients (27%) in the trabeculectomy group (P = 0.37). Serious complications producing vision loss and/or requiring a reoperation were observed in 3 patients (2%) in the tube group and 9 patients (8%) in the trabeculectomy group (P = 0.11). Cataract progression was seen in 65 patients (52%) in the tube group and 52 patients (44%) in the trabeculectomy group (P = 0.30). Surgical complications were not associated with a higher rate of treatment failure (P = 0.61), vision loss (P = 1.00), or cataract progression (P = 0.77) CONCLUSIONS: A large number of surgical complications were observed in the PTVT Study, but most were transient and self-limited. The incidence of early postoperative complications was higher following trabeculectomy with MMC than with tube shunt surgery. The rates of late postoperative complications, serious complications, and cataract progression were similar with both surgical procedures after 5 years of follow-up. Surgical complications did not increase the risk of treatment failure, vision loss, or cataract progression.

Adjunctive steroid therapy versus antibiotics alone for acute endophthalmitis after intraocular procedure

BACKGROUND

Endophthalmitis refers to severe infection within the eye that involves the aqueous humor or vitreous humor, or both, and that threatens vision. Most cases of endophthalmitis are exogenous (i.e. due to inoculation of organisms from an outside source), and most exogenous endophthalmitis is acute and occurs after an intraocular procedure. The mainstay of treatment is emergent administration of broad-spectrum intravitreous antibiotics. Due to their anti-inflammatory effects, steroids in conjunction with antibiotics have been proposed as being beneficial in endophthalmitis management.

OBJECTIVES

To assess the effects of antibiotics combined with steroids versus antibiotics alone for the treatment of acute endophthalmitis following intraocular surgery or intravitreous injection.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2021, Issue 8), MEDLINE Ovid (1946 to August 2021), Embase Ovid (1980 to August 2021), LILACS (Latin American and Caribbean Health Sciences Literature database) (1982 to August 2021), the ISRCTN registry; searched August 2021, ClinicalTrials.gov; searched August 2021, and the WHO International Clinical Trials Registry Platform; searched August 2021. We did not use any date or language restrictions in the electronic searches for trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing the effectiveness of adjunctive steroids with antibiotics alone in the management of acute, clinically diagnosed endophthalmitis following intraocular surgery or intravitreous injection. We excluded trials with participants with endogenous endophthalmitis unless outcomes were reported by source of infection. We imposed no restrictions on the method or order of administration, dose, frequency, or duration of antibiotics and steroids.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology, and graded the certainty of the body of evidence for six outcomes using the GRADE classification.

MAIN RESULTS

We included four RCTs with a total of 264 eyes of 264 participants in this review update. The studies were conducted in South Africa, India, and the Netherlands. All studies used intravitreous dexamethasone for adjunctive steroid therapy and a combination of two intravitreous antibiotics that provided gram-positive and gram-negative coverage for the antibiotic therapy. We judged two trials to be at overall low risk of bias, and the other two studies to be at overall unclear risk of bias due to lack of reporting of study methods. Only one study was registered in a clinical trial register.  While none of the included studies reported the primary outcome of complete resolution of endophthalmitis as defined in our protocol, one study reported combined anatomical and functional success (i.e. proportion of participants with intraocular pressure of at least 5 mmHg and visual acuity of at least 6/120). Very low certainty evidence suggested no difference in combined success when comparing adjunctive steroid to antibiotics alone (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.80 to 1.45; 32 participants). Low certainty evidence from two studies suggested that adjunctive dexamethasone may result in having a good visual outcome (Snellen visual acuity 6/6 to 6/18) at 3 months compared with antibiotics alone (RR 1.95, 95% CI 1.05 to 3.60; 60 participants); however, the evidence was less conclusive at 12 months (RR 1.12, 95% CI 0.92 to 1.37; 2 studies; 195 participants; low certainty evidence). Investigators of one study reported improvement in visual acuity, but we could not estimate the effect of adjunctive steroid therapy because the study investigators did not provide any estimates of precision. Only one study examined intraocular pressure (IOP). The evidence suggests that adjunctive dexamethasone may reduce IOP slightly after 12 months of interventions (mean difference -1.90, 95% CI -3.78 to 0.07; 1 study; 167 participants; low certainty evidence). Three studies reported adverse events (retinal detachment, hypotony, proliferative vitreoretinopathy, seclusion of pupil, floaters, and pucker). The total numbers of adverse events were 14 out of 111 (12.6%) for those who received dexamethasone versus 12 out of 116 (10.3%) for those who did not. We could only perform a pooled analysis for the occurrence of retinal detachment: any difference between the two treatment groups was uncertain (RR 1.41, 95% CI 0.53 to 3.74; 227 participants; low certainty evidence). No study reported cost-related outcomes.

AUTHORS' CONCLUSIONS

The currently available evidence on the effectiveness of adjunctive steroid therapy versus antibiotics alone in the management of acute endophthalmitis after intraocular surgery is inadequate. We found no studies that had enrolled cases of acute endophthalmitis following intravitreous injection. A combined analysis of two studies suggests that use of adjunctive steroids may provide a higher chance of having a good visual outcome at three months than not using adjunctive steroids. However, considering that most of the confidence intervals crossed the null, and that this review was limited in scope and applicability to clinical practice, it is not possible to conclude whether the use of adjunctive steroids is effective at this time. Any future trials should examine whether adjunctive steroids may be useful in certain clinical settings such as type of causative organism or etiology. These studies should include outcomes that take patients' symptoms and clinical examination into account; report outcomes in a uniform and consistent manner; and follow up at short- and long-term intervals.

Corneal Edema and Keratoplasty: Risk Factors in Eyes With Previous Glaucoma Drainage Devices

PURPOSE

To assess risk factors contributing to corneal decompensation following glaucoma drainage device (GDD) implantation.

DESIGN

Retrospective case control study.

METHODS

Records of 1610 eyes that underwent GDD implantation between June 1, 2009, and April 1, 2020, at the Johns Hopkins Wilmer Eye Institute were reviewed. Seventy-nine eyes (5%) developed corneal decompensation, of which 46 underwent keratoplasty. These 79 cases were matched with 220 controls. Cox proportional hazard models with robust standard error estimates to account for clustering at the matched-pair level were used to assess risk factors for corneal decompensation. Kaplan-Meier survival analysis analyzed time to corneal decompensation.

RESULTS

The mean (SD) age of cases and controls was 68 (12.3) and 60.5 (15.9) years, respectively. The mean time from GDD implantation to corneal decompensation was 32 months, and the cumulative probability of developing decompensation at 3, 6, and 9 years was 4.7%, 9.2%, and 14.8%, respectively. Final visual outcomes in cases were worse, with a final mean ± SD visual acuity (logMAR) of 1.96±1.25 relative to a mean±SD visual acuity of 1.11±1.36 in controls (P < .001). In the multivariable model, significant risk factors for corneal decompensation were increased age (adjusted hazard ratio [AHR] 1.39, 95% CI 1.18, 1.63; P ≤ .001), history of Fuchs dystrophy or iridocorneal endothelial syndrome (AHR 9.18, 95% CI 5.35, 15.74; P ≤ .001), and postoperative complications such as hypotony (AHR 3.25, 95% CI 1.85, 5.72; P ≤ .001) and tube-cornea touch (AHR 6.37, 95% CI 3.77, 10.75; P ≤ .001).

CONCLUSIONS

The risk of postoperative corneal decompensation is persistent over time. Patients receiving GDDs, particularly those with advanced age, preexisting corneal pathology, and postoperative complications, should be counseled regarding their increased risk for corneal decompensation.

iSTAT (Intraluminal Suture Transfixed and Titratable) technique for ligature-free Reversal of long-term drainage implant hypotony

Purpose

To describe the iSTAT (Intraluminal Suture Transfixed and Titratable) technique, an improvement on prior tube occlusion methods, allowing for variable flow.

