Ayman Naseri

Cost-Effectiveness Analysis of Intracameral Cefuroxime Use for Prophylaxis of Endophthalmitis after Cataract Surgery

OBJECTIVE To evaluate the cost-effectiveness of intracameral cefuroxime for postoperative endophthalmitis prophylaxis, and to determine the efficacy threshold necessary for alternative antibiotics to attain cost-effective equivalence with intracameral cefuroxime. DESIGN Cost-effectiveness analysis. PARTICIPANTS We study a hypothetical cohort of 100,000 patients undergoing cataract surgery as a part of the cost analysis. METHODS A cost-effectiveness model was constructed to analyze different antibiotic prophylactic regimens for postoperative endophthalmitis with intracameral cefuroxime as our base case. Efficacy was defined as the absolute reduction in rate of infection from background rate of infection, which was sourced from the literature. Antibiotic cost data were derived from the Red Book 2007 edition, and salary data were taken from the United States Bureau of Labor Statistics. Multivariate sensitivity analysis assessed the performance of antibiotic options under different scenarios. MAIN OUTCOME MEASURES Cost per case of endophthalmitis prevented; theoretical maximal cost-effectiveness; efficacy threshold necessary to achieve cost-effective equivalence with intracameral cefuroxime; ratio indicating how many times more effective or less expensive alternative antibiotics would have to be to achieve cost-effective equivalence with intracameral cefuroxime. RESULTS The cost-effectiveness ratio for intracameral cefuroxime is

Herpes zoster virus sclerokeratitis and anterior uveitis in a child following varicella vaccination

1403 per case of postoperative endophthalmitis prevented. By comparison, the least expensive topical fluoroquinolone in our study, ciprofloxacin, would have to be >8 times more effective than intracameral cefuroxime to achieve cost-effective equivalence. The most expensive topical fluoroquinolones studied, gatifloxacin and moxifloxacin, would have to be > or =19 times more effective than intracameral cefuroxime to achieve cost-effective equivalence. A sensitivity analysis reveals that even in the worst case scenario for intracameral cefuroxime efficacy and with a 50% reduction in the cost of 4th-generation fluoroquinolones, gatifloxacin and moxifloxacin would have to be > or =9 times more effective than intracameral cefuroxime to achieve cost-effective equivalence. CONCLUSIONS Administration of intracameral cefuroxime is relatively cost-effective in preventing endophthalmitis after cataract surgery. Owing to their high costs, many commonly used topical antibiotics are not cost-effective compared with intracameral cefuroxime, even under optimistic assumptions about their efficacy.

Prophylaxis of postoperative endophthalmitis following cataract surgery: current status and future directions.

PURPOSE To report a case of herpes zoster virus sclerokeratitis with anterior uveitis following vaccination with live attenuated varicella vaccine (Oka strain). DESIGN Case report. METHODS The case records of the patient were reviewed retrospectively. Pertinent literature citations were identified using MEDLINE. RESULTS A 9-year-old boy presented with herpes zoster ophthalmicus 3 years following vaccination with live attenuated varicella vaccine (Oka strain). Examination of the affected eye revealed a moderate follicular response on the palpebral conjunctiva, decreased corneal sensation, mildly elevated intraocular pressure, diffuse anterior scleritis with marginal keratitis, and a moderately severe anterior uveitis. Amplified DNA from fluid taken from the base of a cutaneous vesicle produced wild-type varicella zoster virus (VZV) DNA, not Oka strain. CONCLUSIONS Herpes zoster virus infection needs to be considered in all patients who present with scleritis, keratitis, or anterior uveitis, regardless of their varicella vaccination status.

Predictors of Matching in an Ophthalmology Residency Program

Endophthalmitis is an uncommon but potentially devastating intraocular infection that can occur after routine cataract surgery. Although a broad spectrum of organisms have been shown to cause acute postoperative endophthalmitis, most cases are caused by Gram-positive bacteria, which may be introduced at the time of surgery from colonization of adjacent conjunctiva or eyelid skin. Risk factors for the development of endophthalmitis following cataract surgery include patient age, intraoperative surgical complications and poor wound construction. There are several antibacterial strategies employed to prevent postoperative endophthalmitis, with topical, intracameral and subconjunctival delivery being the most common. Worldwide, there seems to be significant regional variance in the type and method of prophylactic antibacterial regimens; for example, topical fluoroquinolones are commonly used in the US, while intracameral cephalosporins are employed widely in Europe. The optimal antibacterial strategy for the prevention of endophthalmitis should be safe, inexpensive and broad in microbiological activity spectrum, while not requiring patient compliance for its effectiveness.

