Amy Chomsky

Intraoperative Floppy Iris and Prevalence of Intraoperative Complications: Results From Ophthalmic Surgery Outcomes Database

PURPOSE To estimate the prevalence of untoward events during cataract surgery with the use of pupillary expansion devices and intraoperative floppy iris (IFIS). DESIGN Retrospective analysis of 4923 cataract surgery cases from the Veterans Affairs Ophthalmic Surgical Outcomes Data Project. METHODS Outcomes from 5 Veterans Affairs medical centers were analyzed, including use of alpha-blockers (both selective and nonselective), IFIS, intraoperative iris trauma, intraoperative iris prolapse, posterior capsular tear, anterior capsule tear, intraoperative vitreous prolapse, and use of pupillary expansion devices. P values were calculated using the χ(2) test. RESULTS A total of 1254 patients (25.5%) took alpha-blockers preoperatively (selective, 587; nonselective, 627; both, 40). Of these 1254 patients, 428 patients (34.1%) had documented IFIS. However, 75.2% of patients with IFIS (428/569) had taken alpha-blockers preoperatively (P < .00001). A total of 430 patients (8.7%) had a pupillary expansion device used during their cataract surgery, of which 186 patients (43.4%) had IFIS (P < .0001). Eighty-six patients with IFIS had at least 1 intraoperative complication and 39 patients with IFIS had more than 1 intraoperative complication (P < .001). CONCLUSIONS The use of either selective or nonselective alpha-antagonists preoperatively demonstrated a significant risk of IFIS. Nonselective alpha-antagonists caused IFIS at a higher prevalence than previously reported. This study did demonstrate statistically significant increased odds of surgical complications in patients with IFIS vs those without IFIS in all groups (those taking selective and nonselective alpha-antagonists and also those not taking medications).

Reducing the Risk of Endophthalmitis After Intravitreous Injection

I NTRAVITREOUS (IVT) INJECtion is the fastest growing procedure in ophthalmology. The number of IVT injections performed in the United States, estimated from Medicare procedure codes, increased from fewer than 3000 injections per year in 1999 to more than 1 million injections in 2008, and the number of injections will continue to increase given the aging population and the expanding indications. Because of the potential for severe vision loss, endophthalmitis remains the most feared complication after IVT injection, with a reported incidence ranging from 0.02% to 0.2%. However, because many retinal conditions require long-term serial injections, the cumulative risk per treated patient is more significant. Furthermore, several recent outbreaks of endophthalmitis have occurred in cities across the United States owing to contaminated bevacizumab, which has raised further safety concerns regarding this procedure. With the rapid increase in injections, this subject merits further review and summative assessments of best practice.

Antibacterial properties of 2% lidocaine and reduced rate of endophthalmitis after intravitreal injection.

Purpose: To determine whether the application of subconjunctival 2% lidocaine/0.1% methylparaben for anesthesia may reduce rates of endophthalmitis after intravitreal (IVT) injection. Methods: We performed in vitro experiments to determine the antibacterial properties of 2% lidocaine/0.1% methylparaben (lidocaine) against causative organisms of endophthalmitis. Isolates of Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus viridans from patients with endophthalmitis were incubated with or without lidocaine. Aliquots (100 µL) were plated on Mueller–Hinton (S. aureus and S. epidermidis) or blood agar plates (S. viridans) at 0, 10, 30, 120, and 240 minutes, and colonies were counted after 24 hours. A retrospective review of 15,042 IVT injections was performed from January 2004 to February 2011 to determine the rate of endophthalmitis with or without application of subconjunctival lidocaine for anesthesia. Results: Lidocaine demonstrated rapid bactericidal effects against all 3 organisms. After 10 minutes of exposure, there was approximately a 90% (P < 0.01), 95% (P < 0.001), and 92% (P < 0.001) reduction in colony forming units when compared with time 0 for S. aureus, S. epidermidis, and S. viridans, respectively. Complete elimination of colony forming units occurred at subsequent time points for each organism in contrast to logarithmic increase for control plates. There were a total of 0 cases of endophthalmitis of 6,853 IVT injections performed with subconjunctival lidocaine and 8 cases of endophthalmitis of 8,189 (0.1%) IVT injections performed with other methods of anesthesia (P = 0.03). Conclusion: Application of subconjunctival 2% lidocaine/0.1% methylparaben for anesthesia may reduce the incidence of endophthalmitis after IVT injection.

Outcomes of cataract surgery with residents as primary surgeons in the Veterans Affairs Healthcare System.