Observations

A 76-year-old woman who underwent an uncomplicated glaucoma drainage device (GDD) placement for uncontrolled mixed mechanism glaucoma presented with hypotony 4 years post-operatively. The iSTAT technique was performed to adjust the flow in the GDD tube: a 4-0 polypropylene suture tip was blunted with a low-temperature cautery, creating a bulbed end that would occlude the tube. The suture was introduced into the tube bulb-first intracamerally, extending to the plate. If partial occlusion of the tube is desired, the suture can be secured in place by piercing the side wall of the tube tip with the distal end of the suture. After complete occlusion of the GDD tube with a large bulb, the patient had intraocular pressures (IOPs) > 40 mmHg on post-operative day 1, which remained in the 25-30 mmHg range 2-3 weeks post-operatively on maximally tolerated medications. Patient underwent a second revision with a smaller-bulbed stent (with a 3-0 polypropylene suture), which stabilized her IOP at 8 mmHg.

Conclusion and Importance

The iSTAT technique allows for an ab interno revision, titration of flow, and stabilization of the stent in the wall of the tube. The ab interno approach precludes the need for conjunctival incisions, thus maintaining bleb integrity and permitting surgery under topical anesthesia. The intracameral stabilization of the stent in the tube allows for smaller bulbs to titrate the flow without external ligatures.

Netzhaut-Glaskörperchirurgie bei Glaukom

Abstract (deutsch): Die Glaukome gehen mit einem Untergang von retinalen Ganglienzellen und deren Axonen einher, welche sich vornehmlich in der Netzhaut befinden. Die Vitreoretinale- und die Glaukomchirurgie überschneiden sich bei bestimmten Krankheitsbildern in einem nicht geringen Ausmaß. Ziel des vorliegenden Übersichtsartikels ist es diese Krankheitsbilder darzustellen und Behandlungsstrategien und die jeweiligen Wirkungsweisen gesammelt aufzuzeigen. Im Rahmen des vorliegenden Artikels werden die Themen malignes Glaukom / aqueous misdirection syndrome, Netzhautchirurgie bei Aderhautamotio und expulsiver Aderhautblutung, postoperative Blebitis und Endophthalmitis nach Glaukomoperation und Vitrektomie nach Glaukomoperationen zusammen beschrieben und die bestehenden Therapiepfade beim Management von auftretenden Komplikationen aufgezeigt. Insgesamt sind die Bereiche Glaukom- und Netzhaut-Glaskörperchirurgie eng miteinander verbunden. Kollegen beider Subspezialitäten sollten Kenntnisse über diese sie beide betreffenden Krankheitsbilder haben. Abstract (englisch): Glaucoma is associated with the demise of retinal ganglion cells and their axons, which are primarily located in the retina. Vitreiretinal and glaucoma surgery overlap to a not inconsiderable extent in certain diseases. The aim of this overview article is to present these diseases and to highlight treatment strategies and the respective modes of action in a collective manner. Within the scope of this article, the topics of malignant glaucoma / aqueous misdirection syndrome, retinal surgery for choroidal detachment and expulsive choroidal hemorrhage, postoperative blebitis and endophthalmitis after glaucoma surgery and vitrectomy after glaucoma surgery are described together and the existing therapeutic paths for the management of complications are shown. The areas of glaucoma and vitreoretinal surgery are tightly linked. Colleagues from both subspecialties should be familiar with a certain overview of diseases concerning both subject areas.

Cost-analysis of Surgical Intraocular Pressure Management in Glaucoma

PRCIS

The multiplicity of treatment options for lowering intraocular pressure (IOP) is both a blessing and a challenge. Some attention to cost-analysis might assist in choosing an optimal therapy, especially in a cost-constrained, international setting.

PURPOSE

The aim of this study was to quantify and to analyze the relative cost of various glaucoma surgical procedures and selective laser trabeculoplasty surgery per mm Hg IOP reduction ($/mm Hg) since standard cost-utility methods are not well suited to the study of glaucoma which characteristically only claims visual acuity in its end stages.

METHODS

Published glaucoma treatment studies were reviewed to quantitate the reduction of mean IOP and glaucoma medications for a given treatment modality. A US perspective was adopted, using Medicare allowable costs were used to calculate a newly introduced parameter-cost per mm Hg IOP reduction-at 1 year postoperatively.

RESULTS

The cost per mm Hg IOP reduction after 1 year of treatment ranged from $190/mm Hg for trabeculectomy to $1376/mm Hg for iStent. For reference, the cost of selective later trabeculoplasty surgery was $121/mm Hg. After the first year, cost/mm Hg ranged from $12 to $61/mm Hg.

CONCLUSIONS

Conventional glaucoma surgeries and selective laser trabeculoplasty surgery were the most cost-efficient surgical methods to lower IOP compared with the various minimally invasive glaucoma surgeries options. They may be more appropriate management when cost is an important issue.

Reoperation for complications within 90 days of minimally invasive glaucoma surgery

OBJECTIVE

To describe reoperations that occurred within 90 days of minimally invasive glaucoma surgery (MIGS) at a single institution over a 30-month period.

SETTING

Tertiary care hospital.

DESIGN

Retrospective case series.

METHODS

Charts of adult patients who underwent trabecular microbypass stents, gel microstents, and goniotomy procedures (including gonioscopy-assisted transluminal trabeculotomy) from October 1, 2017, to March 15, 2020, at Wills Eye Hospital were examined. Outcome measures were unanticipated reoperations within the first 90 days after MIGS procedures and the complications that led to these reoperations.

RESULTS

A total of 448 MIGS procedures were performed on 436 eyes of 348 patients over a 30-month period by 6 glaucoma surgeons. Of these, 206 (46.0%) were trabecular microbypass stents (198 iStent/iStent inject and 8 Hydrus), 152 (33.9%) were gel microstents, and 90 (20.1%) were goniotomy procedures. Combined phacoemulsification took place in 256 eyes (58.7%). Reoperation within 90 days took place in 23 (5.3%) of 436 eyes, including 16 (10.5%) of 152 eyes in the gel microstent group, 4 (2.0%) of 198 eyes in iStent/iStent inject group, and 3 (3.3%) of 90 eyes in the goniotomy group. Indications for reoperation were elevated intraocular pressure (IOP) in 16 (69.6%) of 23 eyes, gel microstent tip exposure with wound leakage in 3 (13.0%) of 23 eyes, and early gel microstent encapsulation without elevated IOP in 1 (4.3%) of 23 eyes. Two (8.7%) of 23 eyes required reoperation for intraocular lens complications, whereas 1 (4.3%) of 23 eyes had elevated IOP and aphakia requiring reoperation.

CONCLUSIONS

The rate of reoperation within the first 90 days after MIGS was low. Elevated IOP and complications associated with gel microstents were the main indications for reoperation.

Need for Additional Glaucoma Surgery and Complications Following Glaucoma Drainage Device Surgery

PRCIS

In this longitudinal study of patients with open-angle (OAG), pseudoexfoliative (PXE), or neovascular glaucoma (NVG) receiving glaucoma drainage devices (GDD), posttube cumulative rates of reoperation, corneal graft, and visually threatening complications (VT-complications) increased beyond 5 years and were not significantly affected by glaucoma type.

PURPOSE

To study the need for additional glaucoma surgery and development of complications after first GDD surgery in eyes with primary OAG, PXE, or NVG glaucoma.

PATIENTS AND METHODS

There were 306 eyes with OAG (n=185), PXE (n=60), or NVG (n=61) glaucoma who received a first GDD between 1996 and 2017. Outcomes including glaucoma reoperation, corneal graft procedure, and VT-complications after GDD were measured. Kaplan-Meier analysis was used to compare cumulative rate of reaching outcomes over time after GDD placement among the 3 glaucoma groups.

RESULTS

When comparing the OAG, PXE, and NVG groups, there were no significant differences in post-GDD cumulative rates of reoperation (P=0.33), corneal graft (P=0.26), or VT-complications (P=0.65) over time. For all eyes, the overall cumulative rates for each outcome measure increased beyond 5 years, and specific Kaplan-Meier rates (5-y, 10-y) included: reoperation (16%, 25%), corneal graft (6%, 12%), VT-complications (9%, 14%). When comparing specific GDDs, the Ahmed FP7 had a higher cumulative reoperation rate over time compared with the Baerveldt 350 (P=0.019).

