Effect of a 7.0 mm intraocular lens optic on peripheral retinal illumination with implications for negative dysphotopsia.

PURPOSE: To use optical modeling to compare a 6.0 mm and 7.0 mm intraocular lens (IOL) optic diameters on peripheral retinal illumination with implications for negative dysphotopsia. SETTING: Mayo Clinic, Rochester, Minnesota, and Simpson Optics LLC, Arlington, Texas. DESIGN: Model eye. METHODS: Ray-tracing software was used to simulate retinal illumination from an extended light source for a pseudophakic eye with in-the-bag biconvex IOLs (refractive index [n] = 1.46 and 1.55) and a 2.5 mm pupil. Ray-tracing diagrams and simulated retina illumination profiles were compared using the 6.0 mm and 7.0 mm optic diameter IOLs. Retinal locations were scaled to relative visual angles from 70 to 110 degrees horizontally. RESULTS: A 7.0 mm optic (n = 1.46) expands the image field by 2.8 degrees compared with a 6.0 mm optic. High-angle input light misses a 7.0 mm optic at a larger visual angle than a 6.0 mm optic, shifting illumination of the peripheral retina by this light anteriorly by 5.6 degrees. Consequently, a region of nonilluminated peripheral nasal retina is enlarged and shifted peripherally using a 7.0 mm optic (visual angle, 86.3 to 96.3 degrees) compared with a 6.0 mm optic (visual angle, 83.5 to 90.7 degrees). Similar illumination changes were seen modeling a 1.55 n IOL. CONCLUSIONS: A narrow dark region in the nasal retina when using a 6.0 mm optic is changed to a broader, more peripheral dark region when using a 7.0 mm optic. An extended, more peripheral dark nasal region may make a temporal shadow less bothersome and explain lower negative dysphotopsia rates using a 7.0 mm optic.

A Population-Based Study of Anterior Ischemic Optic Neuropathy Following Cataract Surgery.

PURPOSE: To determine if there is an increased incidence rate of post-cataract surgery (pcs) anterior ischemic optic neuropathy (AION) compared to spontaneous AION (sAION). DESIGN: Retrospective, population-based cohort. METHODS: Patients diagnosed with AION from January 1, 1990, through December 31, 2016, while residing in Olmsted County, Minnesota. Patients with cataract surgery preceding AION were included in the pcsAION cohort defined in 2 ways: AION within 2 months and AION within 1 year of cataract surgery. The incidence rates of pcsAION and sAION were compared using Poisson regression models. RESULTS: During the study period, 102 residents developed AION. The median age was 65 years (range, 40-90 years), 44 (43.1%) were female. Twenty of 102 (19.6%) patients had previous cataract surgery, of which 2 and 9 developed AION within 2 months and 1 year of surgery, respectively. The annual incidence rate of pcsAION within 2 months of surgery (8.6 per 100,000) was not significantly greater than the annual incidence rate of sAION (6.9 per 100,000; P = .78). However, the annual incidence rate of pcsAION within 1 year of surgery (38.9 per 100,000) was significantly higher than the incidence rate of sAION (6.5 per 100,000; P < .001). CONCLUSION: The incidence of AION is increased in the first year after cataract surgery, but not in the early (i.e., 2 months) postoperative period.

Angle alpha orientation and magnitude distribution in a cataract surgery population.

PURPOSE: To report normative angle alpha orientation and magnitude distribution in a cataract surgery patient population. SETTING: U.S. academic medical center. DESIGN: Retrospective review. METHODS: A total of 11 871 wavefront aberrometer/corneal topographer angle alpha measurements were performed over 40 months, yielding 8773 bilateral measurements (73.9%) with zero bad wavefront datapoints. The analysis was limited to the first right-eye scan for 3382 unique patients. The angle alpha magnitudes (millimeters) and orientations (degrees) were analyzed for these unique right eyes. RESULTS: For the 3,382 unique patients, the mean angle alpha magnitude was 0.44 ± 0.15 mm (median, 0.44 mm; 25th and 75th percentiles 0.34 mm, 0.53 mm). Angle alpha orientation was predominantly horizontal (P < .01), with a mean of 186 ± 32 degrees. The expected point of intraocular lens (IOL) centration (EPIC) based on the geometric center of the corneal limbus was temporal to the visual axis in 3212 eyes (95%), nasal in 92 eyes (2.7%), inferior in 56 eyes (1.7%), and superior in 22 eyes (0.6%). The mean angle alpha magnitude was 0.3 mm or less in 607 eyes (18%) and 0.5 mm or greater in 1089 eyes (32%). CONCLUSIONS: Angle alpha is a predominantly horizontal phenomenon with a mean EPIC of 0.44 mm temporal to the visual axis. This information may assist in determining eligibility for patients in multifocal IOL implantation.