Purpose To explore visual outcomes, functional visual improvement, and events in resident‐operated cataract surgery cases. Setting Veterans Affairs Ophthalmic Surgery Outcomes Database Project across 5 Veterans Affairs Medical Centers. Design Retrospective data analysis of deidentified data. Methods Cataract surgery cases with residents as primary surgeons were analyzed for logMAR corrected distance visual acuity (CDVA) and vision‐related quality of life (VRQL) measured by the modified National Eye Institute Vision Function Questionnaire and 30 intraoperative and postoperative events. In some analyses, cases without events (Group A) were compared with cases with events (Group B). Results The study included 4221 cataract surgery cases. Preoperative to postoperative CDVA improved significantly in both groups (P < .0001), although the level of improvement was less in Group B (P = .03). A CDVA of 20/40 or better was achieved in 96.64% in Group A and 88.25% in Group B (P < .0001); however, Group B had a higher prevalence of preoperative ocular comorbidities (P < .0001). Cases with 1 or more events were associated with a higher likelihood of a postoperative CDVA worse than 20/40 (odds ratio, 3.82; 95% confidence interval, 2.92‐5.05; P < .0001) than those who did not experience an event. Both groups had a significant increase in VRQL from preoperative levels (both P < .0001); however, the level of preoperative to postoperative VRQL improvement was significantly less in Group B (P < .0001). Conclusion Resident‐operated cases with and without events had an overall significant improvement in visual acuity and visual function compared with preoperatively, although this improvement was less marked in those that had an event. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

Functional Visual Improvement After Cataract Surgery in Eyes With Age-Related Macular Degeneration: Results of the Ophthalmic Surgical Outcomes Data Project.

PURPOSE To determine if cataract surgery on eyes with AMD confers as much functional visual improvement as surgery on eyes without retinal pathology. METHODS This is a retrospective analysis of 4924 cataract surgeries from the Veterans Healthcare Administration Ophthalmic Surgical Outcomes Data Project (OSOD). We included cases of eyes with AMD that had both preoperative and postoperative NEI-VFQ-25 questionnaires submitted and compared their outcomes with controls without retinal pathology. We excluded patients with other retinal pathologies (740 patients). The analyses compared changes in visual acuity and overall functional visual improvement and its subscales using t-tests, multivariate logistic regressions, and linear regression modeling. RESULTS Preoperative and postoperative questionnaires were submitted by 58.3% of AMD and 63.8% of no retinal pathology cases (controls). Analysis of overall score showed that cataract surgery on eyes with AMD led to increased visual function (13.8 ± 2.4 NEI-VFQ units, P < 0.0001); however, increases were significantly less when compared with controls (-6.4 ± 2.9 NEI-VFQ units, P < 0.0001). Preoperative best-corrected visual acuity (preBCVA) in AMD was predictive of postoperative visual function (r = -0.38, P < 0.0001). In controls, postoperative visual function was only weakly associated with preBCVA (r = -0.075, P = 0.0002). Patients with AMD with vision of 20/40 or better had overall outcomes similar to controls (-2.2 ± 4.7 NEI-VFQ units, P = 0.37). CONCLUSIONS Cataract surgery on eyes with AMD offers an increase in functional visual improvement; however, the amount of benefit is associated with the eyes preBCVA. For eyes with preBCVA of 20/40 or greater, the improvement is similar to that of patients without retinal pathology. However, if preBCVA is less than 20/40, the amount of improvement was shown to be significantly less and decreased with decreasing preBCVA.Purpose: To determine if cataract surgery on eyes with age-related macular degeneration (AMD) confers as much functional visual improvement as on eyes without retinal pathology. Methods: This is a retrospective analysis of 4,924 cataract surgeries from the VA Ophthalmic Surgical Outcomes Data Project. We included cases of eyes with AMD which had both preoperative and postoperative NEI-VFQ-25 questionnaires submitted and compared their outcomes to controls without retinal pathology. We excluded patients with other retinal pathologies. The analyses compared changes in visual acuity and overall functional visual improvement and its subscales. Results: Preoperative and postoperative questionnaires were submitted by 58.3% of AMD and 63.8% of controls. Analysis of overall score showed that cataract surgery on eyes with AMD led to increased visual function (13.8± 2.4 NEI-VFQ units, P<0.0001); however, increases were significantly less when compared to controls (-6.4± 2.9 NEI-VFQ units, P<0.0001). Preoperative best corrected visual acuity (preBCVA) in AMD was predictive of postoperative visual function (r=-0.38, P<0.0001). In controls, postoperative visual function was only weakly associated with preBCVA (r=-0.075, P=0.0002). AMD patients with vision of 20/40 or better had overall outcomes similar to controls (-2.2± 4.7 NEI-VFQ units, P=0.37). Conclusions: Cataract surgery on eyes with AMD offers an increase in functional visual improvement; however, the amount of benefit is associated with the eyes preBCVA. For eyes with preBCVA ≥20/40, the improvement is similar to that of patients without retinal pathology. However, if preBCVA is <20/40, the amount of improvement was shown to be significantly less and decreased with decreasing preBCVA.

