The relation of volume and outcome in trabeculectomy

Prospective Study of Canaloplasty and Trabeculotomy Performed by Trainees

Purpose

To evaluate outcomes of new adopters of the OMNI® Surgical System (Sight Sciences, Inc.) by prospectively evaluating intermediate-term outcomes of patients operated by trainees.

Patients and Methods

This was a prospective study of surgeries performed by trainees on patients with open angle glaucoma undergoing simultaneous cataract surgery and ab interno canaloplasty and trabeculotomy using the OMNI Surgical System. Pre-operative intraocular pressure (IOP) and number of glaucoma medications were recorded. Only patients with a minimum of 6-month follow up were included. Baseline IOP was used to separate subjects into two groups: Group 1 (IOP ≥18 mmHg) and Group 2 (IOP <18 mmHg). Mean decrease in IOP and medications was calculated and compared with paired t-tests for the overall sample as well as the subgroups. Success was defined as those with a ≥20% reduction from pre-operative IOP or with an IOP ≤18 mmHg and ≥6 mmHg and on the same or fewer number of medications while not requiring additional surgery. Adverse events were also recorded.

Results

Forty-two eyes of 31 patients were included. Mean pre-operative IOP was 17.2 ± 4.8 mmHg and mean number of medications was 2.4 ± 1.2. The primary endpoint was reached in 83.3% of patients at 12 months. IOP was reduced by 22.3% to 13.4 ± 2.4 (p<0.001). Mean number of medications decreased to 1.7 ± 1.6 (p<0.001). Group 1 mean IOP decreased 35.4% from 22.2 ± 4.6 mmHg to 14.3 ± 2.8 mmHg (p<0.001). Group 2 mean number of medications decreased from 2.3 ± 1.1 to 1.6 ± 1.5 (p<0.001).

Conclusion

When operated on by the novice MIGS surgeon, the OMNI device provides effective IOP and glaucoma medication reduction with minimal adverse events. Efficacy and safety of the device in the hands of trainees was comparable to experienced glaucoma surgeons suggesting its ease of adoption.

The Ophthalmology Surgical Competency Assessment Rubric for Trabeculectomy

PURPOSE

To produce an internationally valid tool to assess skill in performing trabeculectomy surgery.

METHODS

A panel of 5 experts developed a tool for assessing trabeculectomy surgery by using a modified Dreyfus scale of skill acquisition and providing descriptors for each level of skill for each category. The tool was then reviewed by a panel of 10 international content experts for their constructive comments, which were incorporated into the final rubric tool.

RESULTS

A final rubric, incorporating the suggestions of the international panel, published here as the ICO-OSCAR: Trabeculectomy.

CONCLUSIONS

The tool ICO-OSCAR: Trabeculectomy has content and face validity. It can be used internationally to assess trabeculectomy surgery skill. Predictive and construct validity, and reliability are yet to be determined.

Incidence of short-term complications and associated factors after primary trabeculectomy in Chiang Mai University Hospital

BACKGROUND

To determine the incidence of early postoperative complications and associated factors after primary trabeculectomy in Thai glaucoma patients.

DESIGN

This was a retrospective observational study performed in Chiang Mai University Hospital.

PARTICIPANTS

One hundred and eighteen glaucoma patients participated in the study.

METHODS

All glaucoma patients underwent primary trabeculectomy with mitomycin C (MMC) using fornix-based conjunctival flap technique between December 2011 and May 2013. Surgical complications during the first 3 months of follow-up were recorded, and associated risk factors were analyzed.

MAIN OUTCOME MEASURES

The incidence of posttrabeculectomy complications was the main outcome measure.

RESULTS

One hundred and eighteen eyes of 118 patients were included. Early postoperative complications developed in 55 eyes (56.7%). Complications included hypotony (25 eyes, 27.2%), serous choroidal detachment (CD) (14 eyes, 15.6%), subconjunctival hemorrhage (12 eyes, 13.0%), hyphema (11 eyes, 12.4%), bleb leak (8 eyes, 8.8%), encapsulated bleb (2 eyes, 2.2%), aqueous misdirection (1 eyes, 1.1%), corneal epithelial defect (1 eyes, 1.1%), and overfiltration (1 eyes, 1.1%). There were no reported cases of endophthalmitis or blebitis. Hypotony was associated with serous CD (P = 0.006), and hyphema was associated with neovascular glaucoma (NVG) patients (P = 0.009). NVG was not associated with the increased rate of surgical failure (P = 0.083).

CONCLUSIONS

The incidence of early complications after first-time trabeculectomy with MMC was high (56.7%) in this Thai clinic setting, but most were transient and self-limited conditions. The correlations between hypotony and CD as well as hyphema and NVG were compatible with the previous studies.

Clinic-based glaucoma care in the era of surgical subspecialization

PURPOSE

To evaluate the impact of surgeon practice profile on clinic-based glaucoma care.

DESIGN

Population-based study of glaucoma care patterns in Ontario, Canada from 2000-2010.

METHODS

Using comprehensive physician services data from the Ontario Health Insurance Plan database, ophthalmologists were divided into 5 surgical practice subgroups. The role of each subgroup in the provision of glaucoma care was evaluated. Consultations and office visits were used to assess nonsurgical care, while laser trabeculoplasty procedures were used to assess clinic-based procedural care.

RESULTS

Between 2000 and 2010, the population rate of glaucoma consultations and follow-up visits provided by ophthalmologists who do not perform incisional glaucoma surgery increased at average annual rates of 1.6% (P < .0002) and 3.3% (P < .0001), respectively. In contrast, no significant growth in the rate of glaucoma consultations or follow-up visits provided by glaucoma surgeons was observed (0.8%/year [P = .2] for consultations; 0.2%/year [P = .6] for follow-up visits). Between 2000 and 2010, the rate of laser trabeculoplasty procedures provided by ophthalmologists who do not perform incisional glaucoma surgery increased 19.3% annually (P < .0001), while growth among glaucoma surgeons was more modest (annual growth of 9.2% [P = .0002]).

CONCLUSIONS

While subspecialization is a growing reality in most areas of medicine, we found that the provision of clinic-based glaucoma care remains dependent on ophthalmologists who do not perform incisional glaucoma surgery. With increasing focus on integrated care, these findings will have important implications for residency education programs and their accrediting bodies and will inform decisions of health care policymakers, hospitals, and academic departments.

Orbital decompression for Graves' orbitopathy in England

AIMS

The purpose of this study was to obtain data on orbital decompression procedures performed in England, classed by hospital and locality, to evaluate regional variation in care.

METHODS

Data on orbital decompression taking place in England over a 2-year period between 2007 and 2009 were derived from CHKS Ltd and analysed by the hospital and primary care trust.

RESULTS AND CONCLUSIONS

In all, 44% of these operations took place in hospitals with an annual workload of 10 or fewer procedures. Analysis of the same data by primary care trust suggests an almost 30-fold variance in the rates of decompression performed per unit population. Expertise available to patients with Graves' orbitopathy and rates of referral for specialist care in England appears to vary significantly by geographic location. These data, along with other outcome measures, will provide a baseline by which progress can be judged.