Eugene A. Lowry

Resident-Performed Selective Laser Trabeculoplasty in Patients With Open-Angle Glaucoma

IMPORTANCE To our knowledge, this is the first study to investigate effectiveness and complication rates of resident-performed selective laser trabeculoplasty (SLT). OBJECTIVES To evaluate the effectiveness and complications of SLT performed by resident ophthalmologists and to identify predictors for success. DESIGN, SETTING, AND PARTICIPANTS Retrospective case series of 81 patients with open-angle glaucoma undergoing 110 SLT procedures from November 17, 2009, through December 16, 2011, at the San Francisco Veterans Affairs Medical Center. INTERVENTION Resident-performed SLT. MAIN OUTCOMES AND MEASURES Intraocular pressure (IOP) reduction. Secondary outcomes included change in eyedrop medications, complication rates, and predictors of SLT success defined as a 20% reduction in IOP. RESULTS The mean IOP at baseline, defined as the average IOP of the 2 appointments prior to the SLT procedure, was 18.7 mm Hg. The mean decrease in postoperative IOP compared with baseline was 2.2 mm Hg (12%; 95% CI, 5%-19%) at 12 months and 3.3 mm Hg (18%; 95% CI, 13%-23%), 2.8 mm Hg (15%; 95% CI, 10%-21%), and 3.6 mm Hg (19%; 95% CI, 11%-27%) at 3, 6, and 24 months, respectively (all P < .001, linear mixed-effects regression). Success rates were 36% (95% CI, 27%-47%) at 12 months and 41% (95% CI, 31%-53%), 50% (95% CI, 40%-60%), and 39% (95% CI, 26%-53%) at 3, 6, and 24 months, respectively. The most common complication was a temporary IOP spike, with increases of at least 6 mm Hg occurring in 7% (95% CI, 4%-14%) of the population. The largest IOP spike was 11 mm Hg. Increased number of laser shots performed was not associated with better IOP control but was associated with a reduction in number of eyedrop medications (P = .02). Increased baseline IOP was associated with an odds ratio for success of 1.24 (95% CI, 1.08-1.44) at 3 months, 1.20 (95% CI, 1.05-1.37) at 6 months, and 1.31 (95% CI, 1.13-1.53) at 12 months of follow-up (P = .003, P = .006, and P < .001, respectively, logistic regression). In a multivariate analysis, baseline IOP remained the greatest predictor of effectiveness. CONCLUSIONS AND RELEVANCE Resident-performed SLT obtains outcomes similar to the IOP reduction reported in the literature for attending-performed SLT with low levels of complications. Increasing the number of shots in a treatment session may lead to less long-term need for eyedrop medications. In this patient group, higher baseline IOP was the strongest predictor of treatment effectiveness.

A Comparison of Resident-performed Argon and Selective Laser Trabeculoplasty in Patients With Open-angle Glaucoma.

Purpose:To compare intraocular pressure (IOP) reduction and complications of resident-performed argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT). Patients and Methods:This was a retrospective, interventional, comparative case series performed at the San Francisco Veterans Affairs Hospital. The study included 77 patients each undergoing 1 resident-performed ALT procedure from April 2006 through November 2009, and 81 patients each undergoing 1 resident-performed SLT procedure from November 2009 through December 2011. Reduction in IOP at 12 months and a longitudinal analysis across 24 months was determined. Secondary outcomes investigated included additional interventions of either repeat trabeculoplasty or trabeculectomy as well as change in eye drop medications. Results:There was no evidence of a difference between IOP reductions in patients undergoing ALT compared with SLT at 12 months (P=0.41, linear modeling) or across all follow-up appointments (P=0.62, linear-mixed effects regression). Patients undergoing ALT had a significantly increased number of eye drops (+0.6 vs. −0.1 drops, P<0.001, Wilcoxon rank-sum test) and trend toward increased rates of additional interventions (P=0.06, Weibull regression). There was no difference in immediate postprocedure IOP rise between the 2 groups (P=0.75, Wilcoxon rank-sum test) or any evidence of change in visual acuity. Conclusions:We found no difference in IOP reduction between patients undergoing resident-performed ALT compared with SLT. However, patients undergoing ALT had a significant increase in eye drop medications and trend toward additional interventions compared with patients undergoing SLT.