Influence of the intraocular lens optic-haptic junction on illumination of the peripheral retina and negative dysphotopsia.

PURPOSE: Use optical modeling to evaluate the effect of the intraocular lens (IOL) optic-haptic junction on retinal illumination and negative dysphotopsia. SETTING: Mayo Clinic, Rochester, Minnesota, USA. DESIGN: Schematic model eye. METHODS: Ray-tracing software for an extended light source was used to simulate retina illumination in a pseudophakic eye with a biconvex high-index acrylic IOL and a 2.5 mm pupil. The haptic junction was modeled using an annular cone of haptic material of 0.75 mm width located between the optic and haptic. Ray-tracing diagrams and simulated retina illumination profiles were compared with and without the haptic junction. Retinal locations were scaled to visual angles from 70 to 110 degrees horizontally. RESULTS: Light incident on the peripheral optic creates a nonuniform retina illumination pattern consisting of a 5-degree band of nonilluminated retina bounded posteriorly by light refracted by the optic and anteriorly by light that missed the optic. Light incident on the haptic junction illuminates retina differently in that light that typically misses the optic (input angle 79 to 91 degrees) is instead refracted at a large angle or internally reflected by the haptic junction, which removes the illuminated peripheral retina that would otherwise delineate the shadow region. Further modification to the haptic junction region improved peripheral retina illumination and shifted the shadow region 10 degrees anteriorly. CONCLUSIONS: The haptic junction illuminated the peripheral retina differently than the peripheral optic, and this might explain why a horizontal haptic junction minimizes negative dysphotopsia. A modification to the optic-haptic junction redirected illumination and shifted the retina shadow anteriorly, possibly decreasing awareness.

Anesthesia recovery after ophthalmologic surgery at an ambulatory surgical center.

PURPOSE: To examine anesthesia recovery duration after ophthalmologic procedures performed at an ambulatory surgical center (ASC) and provide information that could be used to increase postanesthesia recovery unit efficiency. SETTING: Ambulatory surgical center at tertiary medical center, Rochester, Minnesota, USA. DESIGN: Retrospective case series. METHODS: Health records of adult patients having ophthalmologic procedures at an ASC from July 1, 2010, through September 30, 2016 were reviewed, and anesthesia recovery duration was calculated. Potential associations were assessed between clinical factors and prolonged recovery (upper 10th percentile of recovery duration by anesthesia type [general, intravenous sedation, or topical]). RESULTS: Among 20 116 procedures, the median recovery was 36 minutes (interquartile range [IQR], 28 to 48); general anesthesia had the longest recovery (79 minutes; IQR, 52 to 104 minutes) (P < .001). Recovery was longest for orbitotomy and strabismus procedures and shortest for cataract procedures. Female sex, obstructive sleep apnea, greater disease burden, longer procedures, and intraoperative fentanyl administration were associated with prolonged recovery. Patients with prolonged recovery had more severe pain episodes (pain score ≥7 [scale 0 to 10]; 138 patients [6.9%] versus 140 [0.8%]; P < .001) and received opioid analgesics during recovery (278 patients [13.8%] versus 293 [1.6%]; P < .001). Prolonged recovery involved higher rates of emergency department visits and hospitalizations in the first 48 postoperative hours and higher 30-day mortality rates. CONCLUSIONS: Anesthesia recovery after ophthalmologic procedures at an ASC was associated primarily with the procedure and anesthesia type. Prolonged recoveries were associated with intraoperative fentanyl use, severe postoperative pain, and postoperative opioid requirements.