Amelanotic corneal melanoma after a blast injury

PURPOSE To examine the characteristics of US medical students applying for ophthalmology residency and to determine the predictors of matching. DESIGN A retrospective case series. PARTICIPANTS A total of 3435 medical students from the United States who applied to an ophthalmology residency program from 2003 to 2008 were included. METHODS Matched and unmatched applicants were compared and stratified by predictor variables, including United States Medical Licensing Examination (USMLE) Step 1 score, Alpha Omega Alpha (AOA) status, medical school reputation, and medical school geographic region. Differences in proportions were analyzed using the Fisher exact test. Logistic regression was used to determine the predictors of successful matching. MAIN OUTCOME MEASURES Successful matching to an ophthalmology program. RESULTS The majority of applicants (72%, 2486/3435) matched in ophthalmology. In multivariate analysis, AOA membership (odds ratio [OR], 2.6, P<0.0001), USMLE score (OR, 1.6; P<0.0001), presence of an ophthalmology residency at medical school (OR, 1.4; P = 0.01), top 25 medical school (OR, 1.4; P<0.03), top 10 medical school (OR, 1.6; P<0.02), and allopathic degree (OR, 4.0; P<0.0001) were statistically significant predictors of matching. Approximately 60% (1442/2486) of applicants matched to the same geographic region as their medical school. Applicants were more likely to match at a program in the same geographic region as their medical school than would be predicted by chance alone (P<0.0001). In multivariate analysis, higher USMLE score (OR, 0.9; P<0.0001) and top 10 medical school (OR, 0.7; P = 0.027) were statistically significant predictors of matching to outside the geographic region as ones medical school. CONCLUSIONS The majority of applicants applying for an ophthalmology residency position match successfully. Higher performance on quantitative metrics seems to confer an advantage for matching. The majority of applicants match at a residency program within the same geographic region as ones medical school.

Cataract surgery after refractive surgery.

PURPOSE To report a case of a corneal melanoma after trauma. METHODS Case report. RESULTS A 68-year-old man sustained an ocular injury from a blast furnace explosion in 1958. In 1998, he underwent a penetrating keratoplasty for a corneal scar. Histologic examination and cell markers of the host button revealed intrastromal and subepithelial melanoma. No clinical or microscopic evidence of adjacent conjunctival or uveal melanoma was found. CONCLUSION Melanoma of the cornea can present as a stromal opacity after trauma.

Common Reasons That Asymptomatic Patients Who Are 65 Years and Older Receive Carotid Imaging

Purpose of review To review recent contributions addressing the challenge of intraocular lens (IOL) calculation in patients undergoing cataract extraction following corneal refractive surgery. Recent findings Although several articles have provided excellent summaries of IOL selection in patients wherein prerefractive surgery data are available, numerous authors have recently described approaches to attempt more accurate IOL power calculations for patients who present with no reliable clinical information regarding their refractive history. Additionally, results have been reported using the Scheimpflug camera system to measure corneal power in an attempt to resolve the most important potential source of error for IOL determination in these patients. Summary IOL selection in patients undergoing cataract surgery after corneal refractive surgery continues to be a challenging and complex issue despite numerous strategies and formulas described in the literature. Current focus seems to be directed toward approaches that do not require preoperative refractive surgery information. Due to the relative dearth of comparative clinical outcomes data, the optimal solution to this ongoing clinical problem has yet to be determined. Until such data are available, many cataract surgeons compare the results of multiple formulas to assist them in IOL selection for these patients.