CONCLUSION

Glaucoma type did not significantly affect post-GDD cumulative rates of reoperation, corneal graft, and VT-complication among the OAG, PXE, and NVG groups. For all eyes, cumulative rates of reoperation, corneal graft, and VT-complications increased beyond 5 years. The Ahmed FP7 had a significantly higher cumulative reoperation rate compared with the Baerveldt 350 over time.

Safety and efficacy of microinvasive glaucoma surgery with cataract extraction in patients with normal-tension glaucoma

This study assesses the safety and efficacy of microinvasive glaucoma surgery (MIGS) with cataract extraction in patients with normal-tension glaucoma (NTG). In our sample of 45 NTG patients, mean intraocular pressure (IOP) decreased from 13.7 to 12.3 mmHg at 2.5 years, and mean medication burden decreased from 2.0 to 1.1 at 1.5 years. For success defined as IOP reduction ≥ 30% from baseline IOP with medication burden reduction from preoperative levels, success probability was 5.4% at 1.5 years. For success defined as medication burden reduction with an IOP reaching goal IOP as determined by the glaucoma specialist, success probabilities were 67.2% at 1.5 years and 29.4% at 2.5 years. At the last follow-up visit, eyes with two MIGS procedures with different mechanisms of action achieved successful medication reduction 68.8% of the time versus 35.7% achieved by a single MIGS procedure (p = 0.052). At their last visit, visual acuity was unchanged or improved in all eyes (100%). MIGS with cataract surgery results in modest reductions in IOP and medication burden in NTG patients, which may lead to lower costs and better therapeutic compliance. A combination of two MIGS procedures with different mechanisms of action may potentially be more effective in reducing medication burden than a single MIGS procedure in NTG patients. Further research is necessary to ascertain whether MIGS for NTG patients may help decrease medication burden while helping achieve goal IOP.

Ethics of Glaucoma Widgets

How to cite this article: Dada T, Ramesh P, Sethi A, et al. Ethics of Glaucoma Widgets. J Curr Glaucoma Pract 2020;14(3):77–80.

Glaucoma Drainage Devices and Reasons For Keratoplasty

PRéCIS:: Over 10 years in a tertiary care setting, glaucoma drainage devices (GDDs) have not increased as a reason for keratoplasty.

PURPOSE

The purpose of this study was to determine whether the reasons for keratoplasty have changed between 10 years in a tertiary care setting, with special attention to the rate of GDDs as a reason for keratoplasty.

METHODS

Patients aged 18 years or above who underwent keratoplasty at Mayo Clinic, Rochester, MN from 2005 to 2006 and 2015 to 2016 were studied. All reasons for keratoplasty performed in the study time period are assessed, including patients who previously had a GDD implanted in the same eye. After analyzing the reasons for keratoplasty, we assess whether the reasons for keratoplasty have changed between 2005 to 2006 and 2015 to 2016 in association with the increasing placement of GDDs.

RESULTS

The number of keratoplasty procedures performed in the 2 time periods increased by 62% from 163 (2005 to 2006) to 264 (2015 to 2016), whereas GDD placement increased by 164% from 80 GDD (2005 to 2006) to 211 GDD (2015 to 2016). Although the performance of keratoplasty increased between the 2 points in time, the frequency of each cause for keratoplasty did not change significantly. The majority of keratoplasties were performed due to corneal disease, and GDDs made up a small portion of reasons for keratoplasty (2005 to 2006, 4.29%; 2015 to 2016, 5.68%).

CONCLUSIONS

The frequency of GDDs as a reason for keratoplasty has not changed significantly between 10 years in this tertiary care setting. Patients with GDDs who later required keratoplasty had associated features including multiple surgical procedures and comorbid infection, pseudophakic bullous keratopathy, Fuchs dystrophy, pseudoexfoliation, uveitis, and congenital glaucoma.

Prompt vitrectomy for management of endophthalmitis in setting of unexposed glaucoma drainage implant

Purpose

To highlight a rare case of fulminant endophthalmitis in the late post-operative stage after glaucoma drainage device implantation without evidence of device exposure, and to share the unique management that resulted in successful restoration of vision and intraocular pressure control.

Observations

Endophthalmitis after glaucoma drainage implantation (GDI) is a rare complication most often associated with exposure of the device. Management options are limited, but removal of GDI is a common approach in the setting of an exposed implant. Visual acuity outcomes are often significantly reduced despite adequate treatment. There is little in the existing literature about management of late-onset endophthalmitis in the setting of a GDI without implant exposure. Here we present such a case that was successfully managed by prompt pars plana vitrectomy and removal of tube from the anterior chamber with subsequent re-insertion and patch graft. Our case results in a restoration of baseline visual acuity and IOP control at 7 months follow up.

Conclusions and importance

Endophthalmitis occurring after GDI implantation is a challenging complication to manage. Many physicians resort to removal of device for treatment, and a majority would treat initially with intravitreal antibiotic injection of antibiotics rather than prompt pars plana vitrectomy. This article provides a different approach that avoids removal of the device.

Reoperation rates after Ex-PRESS versus trabeculectomy for primary open-angle or normal-tension glaucoma: a national database study in Japan

OBJECTIVE

To compare reoperation rates between Ex-PRESS implantation and trabeculectomy.

METHODS

We performed a retrospective cohort study using a national inpatient database in Japan. Patients aged 18-85 years with primary open-angle glaucoma or normal-tension glaucoma who underwent Ex-PRESS or trabeculectomy from 2010 to 2017 were included. We compared the reoperation rates between Ex-PRESS and trabeculectomy using mixed effects cox regression models. Covariates were sex, age, diabetes mellitus, simultaneous cataract surgery, ocular surgical history, and annual hospital volume for glaucoma surgery. Furthermore, we conducted propensity score (PS) matching and instrumental variable (IV) analyses to confirm the results of the conventional cox regression. We also compared total hospitalisation costs between the two treatments in the PS-matched groups.

RESULTS

In total, 1027 eyes underwent Ex-PRESS and 6910 eyes underwent trabeculectomy. The reoperation rates were 7.6% and 5.8% in the Ex-PRESS and trabeculectomy groups, respectively. The most frequently performed type of reoperation was trabeculectomy in both groups. The mixed effects cox regression showed that Ex-PRESS had significantly higher reoperation rates than trabeculectomy [adjusted hazard ratio (aHR), 1.72; 95% confidence interval (CI), 1.31-2.25; p < 0.001]. The PS and IV analyses also showed similar results (for PS analysis: aHR, 2.13; 95% CI, 1.45-3.13; p < 0.001; for IV analysis: aHR, 2.26; 95% CI, 1.05-4.85; p = 0.037). The total hospitalisation cost of Ex-PRESS (US$7076) was significantly greater than that of trabeculectomy (US$6223) (p < 0.001).

CONCLUSION

Ex-PRESS implantation had significantly higher reoperation rates and greater cost than trabeculectomy.

Access to Ophthalmologists in States Where Optometrists Have Expanded Scope of Practice

Importance

As the United States considers how to best structure its health care services, specialty care availability is receiving increased focus. This study assesses whether patients lack reasonable access to ophthalmologists in states where optometrists have been granted expanded scope of practice.

Objective

To determine the estimated travel time (ETT) to the nearest ophthalmologist office for persons residing in states that have expanded scope of practice for optometrists, and to quantify ETT to the nearest ophthalmologist for Medicare beneficiaries who received surgical care from optometrists in those states between 2008 and 2014.

Design, Setting, and Participants

This study used data from the 2010 US census, a 2016 American Academy of Ophthalmology member database, and a data set of claims data for a random sample of 20% of beneficiaries enrolled in Medicare nationwide from 2008 to 2014 (n=14 063 725). Combining these sources with geographic information systems analysis, the ETT to the nearest ophthalmologist office was calculated for every resident of Kentucky, Oklahoma, and New Mexico. This study also assessed ETT to the nearest ophthalmologist for Medicare beneficiaries in those states who had received surgery from an optometrist from 2008 to 2014. Data analyses were conducted from July 2016 to July 2017.