A modified intraocular lens design to reduce negative dysphotopsia.

PURPOSE: To use ray-tracing analysis and simulated retinal illumination profiles to design an intraocular lens (IOL) that prevents or reduces negative dysphotopsia after cataract surgery. SETTING: Mayo Clinic, Rochester, Minnesota, and Simpson Optics LLC, Arlington, Texas, USA. DESIGN: Experimental study. METHODS: Ray-tracing software was used to simulate peripheral retina illumination from an extended light source for a pseudophakic eye with a biconvex high refractive index IOL. Ray intensities were adjusted to include the effects of the surface reflections and the energy reduction caused by pupil obliquity at high incident angles. The results were compared with similar optical modeling of a modified IOL design with a concave region on the peripheral posterior surface. RESULTS: For a standard biconvex high refractive index IOL, simulated retina illumination profiles showed an area of nonilluminated peripheral nasal retina at a relative visual angle of approximately 85 degrees to 93 degrees. Using a modified IOL optic with a peripheral concave posterior surface, ray-tracing diagrams showed that peripheral input rays were redirected anteriorly into the nonilluminated dark area of the peripheral retina. Simulated retina illumination images confirmed that the redirected input rays improved illumination to the peripheral retina, including the dark area. CONCLUSIONS: Optical modeling showed that the new IOL design provides more uniform illumination of the peripheral nasal retina and specifically illuminates the dark region of the nasal retina associated with negative dysphotopsia. This modified IOL design could prevent or reduce negative dysphotopsia after cataract surgery.

Effect of a sulcus-fixated piggyback intraocular lens on negative dysphotopsia: Ray-tracing analysis.

PURPOSE: To use optical modeling to demonstrate how a sulcus-fixated piggyback intraocular lens (IOL) affects negative dysphotopsia. SETTING: Mayo Clinic, Rochester, Minnesota, USA. DESIGN: Retrospective case series. METHODS: Optical modeling was performed on 3 patients with negative dysphotopsia who were treated with a sulcus-fixated piggyback IOL. Ray-tracing software was used to simulate peripheral retina illumination preoperatively and postoperatively. Biometric data and ultrasound biomicroscopy images were used to construct eye models. Ray intensities were adjusted for surface reflections and normalized by cosine function to compensate for pupil obliquity at high incident angles. RESULTS: Preoperatively, retinal illumination profiles showed a region of dim or nonilluminated peripheral nasal retina at visual angles of approximately 83 to 95 degrees. A piggyback IOL shifted the iris anteriorly (mean 0.41 mm; range 0.37 to 0.47 mm) and the primary IOL posteriorly (mean 0.10 mm; range 0.05 to 0.19 mm) and increased the mean distance between the iris and primary IOL from 0.46 mm preoperatively to 0.75 mm postoperatively. This increased distance allowed input rays to begin missing the primary IOL at lower incident angles (≥76 degrees) compared with preoperatively (≥84 degrees), resulting in increased illumination of the peripheral retina. Illumination of the peripheral retina, including the preoperative dark area, was increased in 2 patients. The negative dysphotopsia shadow resolved in 2 eyes and was unchanged in 1 eye. CONCLUSIONS: In negative dysphotopsia patients, a secondary piggyback IOL allowed additional light to miss the primary IOL and illuminate larger areas of peripheral retina. Increased illumination of the peripheral retina that included the preoperative dark region was associated with improved negative dysphotopsia postoperatively.

Racial/ethnic differences in rates of complex cataract surgery among United States Medicare beneficiaries.