Return to the Operating Room After Resident-Performed Cataract Surgery

IMPORTANCE National guidelines do not agree on the role of carotid screening in asymptomatic patients (ie, patients who have not had a stroke or transient ischemic attack). Recently, several physician organizations participating in the Choosing Wisely campaign have identified carotid imaging in selected asymptomatic populations as being of low value. However, the majority of patients who are evaluated for carotid stenosis and subsequently revascularized are asymptomatic. OBJECTIVE To better understand why asymptomatic patients who undergo revascularization receive initial carotid imaging. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 4127 Veterans Health Administration patients 65 years and older undergoing carotid revascularization for asymptomatic carotid stenosis between 2005 and 2009. MAIN OUTCOMES AND MEASURES Indications for carotid ultrasounds were extracted using trained abstractors. Frequency of indications and appropriateness of initial carotid ultrasound imaging for patients within each rating category after the intervention were reported. RESULTS The mean (SD) age of this cohort of 4127 patients was 73.6 (5.9) years; 4014 (98.8%) were male. Overall, there were 5226 indications for 4063 carotid ultrasounds. The most common indications listed were carotid bruit (1578 [30.2% of indications]) and follow-up for carotid disease (stenosis/history of carotid disease) in patients who had previously documented carotid stenosis (1087 [20.8% of indications]). Multiple vascular risk factors were the next most common indication listed. Rates of appropriate, uncertain, and inappropriate imaging were 5.4% (227 indications), 83.4% (3387 indications), and 11.3% (458 indications), respectively. Among the most common inappropriate indications were dizziness/vertigo and syncope. Among the 4063 patients, 3373 (83.0%) received a carotid endarterectomy. Overall, 663 procedures were performed in patients 80 years and older. CONCLUSIONS AND RELEVANCE Carotid bruit and follow-up for carotid disease accounted for approximately half of all indications provided by physicians for carotid testing. Strong consideration should be given to improving the evidence base around carotid testing, especially around monitoring stenosis over long periods and evaluating carotid bruits. Targeting carotid ultrasound ordering with decision support tools may also be an important step in reducing use of low-value imaging.

A Multicenter Analysis of the Ophthalmic Knowledge Assessment Program and American Board of Ophthalmology Written Qualifying Examination Performance

Return to the Operating Room After Resident-Performed Cataract Surgery Cataract surgery is one of the most commonly performed operations during ophthalmology residency training, and its complications have been well described.1-3 While returns to the operating room within 30 days after routine surgery serve as a benchmark for surgical quality in other specialties such as neurosurgery and general surgery, reoperation after cataract surgery has not been investigated.4,5 The aim of this study was to examine the rate and indications for reoperation after resident-performed cataract surgery at 30 and 90 days.

Predictors of Matching in Ophthalmology Residency for International Medical Graduates

OBJECTIVE To compare the performance on the American Board of Ophthalmology Written Qualifying Examination (WQE) with the performance on step 1 of the United States Medical Licensing Examination (USMLE) and the Ophthalmic Knowledge Assessment Program (OKAP) examination for residents in multiple residency programs. DESIGN Comparative case series. PARTICIPANTS Fifteen residency programs with 339 total residents participated in this study. The data were extracted from the 5-year American Board of Ophthalmology report to each participating program in 2009 and included residency graduating classes from 2003 through 2007. Residents were included if data were available for the USMLE, OKAP examination in ophthalmology years 1 through 3, and the WQE score. Residents were excluded if one or more of the test scores were not available. METHODS Two-sample t tests, logistic regression analysis, and receiver operating characteristic (ROC) curves were used to examine the association of the various tests (USMLE, OKAP examination year 1, OKAP examination year 2, OKAP examination year 3, and maximum OKAP examination score) as a predictor for a passing or failing grade on the WQE. MAIN OUTCOME MEASURES The primary outcome measure of this study was first time pass rate for the WQE. RESULTS Using ROC analysis, the OKAP examination taken at the third year of ophthalmology residency best predicted performance on the WQE. For the OKAP examination taken during the third year of residency, the probability of passing the WQE was at least 80% for a score of 35 or higher and at least 95% for a score of 72 or higher. CONCLUSIONS The OKAP examination, especially in the third year of residency, can be useful to residents to predict the likelihood of success on the high-stakes WQE examination.