Main Outcomes and Measures

The proportion of residents of Kentucky, Oklahoma, and New Mexico who live within an ETT of 10, 30, 45, 60, or 90 minutes of the nearest ophthalmologist office.

Results

The study included 4 339 367 Kentucky residents, 3 751 351 Oklahoma residents, and 2 059 179 New Mexico residents. Of these, 5 140 547 (50.6%) were female. Racial/ethnic composition included 7 154 847 people (70.5%) who were white, 640 608 (6.3%) who were black, and 1 418 246 (14.0%) who were Hispanic. The mean (SD) age was 37.8 (22.8) years. More than 75% of residents in the 3 states lived within an ETT of 30 minutes to the nearest ophthalmology office, and 94% to 99% of residents lived within an ETT of 60 minutes to the nearest ophthalmology office. Among Medicare beneficiaries who received surgery by optometrists, 58.3%, 51.1%, and 46.9% in Kentucky, Oklahoma, and New Mexico, respectively, lived within an ETT of 30 minutes from the nearest ophthalmologist office.

Conclusions and Relevance

In the states where optometrists have expanded scope of practice, most residents lived within an ETT of 30 minutes of the nearest ophthalmologist office, as do half of Medicare beneficiaries who received surgical care from optometrists. These results can help inform policy makers when weighing the pros and cons of scope of practice expansion for optometrists.

Visually Significant Cystoid Macula Edema After Glaucoma Drainage Implant Surgery

PURPOSE

This study examines the incidence of visually significant cystoid macular edema (CME) after glaucoma drainage implant (GDI) surgery and analyses risk factors associated with developing CME and prognosis with treatment.

MATERIALS AND METHODS

In total, 185 eyes from 185 glaucoma patients (mean age, 72.46±13.94 y) who underwent GDI surgery at a tertiary eye institute were recruited. Patients were classified based on the presence (CME) or absence (No-CME) of CME. Pre-GDI and post-GDI best-corrected visual acuity, number of intraocular pressure (IOP)-lowering medications, IOP, standard automated perimetry and post-GDI complications, were recorded and compared between the 2 groups. Optical coherence tomography (OCT) was used to quantify retinal thickness and monitor CME.

RESULTS

In total, 41 (22.2%) eyes developed visually significant CME after GDI surgery. Patients with CME had a higher incidence of pre-GDI nonsteroidal anti-inflammatory drug (P<0.01) use and higher number of prior glaucoma surgeries (P<0.01). CME patients had a higher (P<0.01) incidence of iritis, epiretinal membrane, and hypotony. CME eyes responded well to steroids, with resolving macular edema (458.4±151.9 vs. 322.0±92.0 µm, P<0.01) and improving visual acuity (0.73±0.48 vs. 0.56±0.56 logarithm of minimum angle of resolution, P<0.01). Both CME and non-CME groups had equivalent lowering of IOP and post-GDI glaucoma medications; with no significant elevation in IOP in the steroid-treated CME group.

CONCLUSIONS

Post-GDI surgery visually significant CME rates are potentially higher in a real hospital scenario compared with controlled clinical trials. With diligent treatment, CME resolves effectively restoring visual acuity and central macular thickness.

Long-Term Functional Outcomes of Glaucoma Tube Shunt Revision Surgery

PURPOSE

To characterize long-term outcomes of tube shunt revision surgeries and identify factors associated with their failure.

DESIGN

Retrospective chart review.

PARTICIPANTS

One eye from each of 179 patients who underwent tube shunt revision surgery at the Wilmer Eye Institute between 2004 and 2015 with a minimum follow-up of 6 weeks.

METHODS

Eligible eyes were identified from billing records and data related to their care were extracted from electronic medical records. Eyes were analyzed in aggregate and by indication for revision, including hypotony, high intraocular pressure (IOP), tube reposition, and tube exposure.

MAIN OUTCOME MEASURES

Surgical failure, defined as a need for further tube shunt revision or other glaucoma surgery, unsatisfactory IOP at last follow-up, or both. Secondary outcomes included postoperative infection and functional visual impairment.

RESULTS

With a median follow-up of 4.2 years, 126 failures occurred among 179 eyes. By Kaplan-Meier analysis, the cumulative rates of surgical failure at 1, 2, and 5 years after revision were 49%, 59%, and 74%, respectively. Most revision failures (105/126) were the result of the need for additional surgery, whereas 11 eyes showed IOP above target levels and 10 eyes showed dysfunctionally low IOP at the last follow-up. Factors associated with failure in a stepwise regression model were revision for hypotony (hazard ratio [HR], 6.79; P = 0.002), different surgeons performing the original and revision surgeries (HR, 2.80; P = 0.002), longer duration of symptoms before revision (P = 0.01), revision of a right eye (HR, 1.92; P = 0.03), and presumed preoperative infection (HR, 2.47; P = 0.04). In univariate analysis, success varied significantly by prior surgeon (P = 0.01), but not by revision surgeon. There was a 16% cumulative incidence of postoperative infection, with the highest risk in those with presumed preoperative infections (P = 0.01) and in persons of non-African, non-European derivation (P = 0.03).

CONCLUSIONS

The estimated rate of failure of tube shunt revision is 75% by 5 years, most often because of a need for further surgery. The major potentially modifiable feature associated with success is tube shunt revision being performed by the original surgeon.

[Combined XEN and Baerveldt implant-principles and management of complications]

The treatment of congenital glaucoma requires special expertise and often novel surgical approaches. The combined use of a XEN and a Baerveldt implant is an alternative to conventional tube implants and may be less harmful for long-term corneal endothelial damage. If this technique does not provide sufficient long-term control of intraorbital pressure (IOP), a direct implantation of the Baerveldt tube can be easily performed in a second intervention.

Personalized Prediction of Glaucoma Progression Under Different Target Intraocular Pressure Levels Using Filtered Forecasting Methods

PURPOSE

To generate personalized forecasts of how patients with open-angle glaucoma (OAG) experience disease progression at different intraocular pressure (IOP) levels to aid clinicians with setting personalized target IOPs.

DESIGN

Secondary analyses using longitudinal data from 2 randomized controlled trials.

PARTICIPANTS

Participants with moderate or advanced OAG from the Collaborative Initial Glaucoma Treatment Study (CIGTS) or the Advanced Glaucoma Intervention Study (AGIS).

METHODS

By using perimetric and tonometric data from trial participants, we developed and validated Kalman Filter (KF) models for fast-, slow-, and nonprogressing patients with OAG. The KF can generate personalized and dynamically updated forecasts of OAG progression under different target IOP levels. For each participant, we determined how mean deviation (MD) would change if the patient maintains his/her IOP at 1 of 7 levels (6, 9, 12, 15, 18, 21, or 24 mmHg) over the next 5 years. We also model and predict changes to MD over the same time horizon if IOP is increased or decreased by 3, 6, and 9 mmHg from the level attained in the trials.

MAIN OUTCOME MEASURES

Personalized estimates of the change in MD under different target IOP levels.

RESULTS

A total of 571 participants (mean age, 64.2 years; standard deviation, 10.9) were followed for a mean of 6.5 years (standard deviation, 2.8). Our models predicted that, on average, fast progressors would lose 2.1, 6.7, and 11.2 decibels (dB) MD under target IOPs of 6, 15, and 24 mmHg, respectively, over 5 years. In contrast, on average, slow progressors would lose 0.8, 2.1, and 4.1 dB MD under the same target IOPs and time frame. When using our tool to quantify the OAG progression dynamics for all 571 patients, we found no statistically significant differences over 5 years between progression for black versus white, male versus female, and CIGTS versus AGIS participants under different target IOPs (P > 0.05 for all).

CONCLUSIONS

To our knowledge, this is the first clinical decision-making tool that generates personalized forecasts of the trajectory of OAG progression at different target IOP levels. This approach can help clinicians determine appropriate, personalized target IOPs for patients with OAG.

Choosing wisely and the use of antibiotics in ophthalmic surgery: There is more than meets the eye

BACKGROUND:

One of the directions of modern ophthalmology is toward an odontoiatric model, and new settings of eye care are becoming the standard of care: one day surgery and also office-based therapies.