Cost analysis of virtual-reality phacoemulsification simulation in ophthalmology training programs

High-fidelity virtual-reality simulation is gaining popularity as ophthalmology residency programs continue to look for methods to train residents while maintaining patient safety. The Eyesi surgical simulator (VRmagic Holding AG) is a virtual-reality simulator that allows microsurgical practice on a model eye. This simulator has demonstrated construct validity with improved surgeon versus novice performance in simulated cataract extractions. 1,2 Practice with simulation has also been shown to improve performance on subsequent simulated tasks. 2 The safety benefits of simulator training remain uncertain in applied clinical practice. Use of the Eyesi simulator has not demonstrated a significant reduction in surgical complication rate in any study to date. 3,4,A Since, to our knowledge, there are currently no studies demonstrating a significant reduction in complication rates, the costs and benefits of this simulator may be unclear to many residency programs. However, studies have demonstrated a reduction in resident operating case length for early phacoemulsification surgeries. 4,A These reductions average 5.9 minutes over the first 5 cases but decrease to an average of1.2 minutes over the first 50surgeries as residents gain operating experience that dampens the differences seen in early cases between residents receiving versus those not receiving virtual-reality training. 4,A We investigated the costs and proven operating room cost savings associated with virtual-reality simulation with Eyesi to determine the effective present cost for various sized residencies. The perspective is societal using 2012 United States dollars and a 3% annual discount rate for savings generated in future years. The purchase price of the simulator with only the cataract surgical software is estimated to be

Objective vision screening in 3-year-old children at a multispecialty practice

150000. The number of residents was modeled across a known range for U.S. ophthalmology training programs of 2 to 9 residents. Operating room time saved was estimated by modeling current estimates of operating time difference at 5 and 50 cases to an exponential decay that has been demonstrated for the resident phacoemulsification learning curve. 5 Minimizing the difference of squares between the model and observed data led to the equation:

Repeat Retinomax screening changes positive predictive value.

BACKGROUND Vision screening is rarely effectively accomplished for 3-year-olds as part of pediatric well-child examinations. We investigate changes in screening rates and positive predictive values of referrals for 3-year-olds after introducing a photoscreener to a multispecialty group practice. METHODS The vision screening results of 3-year-old children undergoing routine well-child examinations between 2007 and 2013 were retrospectively reviewed. From 2007 to 2009, the only method available for vision screening was the Kindergarten Eye Test Chart. From 2010 to 2013 a PlusOptix photoscreener was also available. Rates of vision screening before and after PlusOptix adoption were compared. All children who failed screening were referred to a single pediatric ophthalmologist. Referral rates, follow-up rates, and positive predictive values were determined for PlusOptix photoscreening. Cases were defined by cycloplegic retinoscopy using the 2013 American Association for Pediatric Ophthalmology and Strabismus (AAPOS) vision screening recommendations for amblyopia risk factors. RESULTS Of 593 children seen for their 3-year well-child examination between 2007-2009, before introduction of a photoscreener, 59 (10%) received vision screening. The screening rate increased to 766 of 958 (80%) between 2010 and 2013, after introduction of the PlusOptix (P < 0.001). Only 49% of children had a reliable first screening with PlusOptix, and the average number of screenings to obtain a reliable result was 2.39. The positive predictive value of PlusOptix referrals was 51% for amblyopia risk factors and 41% for potential amblyopia. CONCLUSIONS Availability of a photoscreener can increase the rate of vision screening for 3-year-old children in a multispecialty practice.

Comparison of Surgical Outcome After Ahmed Valve Implantation for Patients With and Without Fluocinolone Intravitreal Implant (Retisert).

PURPOSE To quantify changes in autorefraction measurement with repeated readings using the Retinomax autorefractor and to investigate the clinical implications of the results. METHODS Children referred from a preschool vision screening program for a failed autorefraction screening test received repeat autorefraction as well as a comprehensive eye examination with cycloplegic retinoscopy at later follow-up. The intraclass correlation coefficient between initial and follow-up autorefraction was calculated to quantify changes in repeated measurements to determine whether the second autorefraction significantly changed the predictive value that a referred child would meet case definition. Cases were defined by AAPOS Vision Screening Committee amblyogenic risk factors under cycloplegic retinoscopy. RESULTS Repeat Retinomax autorefraction had an intraclass correlation of 0.70 in the right eye and 0.70 in the left eye for mean sphere. Of 636 children who were referred on their initial screening, 169 (26.5%) passed a repeat screening and this subpopulation had 7 cases (4.1%). Of the 467 (73.5%) who again met referral criteria at repeat screening, 268 (57.4%) met case definition. The difference in case rates between these subgroups was highly significant (Fisher exact test, P < 0.001). CONCLUSIONS There was clinically significant variability when autorefraction measurements were repeated among those referred from initial screening, allowing further risk stratification. In our study cohort, few children who passed repeat screening required further examination. Significant money and overtreatment risk may potentially be avoided by rescreening children who are initially referred from screening evaluations and only examining those who meet referral criteria after a second screening.