PURPOSE: To determine racial/ethnic differences in rates of complex cataract surgery among United States Medicare beneficiaries. SETTING: Departments of Ophthalmology and Health Science Research, Mayo Clinic, Rochester, Minnesota, USA. DESIGN: Retrospective case series. METHODS: The U.S. Medicare 5% Limited Data Set, representing a 5% sample of over 28 million fee-for-service Medicare beneficiaries predominantly aged 65 years and older, were analyzed for rates of complex cataract surgery (Current Procedural Terminology [CPT] code 66982) among all beneficiaries who had cataract surgery (CPT codes 66982, 66984), stratified by race/ethnicity between January 1, 2014, and December 31, 2014. Associations were tested by using multivariate regression analysis. RESULTS: Data from approximately 1 087 680 Medicare beneficiaries were analyzed. After adjustment for age and sex, the likelihood of complex cataract surgery was significantly higher in African Americans (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.75-2.08), Asians (OR, 1.57; 95% CI, 1.34-1.85), and Hispanics (OR, 1.42; 95% CI, 1.18-1.71) than in whites among fee-for-service Medicare beneficiaries. Complex cataract surgery was more likely in men (OR, 1.83; 95% CI, 1.73-1.92) than in women, and the likelihood of complex cataract surgery increased in the elderly, with beneficiaries older than 84 years more likely to have complex surgery (OR, 2.68, 95% CI, 2.45-2.93) than beneficiaries aged 65 to 69 years. CONCLUSION: There were racial/ethnic differences in the likelihood of complex cataract surgery among fee-for-service Medicare beneficiaries; racial/ethnic minorities (Hispanics, Asians, and African Americans) were 42% to 90% more likely to have complex cataract surgery than whites.

Variations in Trabeculectomy and Glaucoma Drainage Device Use for the Treatment of Glaucoma in the United States.

PURPOSE: To estimate geographic variations and surgeon and patient characteristics associated with the use of trabeculectomy and glaucoma drainage devices (GDDs) to treat glaucoma among US Medicare fee-for-service (FFS) beneficiaries. DESIGN: Observational cohort study of a Medicare claims database. PARTICIPANTS: US Medicare Part B FFS patients (age ≥65 years) and their glaucoma surgeons. METHODS: Analysis of Limited Data Set claims for the 5% sample from Medicare Provider and Utilization and Payment Data was used to identify trabeculectomy and GDD claims with diagnosis codes for patients treated in the United States from January 1, 2014, to September 30, 2015. The number of patients who underwent trabeculectomy or GDD placement was calculated for each US census region. Regional variations were evaluated with the extremal quotient. Multivariate binomial logistic regression was performed to analyze surgeon (career stage and sex), patient (age, race, sex, and ICD-9-CM diagnosis code), and regional characteristics associated with trabeculectomy and GDD placement. MAIN OUTCOME MEASURES: Rates of trabeculectomy and GDD placement performed for Medicare Part B FFS patients by US census region. RESULTS: From January 1, 2014, to September 30, 2015, the odds that patients received trabeculectomy versus GGD placement varied by region. Patients in the South (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.74-2.66; P < 0.001) and Midwest (OR, 1.42; 95% CI, 1.11-1.83; P < 0.01) were significantly more likely to receive GDD placement than patients in the Northeast. The extremal quotient was 2.16, which confirmed high regional variation. Characteristics associated with increased odds of receiving GDD placement were age greater than 84 years (OR, 1.47; 95% CI, 1.11-1.95), African American race (OR, 1.37; 95% CI, 1.11-1.69), and ICD-9-CM diagnosis of glaucoma associated with vascular disorders (OR, 5.87; 95% CI, 2.78-12.41). CONCLUSIONS: High regional variation in trabeculectomy and GDD placement was observed. Placement of a GDD was more likely to be performed in the South. Placement of a GDD was more likely in African American patients and patients with glaucoma associated with vascular disorders, and was more likely performed by early-career surgeons.

Racial Differences in Age-Related Macular Degeneration and Associated Anti-Vascular Endothelial Growth Factor Intravitreal Injections among Medicare Beneficiaries.