METHODS:

Retrospective analysis of three tertiary-care centers in Italy and analysis of the literature.

RESULTS:

We provide readers with state-of-the-art measures of prophylaxis in ophthalmic surgery.

DISCUSSION AND CONCLUSION:

Role of antibiotics is criticized in the light of stewardship antimicrobial paradigm.

Incidence of Conjunctival Exposure following Drainage Device Implantation in Patients with Glaucoma

Purpose

To evaluate prior studies including a glaucoma drainage device and to describe the timing and incidence of conjunctival exposure. A meta-analysis of previously published articles.

Methods

Articles included were prospective, single cohort, or comparative parallel design, with a mean treatment period of at least 3 months and at least 30 patients per treatment arm. We limited our analysis to studies that evaluated the most common devices, including Ahmed, Baerveldt, and Molteno.

Results

We included 38 studies containing 45 treatment arms (16 Ahmed, 12 Baerveldt, and 17 Molteno). These studies included 3,105 patients and 3,255 eyes with an average follow-up of 26.1±3.3 months. The overall incidence of exposure was 2.0±2.6% (n=64) of eyes with an average exposure/month of 0.09±0.14%. There was no significant correlation between study length and incidence of exposure (p=0.11), although multivariate regression analysis identified length of follow-up as a risk factor for exposure (p=0.001). Among individual drainage devices, there was no significant difference in the incidence of exposure (p=0.22) or percent exposure per month (p=0.18). In addition, no difference existed in the incidence of exposure between sizes for the Baerveldt 250, 350 or 500 mm (p=0.7), number of plates for the Molteno Single or Double (p=0.3), nor between the composition of the Ahmed Silicone or Polypropylene (p=0.7).

Conclusions

This study suggests that tube exposure of glaucoma implants is unusual and the incidence does not differ between the Ahmed, Baerveldt, and Molteno implants. However, exposure appears to occur at any time within the first 5 years following implantation.

Adjunctive steroid therapy versus antibiotics alone for acute endophthalmitis after intraocular procedure

BACKGROUND

Endophthalmitis refers to severe infection within the eye that involves the aqueous humor or vitreous humor, or both, and threatens vision. Most cases of endophthalmitis are exogenous (i.e. due to inoculation of organisms from an outside source), and most exogenous endophthalmitis is acute and occurs after an intraocular procedure. The mainstay of treatment is emergent administration of broad-spectrum intravitreous antibiotics. Due to their anti-inflammatory effects, steroids in conjunction with antibiotics have been proposed to be beneficial in endophthalmitis management.

OBJECTIVES

To assess the effects of antibiotics combined with steroids versus antibiotics alone for the treatment of acute endophthalmitis following intraocular surgery or intravitreous injection.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 11), MEDLINE Ovid (1946 to 8 December 2016), Embase Ovid (1980 to 8 December 2016), LILACS (Latin American and Caribbean Health Sciences Literature Database) (1982 to 8 December 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 8 December 2016, ClinicalTrials.gov (www.clinicaltrials.gov); searched 8 December 2016, and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 8 December 2016. We did not use any date or language restrictions in the electronic searches for trials.

SELECTION CRITERIA

We included randomized controlled trials comparing the effectiveness of adjunctive steroids with antibiotics alone in the management of acute, clinically diagnosed endophthalmitis following intraocular surgery or intravitreous injection. We excluded trials with participants with endogenous endophthalmitis unless outcomes were reported by source of infection. We imposed no restrictions on the method or order of administration, dose, frequency, or duration of antibiotics and steroids.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results, assessed risk of bias, and extracted data using methods expected by Cochrane. We contacted study authors to try to obtain missing information or information to clarify risk of bias. We conducted a meta-analysis for any outcomes that were reported by at least two studies. Outcomes reported from single studies were summarized in the text. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included three trials with a total of 95 randomized participants in this review and identified one ongoing trial. The studies were conducted in South Africa, India, and the Netherlands. Out of the 92 analyzed participants, 91 participants were diagnosed with endophthalmitis following cataract surgery. In the remaining participant, endophthalmitis was attributable to penetrating keratoplasty. All studies used intravitreous dexamethasone for adjunctive steroid therapy and a combination of two intravitreous antibiotics that provided gram-positive and gram-negative coverage for the antibiotic therapy. We judged one trial to be at overall low risk of bias and two studies to be at overall unclear risk of bias due to lack of reporting of study methods. None of the three trials had been registered in a clinical trial register.While none of the included studies reported the primary outcome of complete resolution of endophthalmitis as defined in our protocol, one study reported combined anatomical and functional success (i.e. proportion of participants with intraocular pressure of at least 5 mmHg and visual acuity of at least 6/120). Very low-certainty evidence suggested no difference in combined success when comparing adjunctive steroid antibiotics alone (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.80 to 1.45; 32 participants). Low-certainty evidence from two studies showed that a higher proportion of participants who received adjunctive dexamethasone had a good visual outcome (Snellen visual acuity 6/6 to 6/18) at three months compared with those in the antibiotics-alone group (RR 1.95, 95% CI 1.05 to 3.60; 60 participants). Similarly, low-certainty evidence from one study suggested that more participants in the dexamethasone group had a good visual outcome at 12 months compared to those who did not receive dexamethasone (RR 2.00, 95% CI 0.98 to 4.08; 28 participants). Investigators of one study reported improvement in visual acuity, but we could not estimate the effect of adjunctive steroid therapy because the study investigators did not provide standard deviations or standard errors. Two studies reported adverse events (retinal detachment, hypotony, proliferative vitreoretinopathy, and seclusion of pupil). The total numbers of adverse events were 8 out of 30 (26.7%) for those who received dexamethasone versus 6 out of 30 (20.0%) for those who did not. We could only perform a pooled analysis for the occurrence of retinal detachment; any difference between the two treatment groups was uncertain (RR 1.57, 95% CI 0.50 to 4.90; 60 participants) (very low-certainty evidence). No study reported intraocular pressure or cost outcomes.

AUTHORS' CONCLUSIONS

Current evidence on the effectiveness of adjunctive steroid therapy versus antibiotics alone in the management of acute endophthalmitis after intraocular surgery is inadequate. We found no studies that had enrolled cases of acute endophthalmitis following intravitreous injection. A combined analysis of two studies suggests adjunctive steroids may provide a higher probability of having a good visual outcome at three months than not using adjunctive steroids. However, considering that most of the confidence intervals crossed the null and that this review was limited in scope and applicability to clinical practice, it is not possible to conclude whether the use adjunctive steroids is effective at this time. Any future trials should examine whether adjunctive steroids may be useful in certain clinical settings such as type of causative organism or etiology. These studies should include outcomes that take patient's symptoms and clinical examination into account, report outcomes in a uniform and consistent manner, and follow up at short- and long-term intervals.

Corneal endothelial cell loss after Baerveldt glaucoma drainage device implantation in the anterior chamber

Purpose

To investigate central and peripheral corneal endothelial cell density (ECD) in relation to Baerveldt (BV) glaucoma drainage device (GDD) tube corneal (TC) distance.

Methods

Prospective study of all patients scheduled for glaucoma tube surgery with 36 months follow‐up. A BV GDD was inserted into the anterior chamber (AC). Anterior segment optical coherence tomography (AS‐OCT) scans were made to determine the TC distance. Central and peripheral ECD was measured, preoperatively and at 3, 6, 12, 24 and 36 months postoperatively.

Results

Fifty‐three eyes were included [primary open‐angle glaucoma, (n = 13); secondary glaucoma, (n = 30); and primary angle‐closure glaucoma, (n = 10)]. Central ECD significantly decreased during follow‐up, with a mean decrease of 4.54% per year (p < 0.001), and 6.57% in the peripheral quadrant closest to the BV GDD tube (PQC, p < 0.001). In the PQC, a yearly decrease of 1.57% was shown after transiridial tube placement versus 7.43% after placement ‘free’ into the AC (p = 0.006). Endothelial cell (EC) loss was related to TC distance (mean 1.69 mm), with a central loss of 6.20% and 7.25% in the PQC per year with shorter TC distances, versus a central loss of 4.11% and 5.77% in the PQC per year with longer TC distances (outside mean ± 2SD, p < 0.001). A difference in EC loss by glaucoma subtype was not identified.