Comparison of Peristat Online Perimetry with the Humphrey Perimetry in a Clinic-Based Setting

Purpose:To determine whether long-term, slow-release exposure to corticosteroids with Retisert promotes better surgical outcomes after Ahmed valve implantation. Patients:This comparative retrospective cohort study included 17 study eyes (10 patients) with uncontrolled uveitis requiring Retisert and Ahmed implantation, and 55 control eyes (51 patients) with other types of medically uncontrolled glaucoma that only received Ahmed. Materials and Methods:Main outcome measures were intraocular pressure (IOP), glaucoma eye drops per day, best-corrected visual acuity, early complications, and late complications at 1, 3, 6, and 12 months. Linear mixed effects models were used to model IOP, glaucoma drops per day, and visual acuity at 1 year after surgery. Results:At 1 year, the study eyes had a mean IOP of 12.24, which was lower than that for control eyes at 15.17 (P=0.04). At 1 year, the average number of glaucoma eye drops used per day for study eyes was 1.4, which was lower than that for control eyes at 2.3 (P=0.03). At 1 year, there were no statistically significant differences in change in visual acuity, early complications, and late complications between study and control eyes. Conclusions:Patients who received a Retisert implantation had lower IOP and used fewer glaucoma eye drops compared with control eyes at 1-year post-Ahmed valve surgery. This study suggests that long-term, slow-release corticosteroid medication from Retisert (fluocinolone acetonide) may improve the surgical outcome for patients with an Ahmed valve implantation and/or Retisert helps control uveitis in patients with uveitic glaucoma receiving Ahmed valves.

Cost-effectiveness of School-Based Eye Examinations in Preschoolers Referred for Follow-up From Visual Screening

Purpose We determined the receiver operating characteristic (ROC) curves for Peristat online perimetry at detecting varying degrees of glaucoma and the correlation between Peristat online perimetry and Humphrey visual field. Methods A prospective, comparative study of Peristat online perimetry (an achromatic static computer threshold testing program) and Humphrey visual field (HVF) 24-2 SITA standard testing was performed by 63 glaucoma patients and 30 healthy controls in random order. The number of total adjacent abnormal test points were identified for each test, and compared with Spearman correlation. Receive operating characteristic curves were generated for Peristat online perimetry detection of mild and moderate-severe glaucoma patients using contrast sensitivity thresholds of −16.7, −21.7, and −26.7 dB. Results The area under the ROC curve for glaucoma detection ranged from 0.77 to 0.81 for mild disease (mean deviation [MD], >−6 dB on HVF) and 0.85 to 0.87 for moderate to severe disease (MD, <−6 dB on HVF) depending on contrast threshold. Peristat online perimetry and Humphrey visual field abnormal points were highly correlated with Spearman rank correlations ranging from 0.55 to 0.77 (all P < 0.001). Conclusions Peristat online perimetry exhibits a reasonable ROC curve without specialized equipment and exhibited significant correlation with the conventional 24° Humphrey visual field test. Translational Relevance Low cost widely available internet-based visual fields may complement traditional office-based visual field testing.

Acute Vision Loss From Dacryocystitis

IMPORTANCE Many preschool visual screening programs incorporate school-based comprehensive examinations, but the follow-up rates and cost-effectiveness of this approach are not well studied. OBJECTIVE To determine the follow-up rates and cost-effectiveness of referral to community-based eye care professionals vs to a mobile eye examination unit (mobile follow-up) among preschool children with failed visual screening results. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort cost-effectiveness study with decision analytic modeling and probabilistic sensitivity analysis included 3429 children in 37 public preschools in San Francisco, California, who underwent visual chart screening during the 2009-2012 academic years and 1524 children in the same schools who underwent autorefraction screening during the 2012-2013 academic year. One hundred seventy-five children who underwent visual chart screening were referred for community-based comprehensive eye examinations; 204 who underwent autorefractive screening were referred for preschool-based mobile follow-up. Data were collected from October 1, 2009, to May 29, 2013, and analyzed from June 30, 2013, to January 16, 2016. MAIN OUTCOMES AND MEASURES Cost-effectiveness of community-based vs mobile follow-up standardized for referral method. RESULTS Of the 175 children referred for community-based follow-up (91 boys [52.0%]; 84 girls [48.0%]; mean [SD] age, 3.8 [0.7] years), 104 attended (59.4%). Of 204 children referred for mobile follow-up (89 boys [43.6%]; 115 girls [56.4%]; mean [SD] age, 4.1 [0.6] years), 112 attended (54.9%). Costs per case detected were

Efficient Referral Thresholds in Autorefraction-Based Preschool Screening

664 and