PURPOSE: To determine racial and ethnic differences in age-related macular degeneration (AMD) and the use of anti-vascular endothelial growth factor (VEGF) injections for AMD among United States Medicare beneficiaries. DESIGN: Cross-sectional Medicare database study. PARTICIPANTS: 2014 United States fee-for-service Medicare beneficiaries. METHODS: The 2014 Medicare 5% Limited Data Set Standard Analytic Files, representing a 5% sample of approximately 28 238 660 fee-for-service Medicare beneficiaries 65 years of age and older, were used to identify all beneficiaries who received a diagnosis of AMD and who received intravitreal anti-VEGF injections for AMD, stratified by race, gender, and age. Logistic regression analysis determined racial differences in the likelihood of an AMD diagnosis and anti-VEGF treatment for AMD, adjusted for age and gender. MAIN OUTCOME MEASURES: Number of beneficiaries diagnosed with AMD in 2014 and number of beneficiaries who received anti-VEGF intravitreal injections for AMD in 2014. RESULTS: Among approximately 28 238 660 Medicare beneficiaries in 2014, 2 210 000 (7.8%) were diagnosed with AMD. Among beneficiaries with an AMD diagnosis, 360 640 (16.3%) received 1 or more anti-VEGF intravitreal injection for AMD. After adjustment for age and gender, an AMD diagnosis was 74% less likely in African Americans (odds ratio [OR] 0.26; 95% confidence interval [CI], 0.25-0.27), 44% less likely in Latinos (OR, 0.56; 95% CI, 0.53-0.60), and 19% less likely in Asian Americans (OR, 0.81; 95% CI, 0.77-0.85) than in white beneficiaries. Anti-VEGF injections for AMD were 86% less likely in African Americans (OR, 0.14; 95% CI, 0.12-0.16), 61% less likely in Latinos (OR, 0.39; 95% CI, 0.33-0.45), and 48% less likely in Asian Americans (OR, 0.52; 95% CI, 0.46-0.60) than in whites. Race- and gender-adjusted odds of both AMD and the use of anti-VEGF agents for AMD increased with age (P < 0.001). CONCLUSIONS: There are racial differences in the prevalence of an AMD diagnosis and in receiving anti-VEGF injections for AMD among fee-for-service Medicare beneficiaries 65 years of age or older. African Americans, Latinos, and Asian Americans were 19% to 74% less likely to have a diagnosis of AMD and were 48% to 86% less likely to receive an anti-VEGF intravitreal injection for AMD than in whites.

Comparing Access to Laser Capsulotomy Performed by Optometrists and Ophthalmologists in Oklahoma by Calculated Driving Distance and Time.

PURPOSE: To quantify Medicare beneficiary proximity to his or her yttrium-aluminum-garnet (YAG) laser capsulotomy-providing ophthalmologist and optometrist in Oklahoma by calculating driving distances and times. DESIGN: Cross-sectional cohort study using 2014 Oklahoma Medicare 100% and 5% data sets and Google Maps distance and travel time application programming interfaces. PARTICIPANTS: U.S. fee-for-service Medicare beneficiaries and Oklahoma ophthalmologist and optometrist laser capsulotomy providers. METHODS: The 2014 Medicare Provider Utilization and Payment Limited 100% and 5% datasets from the Centers for Medicare and Medicaid (CMS) were obtained to identify the office street addresses of Oklahoma ophthalmologists and optometrists who submitted claims to Medicare for a YAG laser capsulotomy, and the county addresses of the corresponding Medicare beneficiaries who received the laser capsulotomy. The shortest travel distances and travel times between the beneficiary and the laser provider were calculated by using Google Maps distance and travel time application programming interfaces. MAIN OUTCOME MEASURES: Beneficiary driving distances and times to his or her YAG laser capsulotomy-providing Oklahoma ophthalmologist and optometrist. RESULTS: In 2014, 90 (57%) of 157 Oklahoma ophthalmologists and 65 (13%) of 506 Oklahoma optometrists submitted a total of 7521 and 3751 YAG laser capsulotomy claims to Medicare, respectively. By using the Medicare Limited 5% dataset, there was no difference in driving distance between beneficiaries who received a laser capsulotomy from an ophthalmologist (median, 39 miles; interquartile range [IQR], 13-113 miles) compared with an optometrist (median, 46 miles; IQR, 13-125 miles; P = 0.93) or in driving time to an ophthalmologist (median, 47 minutes; IQR, 19-110 minutes) compared with an optometrist (median, 50 minutes; IQR, 17-117 minutes; P = 0.76). CONCLUSIONS: For Medicare beneficiaries, there was no difference in geographic access to YAG laser capsulotomy whether performed by an Oklahoma ophthalmologist or optometrist as determined by calculated driving distances and times.