Conclusion

The TC distance is of significant influence on corneal ECD, a shorter TC distance causing more severe EC loss, especially in the PQC. Transiridial placement of the BV GDD tube seems safer than placement ‘free’ into the AC.

Combined Scleral Flap with Donor Scleral Patch Graft for Anterior Tube Placement in Glaucoma Drainage Device Surgery

Purpose. To report a new technique for anterior placement of tubes for glaucoma drainage devices to reduce the risk of tube erosions. Methods. Retrospective review of select cases of Ahmed Valve surgery combined with the novel method of a limbal-based scleral flap covered by a scleral patch graft to cover the tube at the entrance through the limbus. Intraoperative and postoperative illustrations are shown to highlight the method of tube placement. Results. In this retrospective case series, 3 patients are presented illustrating the technique. Two had neovascular glaucoma and one had primary open-angle glaucoma (POAG). On average, intraocular pressure was reduced from 39 ± 14 mmHg to 15 ± 2 mmHg and the number of glaucoma medications was reduced from 4 ± 1 to 0. Preoperative and most recent visual acuities were hand-motion (HM) and HM, 20/60 and 20/50, and 20/70 and 20/30, respectively. Conclusion. The combination of a limbal-based scleral flap with scleral patch graft to cover the tube with glaucoma drainage devices may be an effective means to reduce erosion and protect against endophthalmitis.

Intraocular Pressure Control after Implantation of an Ahmed Glaucoma Valve in Eyes with a Failed Trabeculectomy

AIM

To evaluate the results of Ahmed glaucoma valve (AGV) in eyes with a failed trabeculectomy.

MATERIALS AND METHODS

This retrospective study evaluated 61 eyes with a failed trabeculectomy that underwent implantation of an AGV due to uncontrolled intraocular pressure (IOP) on maximal medical therapy. Success was defined as IOP ≤ 21 mm Hg (criterion 1) or 20% reduction in IOP (criterion 2) with or without antiglaucoma medications. Persistent hypotony, loss of light perception, and reoperation for IOP control were defined as failure.

RESULTS

Mean preoperative IOP and mean lOPs at 6, 12, and 24 months were 21.93 ± 6.32 mm Hg (n = 61), 14.15 ± 4.33 mm Hg (n = 59), 13.21 ± 4.44 mm Hg (n = 56), and 13.60 ± 3.27 mm Hg (n = 25) respectively. Mean number of antiglaucoma medications preoperatively and at 6, 12, and 24 months was 3.95 ± 0.85, 2.19 ± 1.38, 2.48 ± 1.44, and 2.40 ± 1.32 respectively. The reductions in the number of medications and IOP measurements were statistically significant at all time intervals (p < 0.001, Wilcoxon signed rank test). According to criterion 1, the Kaplan-Meier survival curve disclosed success rates of 75% at 12 and 24 months. According to criterion 2, the success rates were 57% at 12 months and 55% at 24 months. The most frequent complications were hypertensive phase (18%) and shallow anterior chamber (16.4%).

CONCLUSION

The AGV may effectively reduce IOP in eyes that had a failed trabeculectomy.

CLINICAL SIGNIFICANCE

The AGV is an alternative in eyes with a failed trabeculectomy.

HOW TO CITE THIS ARTICLE

Schimiti RB, Abe RY, Tavares CM, Vasconcellos JPC, Costa VP. Intraocular Pressure Control after Implantation of an Ahmed Glaucoma Valve in Eyes with a Failed Trabeculectomy. J Curr Glaucoma Pract 2016;10(3):97-103.

Care Transfers for Patients With Upper Extremity Trauma: Influence of Health Insurance Type

PURPOSE

To understand the differences in transfer incidence for patients with upper extremity trauma by hospital trauma center designation. We hypothesized that patients with public or no insurance were more likely to be transferred to another facility compared with privately insured patients.

METHODS

Trauma centers are designated by local authorities and verified by the American College of Surgeons. Using the 2012 National Trauma Data Bank, we examined the probability of being transferred from one center to another for patients who sustained isolated upper extremity trauma. We used multivariable logistic regression with a clustered variance method to adjust for intrahospital correlation to compare risk-adjusted transfer incidence for patients with upper extremity injuries by trauma center designation.

RESULTS

In 2012, 6,214 patients ages 18-64 with isolated upper extremity trauma presented to 477 hospitals. Overall, transfer incidence was significantly higher among level III trauma centers (26%) compared with level II (11%) or level I (2%) trauma centers. Adjusting for patient and hospital characteristics patients with Medicaid were more likely to be transferred from level III trauma centers to another center compared with privately insured patients.

CONCLUSIONS

Current regulations may not prevent unnecessary patient transfers based on insurance status among level III trauma centers. Policy makers should compensate or provide incentives to hospitals that take care of poorly insured patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/decision III.

Late onset endophthalmitis associated with unexposed glaucoma valved drainage device

We report an extremely rare presentation of late-onset endophthalmitis in a young adult patient with an unexposed Ahmed tube implant. The implant was inserted 11 years prior to presentation. There was no history of trauma or any obvious exposure on clinical examination and the tube plate was filled with purulent material. After aqueous and vitreous tap, the patient underwent intracameral, intravitreal subconjunctival antibiotic injections and was started on systemic antibiotics with good response. Endophthalmitis associated with tube drainage device can present as late as 11 years and even without an unexposed tube.

Laser suture lysis after trabeculectomy with mitomycin C: analysis of suture selection

OBJECTIVE

This paper analyses to what extent positioning and timing influences the degree of intraocular pressure (IOP) reduction by laser suture lysis (LSL) after trabeculectomy with mitomycin C.

METHODS

The IOP reduction following LSL was assessed in a consecutive case series of 168 eyes (120 patients) after trabeculectomy with mitomycin C. Scleral flap sutures of 3.3±0.6 were placed on average. The IOP reduction was assessed in terms of suture positioning and the time of LSL.

RESULTS

LSL was performed early (<7 d) on 48 of 168 eyes (29%). The mean IOP before trabeculectomy was 22.1±5.9 and 20.3±6.2 mm Hg on the first postoperative day. LSL additionally reduced the IOP by 6.3±6.9 mm Hg. LSL was performed late (>7 d) on 27 of 168 eyes (16%). The mean preoperative IOP was 20.7±6.0 mm Hg, 12.1±7.8 mm Hg on the first postoperative day, and increased again to 21.7±4.5 mm Hg by the time of LSL. The IOP reduction achieved by LSL was 7.0±5.1 mm Hg. In a subgroup of 54 eyes with 3 scleral flap sutures, there was no significant difference in IOP reduction in a comparison of corner and central sutures (P=0.4). The reduction of IOP after LSL was not significantly correlated with the number of respectively remaining scleral flap sutures (P=0.17). There was no correlation between the time of LSL and IOP reduction (P=0.96).

CONCLUSION

The reduction of IOP after LSL is not related to suture selection or the number of remaining scleral flap sutures.

Use of health care claims data to study patients with ophthalmologic conditions

OBJECTIVE

To describe what information is or is not included in health care claims data, provide an overview of the main advantages and limitations of performing analyses using health care claims data, and offer general guidance on how to report and interpret findings of ophthalmology-related claims data analyses.

DESIGN

Systematic review.

PARTICIPANTS

Not applicable.

METHODS

A literature review and synthesis of methods for claims-based data analyses.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

Some advantages of using claims data for analyses include large, diverse sample sizes, longitudinal follow-up, lack of selection bias, and potential for complex, multivariable modeling. The disadvantages include (a) the inherent limitations of claims data, such as incomplete, inaccurate, or missing data, or the lack of specific billing codes for some conditions; and (b) the inability, in some circumstances, to adequately evaluate the appropriateness of care. In general, reports of claims data analyses should include clear descriptions of the following methodological elements: the data source, the inclusion and exclusion criteria, the specific billing codes used, and the potential confounding factors incorporated in the multivariable models.