Outcomes after cataract surgery in eyes with pseudoexfoliation: Results from the Veterans Affairs Ophthalmic Surgery Outcomes Data Project

OBJECTIVE To compare clinical outcomes of cataract surgery in eyes with and without pseudoexfoliation (PXF). DESIGN Retrospective deidentified data analysis. PARTICIPANTS A total of 123 PXF and 4776 non-PXF eyes of patients who underwent cataract surgery. METHODS We compared data on visual acuity, Visual Function Questionnaire (VFQ)-based quality of life, and complications in PXF and non-PXF eyes from the Veterans Affairs (VA) Ophthalmic Surgery Outcomes Data Project across 5 VA medical centres. RESULTS Pupillary expansion devices were used in 31 (25.2%) PXF cases and 398 (8.4%) non-PXF cases (p < 0.0001). Capsular tension rings were used in 6 (4.9%) PXF cases and 55 (1.2%) non-PXF cases (p < 0.004). The following complications occurred more frequently in PXF cases: zonular dehiscence without vitrectomy (4 [3.3%] PXF cases vs 40 [0.8%] non-PXF cases p = 0.02), persistent inflammation (28 [24.1%] vs 668 [14.5%]; p = 0.007), and persistent intraocular pressure elevation (5 [4.3%] vs 68 [1.5%]; p = 0.03). Best corrected visual acuity (BCVA) improved in both groups after 1 month, but 87 (83.7%) PXF cases achieved postoperative BCVA better than or equal to 20/40 compared to 3991 (93.8%) non-PXF cases (p = 0.0003). There was no significant difference in the postoperative composite VFQ scores between PXF (82.1 ± 16.9) and non-PXF cases (84.2 ± 16.8, p = 0.09). CONCLUSIONS Several complications occurred more frequently in the PXF group compared to the non-PXF group, and fewer PXF cases achieved BCVA better than or equal to 20/40. Despite this, both groups experienced similar improvement in vision-related quality of life after cataract surgery.

Incidence and Risk Factors for Chronic Uveitis following Cataract Surgery

Abstract Purpose: To determine the incidence of and associated risk factors for uveitis after cataract surgery. Methods: A total of 17,757 eyes were identified and records of 42 eyes that developed uveitis and 2320 eyes that did not were reviewed. Postsurgical uveitis was defined as persistent inflammation for ≥6 months after surgery. Results: Forty-two eyes of 35 patients developed uveitis (0.24%). Eleven patients underwent consecutive cataract surgery but developed unilateral uveitis, and intraoperative complications occurred in 55% of uveitic eyes compared to 0% in fellow eyes (p < 0.05). Median duration of inflammation was 8 and 11.5 months in eyes with and without vitrectomy (p < 0.05). Intraocular complications occurred in 44 and 8.3% of eyes that did and did not develop uveitis, respectively (p = 0.01). Conclusions: Postsurgical uveitis developed after approximately 1 in 400 cataract surgeries and occurred more frequently in eyes experiencing intraoperative complications.

Cataract Surgery Outcomes in Glaucomatous Eyes: Results From the Veterans Affairs Ophthalmic Surgery Outcomes Data Project

PURPOSE To compare visual acuity outcomes, vision-related quality of life, and complications related to cataract surgery in eyes with and without glaucoma. DESIGN Retrospective cohort study. METHODS Cataract surgery outcomes in cases with and without glaucoma from the Veterans Affairs Ophthalmic Surgical Outcomes Data Project were compared. RESULTS We identified 608 glaucoma cases and 4306 controls undergoing planned cataract surgery alone. After adjusting for age, pseudoexfoliation, small pupil, prior ocular surgery, and anterior chamber depth, we found that glaucoma cases were more likely to have posterior capsular tear with vitrectomy (odds ratio [OR] 1.8, P = .03) and sulcus intraocular lens placement (OR 1.65, P = .03) during cataract surgery. Glaucoma cases were more likely to have postoperative inflammation (OR 1.73, P < .0001), prolonged elevated intraocular pressure (OR 2.96, P = .0003), and additional surgery within 30 days (OR 1.92, P = .03). Mean best-corrected visual acuity (BCVA) and Visual Function Questionnaire (VFQ) scores significantly improved after cataract surgery in both groups (P < .0001), but there were larger improvements in BCVA (P = .01) and VFQ composite scores (P < .0001) in the nonglaucoma vs the glaucoma group. A total of 3621 nonglaucoma cases (94.1%) had postoperative BCVA 20/40 or better, compared to 466 glaucoma cases (89.6%) (P = .0003). CONCLUSIONS Eyes with glaucoma are at increased risk for complications and have more modest visual outcomes after cataract surgery compared to eyes without glaucoma. Despite this, glaucoma patients still experience significant improvement in vision-related outcomes after cataract extraction. Further study is needed to explore potential factors that influence cataract surgery outcomes in glaucomatous eyes.