Gender Differences in Physician Service Provision Using Medicare Claims Data.

OBJECTIVE: To determine differences in the provision of Medicare services based on physician gender in the United States. PATIENTS AND METHODS: Participants included all 2013 Medicare fee-for-service physicians and their patients, a population that is predominantly older than 65 years. The 2013 Medicare Provider Utilization and Payment Data for services rendered between January 1, 2013, and December 31, 2013, were combined with the 2015 Physician Compare National Downloadable files and 2015 Berenson-Eggers Type of Service classification files. Total fee-for-service Medicare payments and Healthcare Common Procedure Coding System procedure codes for all fee-for-service beneficiaries were aggregated according to physician gender, specialty, years since medical school graduation, and type of service classifications. RESULTS: Excluding drug reimbursement, the mean total Medicare payments per female physician, compared with those for male physicians, were 41% in surgical specialties, 72% in hospital-based specialties, and 55% across all specialties (P<.001). The mean overall number of unique beneficiary visits per female physician was 59% of that for male physicians (P<.001). By using the Berenson-Eggers Type of Service classification, procedures and other services by female physicians were of 54% lower overall average intensity (allowed payments/number of unique patients) compared with those of male physicians. These differences persisted irrespective of years since medical school graduation (P<.001). CONCLUSION: Female physicians had smaller average total Medicare payments and fewer unique beneficiary visits than male physicians in the care of fee-for-service Medicare beneficiaries in 2013. The differences persisted across specialty types and years in practice. These data can identify variation but cannot determine causation or explain the reasons behind gender differences. These findings suggest, but do not prove, that female physician Medicare payments are lower due to different practice patterns, consisting of fewer patients cared for and lower intensity of care.

Association between Industry Payments and Anti-vascular Endothelial Growth Factor Use in Medicare Beneficiaries.

PURPOSE: To test for associations between anti-vascular endothelial growth factor (VEGF) industry payments to ophthalmologists who provide intravitreal injections and specific anti-VEGF agent use. DESIGN: Cross-sectional Medicare database study. PARTICIPANTS: US fee-for-service Medicare beneficiaries and all ophthalmologists who submitted intravitreal injection claims for >10 Medicare beneficiaries between August 1, 2013, and December 31, 2013. METHODS: The Sunshine Act Open Payments database was searched for all industry financial relationships in ophthalmology. The Medicare Provider Utilization and Payment Database was searched for all intravitreal injection claims and anti-VEGF drug claims among fee-for-service Medicare beneficiaries. A novel algorithm was used to merge the 2 datasets to identify physician-specific associations between industry payments and specific anti-VEGF agent use. Odds ratios (ORs) and corresponding confidence intervals (CIs) were estimated by using logistic regression models. MAIN OUTCOME MEASURES: Ophthalmologists providing intravitreal injections (Current Procedural Terminology 67028); ophthalmologists with reported nonresearch payment from anti-VEGF industry; physician-specific anti-VEGF agent use (treatment specific J-codes J0178 and J2778). RESULTS: Of 3391 ophthalmologists who performed intravitreal injections, 1187 (35%) received nonresearch payments from anti-VEGF industry. Of these 1187 ophthalmologists, 422 (35%) received payments from Regeneron Pharmaceuticals, 363 (31%) received payments from Genentech, and 402 (34%) received payments from both industries. When compared with ophthalmologists who perform intravitreal injections and who do not receive anti-VEGF industry payments, ophthalmologists receiving Genentech payments (median, $90; interquartile range, $22-$149) were more likely to use ranibizumab (OR, 2.14; 95% CI, 2.12-2.16), those receiving Regeneron payments (median, $55; interquartile range, $22-$131) were more likely to use ranibizumab (OR, 1.55; 95% CI, 1.54-1.56) and aflibercept (OR, 1.23; 95% CI, 1.22-1.24), those with payments from both manufacturers were more likely to use ranibizumab (OR, 2.69; 95% CI, 2.67-2.71) and aflibercept (OR, 1.53; 95% CI, 1.52-1.54), and all were less likely to use bevacizumab (OR, 0.33-0.64; P < 0.001 for all comparisons). CONCLUSIONS: Industry payments to ophthalmologists who perform intravitreal injections were associated with higher odds of ranibizumab and aflibercept use, and lower odds of bevacizumab use. These findings reflect an association, not a cause-and-effect relationship.