CONCLUSIONS

The use of claims data for research is expected to increase with the enhanced availability of data from Medicare and other sources. The use of claims data to evaluate resource use and efficiency and to determine the basis for supplementary payment methods for physicians is anticipated. Thus, it will be increasingly important for eye care providers to use accurate and descriptive codes for billing. Adherence to general guidance on the reporting of claims data analyses, as outlined in this article, is important to enhance the credibility and applicability of findings. Guidance on optimal ways to conduct and report ophthalmology-related investigations using claims data will likely continue to evolve as health services researchers refine the metrics to analyze large administrative data sets.

Optic nerve complex imaging in glaucoma Medicare beneficiaries

PURPOSE

To assess the frequency of fundus photography and scanning computerized ophthalmic diagnostic imaging (SCODI) on patients receiving glaucoma care under Medicare.

METHODS

In this retrospective, observational, Medicare claims-based study, we used a 5% random sample, from 2006-2008, of Medicare beneficiaries, selected for International Classification of Diseases, 9th Revision (ICD-9) diagnoses of glaucoma or glaucoma suspect, who had greater than one year of follow up (N = 143,374). The proportion of patients with an ICD-9 diagnosis of glaucoma or glaucoma suspect who received fundus photography (Physicians' Current Procedural Terminology, CPT 99250) or scanning computerized ophthalmic diagnostic imaging (SCODI; CPT 92135) was determined.

RESULTS

A total of 48% of patients did not have any form of imaging during the study period. Among those who were imaged, 27% were imaged only once. The use of fundus photography was significantly lower than the use of SCODI (p < 0.00005). A total of 75% of those imaged once received SCODI while only 25% were photographed. Analysis of optic nerve complex imaging over time revealed that 20% received SCODI and 6% were photographed in the first quarter of appearance of the glaucoma or suspect diagnosis code in the dataset, with a decline thereafter.

CONCLUSIONS

Optic disc imaging in patients diagnosed with glaucoma or glaucoma suspect may not meet guidelines set by the American Academy of Ophthalmology. While both modalities are underused, optic disc photos are performed less often and repeated less frequently when compared to SCODI. Underuse of imaging may negatively impact detection of disease progression over time in glaucoma patients.

Postoperative complications in the Tube Versus Trabeculectomy (TVT) study during five years of follow-up

PURPOSE

To describe postoperative complications encountered in the Tube Versus Trabeculectomy (TVT) Study during 5 years of follow-up.

DESIGN

Multicenter randomized clinical trial.

METHODS

SETTINGS

Seventeen clinical centers.

STUDY POPULATION

Patients 18 to 85 years of age who had previous trabeculectomy and/or cataract extraction with intraocular lens implantation and uncontrolled glaucoma with intraocular pressure (IOP) ≥18 mm Hg and ≤40 mm Hg on maximum tolerated medical therapy.

INTERVENTIONS

Tube shunt (350-mm(2) Baerveldt glaucoma implant) or trabeculectomy with mitomycin C (MMC 0.4 mg/mL for 4 minutes).

MAIN OUTCOME MEASURES

Surgical complications, reoperations for complications, visual acuity, and cataract progression.

RESULTS

Early postoperative complications occurred in 22 patients (21%) in the tube group and 39 patients (37%) in the trabeculectomy group (P = .012). Late postoperative complications developed in 36 patients (34%) in the tube group and 38 patients (36%) in the trabeculectomy group during 5 years of follow-up (P = .81). The rate of reoperation for complications was 22% in the tube group and 18% in the trabeculectomy group (P = .29). Cataract extraction was performed in 13 phakic eyes (54%) in the tube group and 9 phakic eyes (43%) in the trabeculectomy group (P = .43).

CONCLUSIONS

A large number of surgical complications were observed in the TVT Study, but most were transient and self-limited. The incidence of early postoperative complications was higher following trabeculectomy with MMC than tube shunt surgery. The rates of late postoperative complications, reoperation for complications, and cataract extraction were similar with both surgical procedures after 5 years of follow-up.

Severe adverse events after cataract surgery among medicare beneficiaries

PURPOSE

To determine rates and risk factors associated with severe postoperative complications after cataract surgery and whether they have been changing over the past decade.

DESIGN

Retrospective longitudinal cohort study.

PARTICIPANTS

A total of 221 594 Medicare beneficiaries who underwent cataract surgery during 1994-2006.

METHODS

Beneficiaries were stratified into 3 cohorts: those who underwent initial cataract surgery during 1994-1995, 1999-2000, or 2005-2006. One-year rates of postoperative severe adverse events (endophthalmitis, suprachoroidal hemorrhage, retinal detachment) were determined for each cohort. Cox regression analyses determined the hazard of developing severe adverse events for each cohort with adjustment for demographic factors, ocular and medical conditions, and surgeon case-mix.

MAIN OUTCOME MEASURES

Time period rates of development of severe postoperative adverse events.

RESULTS

Among the 221 594 individuals who underwent cataract surgery, 0.5% (1086) had at least 1 severe postoperative complication. After adjustment for confounders, individuals who underwent cataract surgery during 1994-1995 had a 21% increased hazard of being diagnosed with a severe postoperative complication (hazard ratio [HR] 1.21; 95% confidence interval [CI], 1.05-1.41) relative to individuals who underwent cataract surgery during 2005-2006. Those who underwent cataract surgery during 1999-2000 had a 20% increased hazard of experiencing a severe complication (HR 1.20; 95% CI, 1.04-1.39) relative to the 2005-2006 cohort. Risk factors associated with severe adverse events include a prior diagnosis of proliferative diabetic retinopathy (HR 1.62; 95% CI, 1.07-2.45) and cataract surgery combined with another intraocular surgical procedure on the same day (HR 2.51; 95% CI, 2.07-3.04). Individuals receiving surgery by surgeons with the case-mix least prone to developing a severe adverse event (HR 0.52; 95% CI, 0.44-0.62) had a 48% reduced hazard of a severe adverse event relative to recipients of cataract surgery performed by surgeons with the case-mix most prone to developing such outcomes.

CONCLUSIONS

Rates of sight-threatening adverse events after cataract surgery declined during 1994-2006. Future efforts should be directed to identifying ways to reduce severe adverse events in high-risk groups.

[Glaucoma surgery in childhood]

Technical characteristics and a long-term therapeutic strategy due to a long life expectancy play a key role in pediatric glaucoma surgery. The well-established angle surgery (goniotomy and trabeculotomy) achieves successful results in primary childhood glaucoma. Trabeculectomy seems to have been displaced as a secondary approach by glaucoma drainage devices (GDD) in primary childhood glaucoma due to inferior results, especially for children under 3 years of age. Even for secondary childhood glaucoma the results of GDD are encouraging, especially for therapy refractory aphakic glaucoma. In the first 2 years after GDD surgery success rates are about 80% for pediatric glaucoma and the results appear to be independent of the type of glaucoma and implant used. The complications of GDD are balanced to the faster intraocular pressure (IOP) control during the phase of visual acuity development. Cyclodestructive procedures may be applied as a secondary adjuvant approach but they increase the risk of conjunctival scarring and hypotony for subsequent procedures.

Update on aqueous shunts

Medicare claims data and surveys of the American Glaucoma Society membership show that aqueous shunts are being increasingly utilized in the surgical management of glaucoma. New clinical trials data have identified differences in the efficacy and safety of shunts in common use. Recent studies have reported comparable results with trabeculectomy and aqueous shunts in similar patient groups. Intraoperative and postoperative complications may develop with aqueous shunt surgery related to the implantation of a foreign material. Several modifications in surgical technique have been directed toward improving surgical success, reducing complications, and optimizing efficiency and cost.

Management of complications in glaucoma surgery

Surgical option for glaucoma is considered when other modalities are not working out to keep the intraocular pressure under control. Since the surgical procedures for glaucoma disrupt the integrity of the globe, they are known to produce various complications. Some of those complications can be vision-threatening. To minimize the morbidity, it is very important that one should know how to prevent them, recognize them and treat them. The objective of this article is to provide insight into some of those complications that will help the ophthalmologists in treating glaucoma patients in their clinical practice.