American Society of Anesthesiologists classification in cataract surgery: Results from the Ophthalmic Surgery Outcomes Data Project.

Purpose To explore the association of American Society of Anesthesiologists (ASA) classification with cataract surgery outcomes. Setting Five Veterans Affairs Medical Centers, United States. Design Retrospective observational cohort study. Methods The study analyzed the outcomes of cataract surgery cases. Corrected distance visual acuity (CDVA), unanticipated events, and vision‐related quality of life (VRQL) were assessed using the National Eye Institute Visual Function Questionnaire (NEI‐VFQ), comparing ASA classes I through IV. For some analyses, ASA classes I and II were designated as Group A and ASA classes III and IV were designated Group B. Results Of the 4923 cases, 875 (17.8%) were in Group A, 4032 (81.9%) were in Group B, and 16 (0.3%) had missing data. The mean CDVA and mean composite NEI‐VFQ score improved after cataract surgery in both groups (P < .0001); however, Group A had a better mean postoperative CDVA and postoperative VFQ composite scores than Group B (P < .0001, both outcomes). A higher ASA class was associated with an increased risk for 2 unanticipated events; that is, clinically significant macular edema (CSME) (Group A: 4 [0.47%] versus Group B: 50 [1.28%]; adjusted odds ratio [OR], 3.02; 95% confidence interval [CI], 1.02‐13.05; P = 0.04) and readmission to the hospital within 30 days (2 [0.23%] versus 56 [1.41%]; OR, 8.26; 95% CI, 1.71‐148.62; P = .004) Conclusions Among United States veterans, the ASA classification could be an important predictor of VRQL and visual outcomes. In this cohort, it was associated with an increased risk for 2 serious unanticipated events—CSME and readmission to the hospital—both costly, unwanted outcomes. Financial Disclosure Dr. Vollman is a consultant to Forsight Vision5. None of the authors has a financial or proprietary interest in any material or method mentioned.

Limitations of using billing databases in an attempt to compare cataract surgery outcomes in Veterans Health Administration versus Medicare.

To the Editor: By reviewing billing databases, French et al, in their article “Comparison of Complication Rates in Veterans Receiving Cataract Surgery Through the Veterans Health Administration and Medicare,” try to draw conclusions about quality of care in 3 different systems: Medicare, Veterans Health Administration (VHA), and VHA Fee-Basis Program. There are major “pitfalls” attempting to use administrative data to demonstrate outcomes. It is remarkable that a publication on complications would not examine intraoperative events, and only look at procedures performed within 90 days after the cataract surgery. Table 1 reveals what seems to be an a priori selection bias between the 3 groups, from which any author should question their ability to draw valid conclusions. The authors refute their own conclusion that the “most notable finding in this study is the 3to 5-fold increase risk of vitrectomy and related procedures after routine and complex cataract extractions in the VHA” with their statement that they could not exclude the possibility that these secondary “vitrectomies were unrelated to cataract surgery.” They refer to the VA Surgical Quality Improvement Program (VASQIP), established by VHA in 1994, which continues to monitor morbidity and mortality surgical outcomes and is, in French’s own words, “a model for prospective quality improvement programs.” In 2009, VHA launched a similar pilot program for eye surgery, the Ophthalmic Surgical Outcomes Database Pilot Project (OSOD), which will provide information regarding the quality of VHA cataract surgery. Billing data only reveal the types of procedures performed and demographics of the patients who received them. The data analyzed by French and colleagues do not support their conclusions and thus lead to incorrect assumptions about the quality of VHA cataract surgery. Vigorous methods, such as VASQIP and OSOD, are necessary to measure outcomes, quality, and safety, and VHA is leading the way in this arena.