Surgical removal of dystrophic calcification on a silicone intraocular lens in association with asteroid hyalosis.

We present a case of successful removal of late calcium deposition on the posterior surface of a silicone intraocular lens (IOL) optic in association with asteroid hyalosis using a surgical technique that included pars plana vitrectomy, a lighted pick, and a modified silicone-tipped cannula. The lighted pick provided the most efficient and complete removal of calcium deposits. Postoperatively, the dystrophic calcification was removed and the IOL optic was clear at 6 months follow-up. The patient's symptoms resolved and uncorrected distance visual acuity returned to 20/20. This method can be considered in patients with dystrophic calcification of a silicone IOL in association with asteroid hyalosis and might avoid the need for IOL exchange and its associated complications and uncertain refractive outcomes.

Racial/Ethnic Differences in Rates of Penetrating or Endothelial Keratoplasty for Fuchs Endothelial Corneal Dystrophy Among US Medicare Beneficiaries.

IMPORTANCE: Fuchs endothelial corneal dystrophy (FECD) is the most common indication for corneal transplant in the United States. The association between race/ethnicity and incidence of advanced FECD, defined by a need for endothelial or penetrating keratoplasty, has not been investigated. OBSERVATIONS: The 2014 US Medicare Limited Data Set (5% sample of 27 163 740 fee-for-service Medicare patients) was analyzed for rate of keratoplasty performed for FECD (International Classification of Diseases, Ninth Edition code 371.57), stratified by race/ethnicity. Among all Medicare beneficiaries 65 years or older, a diagnosis code for FECD was used in 1.55% (95% CI, 1.51%-1.59%) of white and 1.38% (95% CI, 1.26%-1.50%) of African American beneficiaries who had an ophthalmologist eye examination in 2014 (P = .01). Among beneficiaries who obtained medical care for FECD, keratoplasty was 1.9 times more likely in white than African American patients (4.7%; 95% CI, 4.2%-5.2% vs 2.5%; 95% CI, 1.1%-3.9%; P < .001) among approximately 6500 patients undergoing 8420 procedures. CONCLUSIONS AND RELEVANCE: In 2014, keratoplasty was 1.9 times more likely in US Medicare fee-for-service white patients than African American patients with FECD. This might be caused by racial/ethnic differences in the biology of FECD, access to care, or other unidentified factors.

High Variation of Intravitreal Injection Rates and Medicare Anti-Vascular Endothelial Growth Factor Payments per Injection in the United States.

PURPOSE: To estimate geographic variation of intravitreal injection rates and Medicare anti-vascular endothelial growth factor (VEGF) drug costs per injection in aging Americans. DESIGN: Observational cohort study using 2013 Medicare claims database. PARTICIPANTS: United States fee-for-service (FFS) Part B Medicare beneficiaries and their providers. METHODS: Medicare Provider Utilization and Payment Data furnished by the Centers for Medicare and Medicaid Services was used to identify all intravitreal injection claims and anti-VEGF drug claims among FFS Medicare beneficiaries in all 50 states and the District of Columbia in 2013. The rate of FFS Medicare beneficiaries receiving intravitreal injections and the mean Medicare-allowed drug payment per anti-VEGF injection was calculated nationally and for each state. Geographic variations were evaluated by using extremal quotient, coefficient of variation, and systematic component of variance (SCV). MAIN OUTCOME MEASURES: Rate of FFS Medicare Part B beneficiaries receiving intravitreal injections (Current Procedural Terminology [CPT] code, 67028), nationally and by state; mean Medicare-allowed drug payment per anti-VEGF injection (CPT code, 67028; and treatment-specific J-codes, J0178, J2778, J9035, J3490, and J3590) nationally and by state. RESULTS: In 2013, the rate of FFS Medicare beneficiaries receiving intravitreal injections varied widely by 7-fold across states (range by state, 4 per 1000 [Wyoming]-28 per 1000 [Utah]), averaging 19 per 1000 beneficiaries. The mean SCV was 8.5, confirming high nonrandom geographic variation. There were more than 2.1 million anti-VEGF drug claims, totaling more than $2.3 billion in Medicare payments for anti-VEGF agents in 2013. The mean national Medicare drug payment per anti-VEGF injection varied widely by 6.2-fold across states (range by state, $242 [South Carolina]-$1509 [Maine]), averaging $1078 per injection. Nationally, 94% of injections were office based and 6% were facility based. CONCLUSIONS: High variation was observed in intravitreal injection rates and in Medicare drug payments per anti-VEGF injection across the United States in 2013. Identifying factors that contribute to high variation may help the ophthalmology community to optimize further the delivery and use of anti-VEGF agents.