Review of results from the Tube Versus Trabeculectomy Study

PURPOSE OF REVIEW

The Tube Versus Trabeculectomy (TVT) Study is a multicenter randomized clinical trial comparing the safety and efficacy of tube-shunt surgery to trabeculectomy with mitomycin (MMC) in eyes with previous cataract and/or unsuccessful glaucoma surgery. This article reviews published results from the TVT Study.

RECENT FINDINGS

Tube-shunt surgery had a higher success rate than trabeculectomy with MMC during the first 3 years of follow-up. Trabeculectomy with MMC produced greater intraocular pressure (IOP) reduction in the early postoperative period compared with tube-shunt placement, but similar IOPs were observed after 3 months. Tube-shunt surgery was associated with greater use of adjunctive-medical therapy than trabeculectomy with MMC during the first 2 years of the study, but no difference in medication use was seen at 3 years. The incidence of postoperative complications was higher after trabeculectomy with MMC compared with tube-shunt surgery, but serious complications associated with vision loss and/or reoperation developed with similar frequency after both surgical procedures. No difference in the rate of vision loss was present following trabeculectomy with MMC and tube-shunt surgery after 3 years of follow-up. Cataract progression was common, but occurred with similar frequency with both procedures.

SUMMARY

Intermediate-term results of the TVT Study support the expanded use of tube shunts beyond refractory glaucomas. Tube-shunt surgery is an appropriate surgical option in patients who have undergone prior cataract and/or unsuccessful filtering surgery.

Cataract surgery to lower intraocular pressure

Cataract and glaucoma are common co morbidities. Cataract surgery is frequently performed in patients with glaucoma. In this study, a review of literature with search terms of cataract, glaucoma and intraocular pressure is followed by evaluation and synthesis of data to determine the effect of cataract surgery on intraocular pressure. Cataract surgery seems to lower intraocular pressure on a sustained basis, especially in patients with higher preoperative intraocular pressure. The mechanism of action of these finds remains speculative.

Adverse events after pars plana vitrectomy among medicare beneficiaries

OBJECTIVES

To assess the complication rates of pars plana vitrectomy (PPV) among older Americans and to determine whether rates of adverse events and additional operations have changed during the past decade.

METHODS

Claims data were reviewed to identify all adults aged 68 years or older in the 5% Medicare sample who underwent their first PPV during 1994-1995, 1999-2000, and 2004-2005. One-year rates of severe complications (endophthalmitis, suprachoroidal hemorrhage, or retinal detachment), less severe complications, receipt of an additional operation, and blindness were calculated and compared among the 3 groups using Cox regression. Analyses were adjusted for prior adverse events (during the previous 3 years), demographic characteristics, and comorbid conditions.

RESULTS

The 1994-1995, 1999-2000, and 2004-2005 cohorts had 3263, 5064, and 5263 patients, respectively. The 1-year severe complication rates did not differ among the 3 groups (range, 4.8%-5.5%). The hazard of a less severe complication or an additional operation was higher in the 2004-2005 cohort than in the earlier cohorts (P < .05 for all comparisons). The hazard of endophthalmitis was higher in black individuals (P = .07) and those of other races (P = .02) than in white patients.

CONCLUSIONS

During the past decade, rates of severe complications after PPV remained stable, but rates of less severe complications and subsequent operations increased. Future studies should explore the potential factors that explain these changes and the alarming elevated incidence of post-PPV endophthalmitis among nonwhite individuals.

Three-year follow-up of the tube versus trabeculectomy study

PURPOSE

To report 3-year results of the Tube Versus Trabeculectomy (TVT) Study.

DESIGN

Multicenter randomized clinical trial.

METHODS

SETTING

Seventeen clinical centers.

STUDY POPULATION

Patients 18 to 85 years of age who had previous trabeculectomy, cataract extraction with intraocular lens implantation, or both and uncontrolled glaucoma with intraocular pressure (IOP) > or =18 mm Hg and < or =40 mm Hg on maximum tolerated medical therapy.

INTERVENTIONS

A 350-mm(2) Baerveldt glaucoma implant or trabeculectomy with mitomycin C (MMC 0.4 mg/ml for 4 minutes).

MAIN OUTCOME MEASURES

IOP, visual acuity, use of supplemental medical therapy, surgical complications, and failure (IOP >21 mm Hg or not reduced by 20%, IOP < or =5 mm Hg, reoperation for glaucoma, or loss of light perception vision).

RESULTS

A total of 212 eyes of 212 patients were enrolled, including 107 in the tube group and 105 in the trabeculectomy group. At 3 years, IOP (mean +/- standard deviation [SD]) was 13.0 +/- 4.9 mm Hg in the tube group and 13.3 +/- 6.8 mm Hg in the trabeculectomy group (P = .78). The number of glaucoma medications (mean +/- SD) was 1.3 +/- 1.3 in the tube group and 1.0 +/- 1.5 in the trabeculectomy group (P = .30). The cumulative probability of failure during the first 3 years of follow-up was 15.1% in the tube group and 30.7% in the trabeculectomy group (P = .010; hazards ratio, 2.2; 95% confidence interval, 1.2 to 4.1). Postoperative complications developed in 42 patients (39%) in the tube group and 63 patients (60%) in the trabeculectomy group (P = .004). Surgical complications were associated with reoperation and/or loss of > or =2 Snellen lines in 24 patients (22%) in the tube group and 28 patients (27%) in the trabeculectomy group (P = .58).

CONCLUSIONS

Tube shunt surgery had a higher success rate compared to trabeculectomy with MMC during the first 3 years of follow-up in the TVT Study. Both procedures were associated with similar IOP reduction and use of supplemental medical therapy at 3 years. While the incidence of postoperative complications was higher following trabeculectomy with MMC relative to tube shunt surgery, most complications were transient and self-limited.

The medical and surgical treatment of glaucoma

BACKGROUND

Ongoing demographic changes in Europe are heightening the importance of adequate treatment for glaucoma, a disorder that is markedly more common in the elderly.

METHOD

A selective search for relevant literature, including Cochrane Reviews and the guidelines of the European Glaucoma Society, regarding the topical and surgical treatment of glaucoma.

RESULTS

It is recommended that the intraocular pressure (IOP) should be lowered by 20% to 50% from its baseline value, depending on the extent of already existing damage, the rate of progression, the baseline IOP, and the age of the patient. Topical monotherapy can lower the IOP by 15% to 30%. The success rate of filtration surgery has risen because of the intraoperative application of topical antimetabolites and currently ranges from 50% to 90%, depending on the study.

CONCLUSIONS

The goal of glaucoma treatment is to protect the patient from blindness and visual impairment while keeping the treatment-related decline in quality of life to a minimum. Any type of glaucoma treatment, be it medical or surgical, must further this aim in consideration of the situation of the individual patient.

Tube shunt complications and their prevention

PURPOSE OF REVIEW

Glaucoma drainage devices (GDDs) have been generally accepted as a treatment of refractory glaucoma. GDDs have their own unique set of complications that are important to evaluate to prevent them.

RECENT FINDINGS

Tube shunts are typically used in eyes with refractory glaucoma. There is increased interest in studying the efficacy of GDDs. Most of the attention has been focused on comparing trabeculectomy with the Baerveldt implant (Advanced Medical Optics, Inc., Santa Anna, California, USA). The other leading implant is the Ahmed Glaucoma Valve. There are several retrospective studies comparing these two devices and a prospective study is ongoing. There is great interest in the complication rate of tube shunts and these have been published both retrospectively and prospectively. Complications such as hypotony, diplopia, strabismus, proptosis, tube erosion, failure, corneal decompensation, endophthalmitis, and visual loss are all important and some have recently been reviewed in the literature. Moreover, the use of glaucoma drainage implants in the pediatric population has been evaluated.

SUMMARY

Glaucoma drainage implants have been a powerful tool in our surgical fight to prevent blindness; however, they are not without complications or controversy.