Microinvasive Glaucoma Surgery in US Ophthalmology Residency: Surgical Case Log Cross-sectional Analysis and Proposal for New Glaucoma Procedure Classification

Glaucoma Surgery SOS: Emergency Department Utilization Greater Among Younger and First-Time Surgical Glaucoma Patients

PURPOSE

To describe the frequency, findings, and interventions of patients' emergency department visits after all types of glaucoma surgery DESIGN: Retrospective cohort study SUBJECTS: All surgical glaucoma patients between 2013 and 2021 METHODS: This single institution study collected demographics, surgery type, and surgical parameters for each patient. Subsequently, for those visiting the emergency department within 50 days of surgery, data was collected on reason for visit, findings, and ophthalmic intervention. Logistic regression models were used to determine the odds of ED visits based on multiple risk factors.

MAIN OUTCOME

Postoperative presentation to ED RESULTS: Among 9155 surgeries in 5505 patients, 5.7% had ED visits within 50 days, with 46.3% having ocular complaints. Patients with ocular diagnoses presented earlier than those without (p < 0.001). Patients who presented to the ED with an ocular diagnosis were found to be significantly younger than those who did not present (62.2 ± 18.6 vs 65.4 ± 18.0 years old, p < 0.028). Furthermore, white patients were more likely than black patients to present with an ocular diagnosis compared to a non-ocular diagnosis (OR 2.64, 95% CI 1.67-4.18, p<0.001). Patients undergoing their first glaucoma surgery had a much higher chance of presenting to the ED compared to patients who had undergone more than one surgery (OR: 3.75, 95%CI 2.74 - 5.14, p < 0.001). Those who underwent traditional surgeries were more likely than patients with trabecular meshwork bypass stent (TMBS) to present to the ED with an ocular diagnosis (OR: 3.02, 95% CI 1.29 - 7.08, p = 0.011). Filtering surgeries and glaucoma drainage device (GDD) revisions exhibited more vision-threatening conditions than glaucoma drainage devices (p = 0.037 and p = 0.010 respectively). Ophthalmology consultation was sought for 88.0% of ocular diagnoses. Most received medical therapy (71.0%), primarily IOP-lowering drops.

CONCLUSION

ED visits after glaucoma surgery are infrequent, yet more often seen in younger patients or those undergoing their first glaucoma surgery. TMBS, but not trabecular meshwork excision and/or Schlemm's canal dilation (TME/SCD), were less likely to present to the ED than traditional surgeries. Filtering surgeries and tube revisions presented more often with visual threatening conditions.

Techniques and Preferences for Nonvalved Aqueous Shunts: A Survey of American Glaucoma Society Members

PURPOSE

To assess practice patterns and opinions of glaucoma specialists regarding indications, surgical technique, and postoperative management for nonvalved aqueous shunts.

DESIGN

Anonymous online survey study.

PARTICIPANTS

American Glaucoma Society (AGS) members.

METHODS

An anonymous online survey was distributed to glaucoma specialists via the AGS forum from June to August 2022.

MAIN OUTCOME MEASURES

Survey questions and responses were assessed in 4 sections: (1) general demographics and practice patterns; (2) nonvalved tubes vs. trabeculectomy; (3) nonvalved tubes vs. valved tubes; and (4) nonvalved tube techniques.

RESULTS

There were 132 respondents; nonvalved tubes were reported to be performed more often than trabeculectomy by 61% of respondents within 5 years of completing training and 23% of respondents with more than 15 years since completing training. The most frequently preferred types of nonvalved tubes were Baerveldt-350 (41%), Baerveldt-250 (27%), and ClearPath-250 (18%). In patients with lower target intraocular pressure (IOP), 92% of respondents preferred trabeculectomy over nonvalved tube; 33% cited a cutoff of < 12 mmHg, and 31% cited a cutoff of < 15 mmHg. In patients with higher preoperative IOP, 50% of respondents preferred valved over nonvalved tubes; 29% cited a cutoff of > 40 mmHg, and 38% cited a cutoff of > 30 mmHg. The most frequently used ligature was 7-0 Vicryl (69%). The most frequently used strategies for early IOP lowering were fenestrations without wicks (70%) and with wicks (22%), with one 10-0 Nylon being the most used wick technique (22%). Overall, 37% of respondents use a ripcord; among ripcord users, 55% use it for hypotony prevention (3-0 Prolene most common for this purpose at 35%), and 40% use it for optional early IOP lowering (4-0 Nylon most common for this purpose at 21%). If IOP is too high at postoperative week 4, 38% of respondents do not open the tube early.

CONCLUSIONS

We demonstrate significant heterogeneity regarding specific indications, surgical technique, and postoperative management for nonvalved tubes. Future work is needed to identify and develop standardized guidelines alongside best practices.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Outcomes of Trainee-performed MIGS at Parkland Memorial Hospital: A Retrospective Cohort Study

Aims and background

As the use of minimally invasive or microinvasive glaucoma surgery (MIGS) continues to expand, it is important to look at its outcomes in the hands of trainees. This study aims to examine the efficacy and safety of Kahook Dual Blade (KDB) goniotomy and endocyclophotocoagulation (ECP) with cataract extraction (CE) done by residents and fellows.

Methods

All cases of KDB or ECP performed with CE between 2012 and 2020 at Parkland were reviewed, excluding cases with multiple MIGS procedures or other procedures.