Statin Use and Incident Cataract Surgery: A Case-Control Study.

PURPOSE: To determine the association between statin use and incident cataract surgery. METHODS: Using the resources of the Rochester Epidemiology Project, a retrospective population-based, case-control study was performed. Cases included 6024 county residents aged 50 years and older who had first-eye cataract surgery between 1 January 2004 and 31 December 2011. Controls included residents who had never had cataract surgery and were matched to cases by age, sex, and index date within 1 month of surgery. Statin medications continuously prescribed for at least 1 year before the surgery date (cases) or index date (controls) were examined. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression models. RESULTS: There were 2557 (42%) statin users among cases having cataract surgery compared to 2038 (34%) statin users among controls never having had cataract surgery (p < 0.0001). Incident cataract surgery was significantly associated with increased odds of statin use (OR 1.29, 95% CI 1.19-1.55) after adjusting for age, sex, diabetes, cardiovascular disease, cerebrovascular disease, peripheral vascular disease, renal disease, oral and inhaled steroid use, and selective serotonin reuptake inhibitor use. The association was consistent in both subgroups of women (OR 1.34, 95%CI 1.22-1.49) and men (OR 1.17, 95% CI 1.05-1.30). CONCLUSIONS: Incident cataract surgery was associated with increased odds of statin use, and underscores the possibility that increasing statin use could be contributing to rising rates of cataract surgery.

Joint Management of Cataract Surgery by Ophthalmologists and Optometrists.

PURPOSE: To estimate the rate and geographic variation of cataract surgery that is managed jointly by ophthalmologists and optometrists in aging Americans. DESIGN: Database study. PARTICIPANTS: United States fee-for-service (FFS) Medicare Part B beneficiaries and their providers. METHODS: Medicare Provider Utilization and Payment Data furnished by the Centers for Medicare and Medicaid were used to identify cataract surgery claims among FFS Medicare Part B beneficiaries in all 50 states and the District of Columbia in 2012 and 2013. Payments and joint management rates of cataract surgery by ophthalmologists and optometrists were calculated for each United States state. Geographic variations were evaluated by using the extremal quotient and coefficient of variation (CV). MAIN OUTCOME MEASURES: Medicare allowed payments for cataract surgery (Current Procedural Terminology codes 66982 and 66984) and number of unique FFS Medicare Part B beneficiaries undergoing cataract surgery. RESULTS: The overall national rate of joint management of cataract surgery by ophthalmologists and optometrists among FFS Medicare Part B beneficiaries was 10.9% (range by state, 0%-75%) in 2012 and 11.1% (range by state, 0%-63%) in 2013. In 2013, the mean extremal quotient was 67 and the CV was 82.2, demonstrating very high variation in joint management between states. The Medicare allowed payment to optometrists in the joint management of cataract surgery was 2.1% of the total Medicare allowed payments for cataract surgery codes in 2012 and 2013. Twenty percent and 24% of all Medicare-participating optometrists submitted 10 or more Medicare claims in the joint management of cataract surgery in 2012 and 2013, respectively. CONCLUSIONS: The overall rate of joint management of cataract surgery by ophthalmologists and optometrists among Medicare beneficiaries was 10.9% in 2012 and 11.1% in 2013. Very high geographic variation was documented, with joint management rates ranging from 0% to 63% across states in 2013.