Results

A total of 153 eyes of 136 patients who underwent KDB and 125 eyes of 124 patients who underwent ECP were included. Mean intraocular pressure (IOP) decreased from 17.2 ± 5.2 at baseline to 15.4 ± 5.5 mm Hg at postoperative (post-op) month (POM) 12 in the KDB group (p = 0.02) and from 18.6 ± 6.3 at baseline to 15.1 ± 4.9 mm Hg at POM12 in the ECP group (p < 0.001), with wide variation in IOP change among subjects for both. The mean change in IOP across all time points was statistically significant for both groups. Medication counts were reduced from baseline at POMs 1, 3, and 6, but not 12, in both the KDB and ECP groups (p = 0.43 and p = 0.35, respectively). The rate of serious complications was very low; the most common complication was cystoid macular edema (CME) (six cases) and active inflammation beyond POM1 (15 cases) for KDB and ECP, respectively.

Conclusion

Combined CE/MIGS procedures performed by trainees were safe but less efficacious in lowering IOP and medications compared to literature reporting outcomes of attending surgeons, apart from ECP/MIGS with regards to IOP lowering, which was found to be similarly efficacious.

Clinical significance

Cataract extraction (CE) combined with KDB or ECP in the hands of trainees decreased mean IOP from baseline and was safe. IOP and medication reduction of MIGS/CE in the hands of trainees were overall lesser than reported values by attending surgeons.

How to cite this article

Da J, Gillings M, Kamat S, et al. Outcomes of Trainee-performed MIGS at Parkland Memorial Hospital: A Retrospective Cohort Study. J Curr Glaucoma Pract 2023;17(3):134-140.

Safety and Efficacy of Resident-Performed Gonioscopy-Assisted Transluminal Trabeculotomy

PRCIS

GATT can be performed efficaciously and safely by PGY-3 and PGY-4 residents, with clinical outcomes and complication rates that mirror those of attending-performed GATT cohorts from the literature.

PURPOSE

Report outcomes of gonioscopy-assisted transluminal trabeculotomy (GATT) performed by PGY-3 and PGY-4 residents.

METHODS

A retrospective chart review was performed for patients undergoing resident-performed GATT. Eyes with previous traditional glaucoma surgery (trabeculectomy or aqueous shunt) or neovascular glaucoma were excluded from this analysis. The primary aim was to assess whether resident-performed GATTs demonstrated success rates comparable with the GATT literature. Surgical success was defined as intraocular pressure (IOP)<21 mmHg, and an IOP reduction of 20% from baseline, and no subsequent IOP-lowering surgery. The secondary and tertiary aims were to describe complication rates and operating times for resident-performed GATTs, respectively.

RESULTS

A total of 50 eyes from 40 patients with various types of glaucoma were included. Eyes either underwent resident-performed GATT-alone (N=9) or GATT+cataract extraction with intraocular lens implantation (CEIOL) (N=41). The surgical success rate at 6 months was 71% for GATT-alone and 42% for GATT+CEIOL. Three eyes required subsequent IOP-lowering surgery. The hyphema rate was 16% at postoperative week 1 and 6% at postoperative month 1. The IOP spike (>30 mmHg) rate was 18%. Mean surgical time for both GATT-alone and GATT+CEIOL was longer for PGY-4s than for PGY-3s, attributable to less attending assistance during PGY-4 cases and more resident-performed cataracts in PGY-4 GATT+CEIOL cases (85%) compared with PGY-3 cases (35%).

CONCLUSIONS

GATT can be performed efficaciously and safely by PGY-3 and PGY-4 residents, with clinical outcomes and complication rates that mirror those of attending-performed GATT cohorts from the literature.

Ophthalmology Resident Ophthalmic Trauma Case Exposure: Trends Over Time and an ACGME Case Log Analysis

Purpose

To describe ophthalmology resident experience with ophthalmic trauma cases in the U.S. 

Methods

We analyzed Accreditation Council for Graduate Medical Education (ACGME) case log data and de-identified case logs from US ophthalmology residency programs for residents graduating in 2018.  Current Procedural Terminology (CPT) codes documented as “Globe Trauma” and  trauma-related “Oculoplastic and Orbit” codes including lid lacerations and lateral canthotomies were analyzed.

Results

38 residency programs provided case logs (response rate: 32.2%). Residents performed an average of 7.24±4.37 open globe repairs, 8.66±6.94 lid laceration repairs, 0.49±1.4 orbital fracture repairs, 1.22±1.81 lateral canthotomies, and 0.28±0.69 anterior chamber washouts as primary surgeon. On average, the most logged “Globe Trauma” procedure was open globe repair as primary surgeon. The more common trauma-related “Oculoplastic and Orbit” procedure was lid laceration repair as primary surgeon.  42.8% of residents did not log any lateral canthotomy procedures. Medium programs performed significantly more canthotomies than large programs (F(2166) = 6.35, p = 0.002), and large programs performed significantly more orbital fracture repairs than small and medium programs (F(2166) = 4.45, p = 0.013).

Conclusion

Significant variation in globe trauma volume exists across programs. ACGME guidelines require a minimum of four globe trauma procedures for graduation, but procedures like anterior chamber paracentesis count towards this requirement. Open globe repairs, simple lid lacerations, and lateral canthotomies are basic skills every graduating resident should be competent in. Updating ACGME case log requirements for ophthalmic trauma and increasing opportunities for wet lab simulations may assist in ensuring graduating ophthalmology residents’ competency in performing these procedures.