Glaucoma Surgery Shifts Among Medicare Beneficiaries After 2022 Reimbursement Changes in the United States.

PRCIS: This study revealed the best-estimated surgical procedural counts for 2021 and 2022 and suggests a direct influence of coding and reimbursement changes on surgical device selection. PURPOSE: To analyze utilization rates of glaucoma surgeries and minimally invasive (microinvasive) glaucoma surgery among US Medicare beneficiaries between 2021 and 2022. DESIGN: Retrospective comparative analysis of 68,118 unique patients. METHODS: National claims data from a 5% sample of all Medicare beneficiaries were utilized to compare glaucoma procedure counts between the first quarter of 2021 and the first quarter of 2022. Duplicate claims were excluded, and 50 modifiers were counted as 2 distinct procedures. A multiplier was applied to estimate annual utilization for the entire Medicare population. χ 2 analysis was employed to compare categorical data from the 2 time periods. RESULTS: Current Procedural Terminology codes for angle-based stenting decreased by an estimated 20,960 procedures between 2021 and 2022 (28.60%). Goniotomy increased by an estimated 11,680 procedures (66.97%) and canaloplasty increased by an estimated 6640 procedures (47.43%). Glaucoma surgeries decreased by an estimated 5760 procedures (4.25%) despite an increase of cataract surgery by 234,960 procedures (15.63%), an increase in YAG capsulotomy by 19,280 procedures (3.31%), and an increase in intravitreal injections by 146,320 procedures (3.86%). CONCLUSION: Despite overall surgical volume increases among the ophthalmology procedures, angle-based stenting utilization decreased significantly with an accompanying trend change following the coding and reimbursement changes implemented in January 2022. Of the minimally invasive (microinvasive) glaucoma surgery procedures, goniotomy and canaloplasty counts increased the most between these periods. Trabeculectomy and glaucoma drainage device procedures continued to decrease, following well-established trends. Future studies are warranted to examine how these shifts in utilization may impact patient care outcomes.

An Ophthalmology Virtual Externship during the COVID-19 Pandemic: A Pilot Study.

Background The evolution of medical school curricula, characterized by truncated preclinical periods and reduced emphasis on ophthalmology, presents formidable obstacles to early exposure for aspiring medical students. The constraints imposed by the coronavirus disease 2019 pandemic further exacerbated the limitations on opportunities, compelling the implementation of innovative initiatives aimed at augmenting students' ophthalmology education through virtual means. Purpose This article assesses the impact of an Ophthalmology Virtual Externship (OVE) on medical students' knowledge, interest, confidence, and seeking mentorship in ophthalmology. Materials and Methods A total of 76 students voluntarily participated in the program. The OVE encompassed four virtual sessions, facilitated by 4th year medical students employing a near-peer mentorship framework. The initiative was tailored for 2nd and 3rd year medical students and was conducted under the supervision of a faculty member. All participating students completed both pre- and postexternship surveys utilizing a 7-point Likert scale to gauge their levels of interest, confidence, and inclination toward mentorship opportunities in the field of ophthalmology. Furthermore, assessments of ophthalmology knowledge were administered prior to and subsequent to the externship participation. The degree of satisfaction derived from the OVE experience was also evaluated. Results Participation in the OVE significantly elevated confidence in knowledge ( p < 0.001) and mentorship interest ( p = 0.029). Ophthalmology knowledge test scores also notably improved post-OVE across all participants, irrespective of prior experience ( p < 0.001), with the most significant increase observed among 2nd and 3rd year students ( p < 0.0001). After OVE participation, 73% of students expressed intent to pursue ophthalmology opportunities, including mentorship or research. The OVE received an average Likert score of 6.35 out of 7 for student satisfaction. Conclusion The OVE serves as a virtual learning instrument beneficial for 2nd and 3rd year students with a proclivity for ophthalmology, offering a means to circumvent curriculum-related constraints. Moreover, given the decline in formal ophthalmic education, our study contributes to future research assessing the effectiveness of an OVE in addressing ophthalmic knowledge gaps among all medical students.

Impact of Fellowship Training on Practice Patterns of Glaucoma Surgeons Treating Medicare fee-for-service Beneficiaries.

PURPOSE: Analyze practice patterns of glaucoma surgeons with and without fellowship training. MATERIALS AND METHODS: Physician-specific 2017 Medicare data were obtained from the Centers for Medicare & Medicaid Services website. Current Procedural Terminology codes identified procedures including iStent, tube shunts, trabeculectomy, complicated trabeculectomy, endoscopic cyclophotocoagulation, internal Xen Implant, external Xen or Express shunt, Gonioscopy-Assisted Transluminal Trabeculotomy, and Kahook Dual Blade Goniotomy. Physicians with fellowship training were identified via the American Glaucoma Society website. RESULTS: A total of 1547 glaucoma surgeons were identified, of which 319 had completed fellowship training. Overall, fellowship-trained glaucoma surgeons performed more services (50.4 ± 47.0 vs 40.5 ± 35.3, P < .001) with a larger variety of procedures (1.8 ± 1.0 vs 1.3 ± 0.6, P < .001) than those without fellowship training. Surgeons without fellowship training were more likely to perform iStent and endoscopic cyclophotocoagulation and less likely to perform the remaining procedures than their fellowship-trained counterparts. Medicare payments did not differ between groups and the number of Medicare beneficiaries only differed for internal Xen implant (P = .03). Patient comorbidity burden was similar between groups with about one-third of patients being diagnosed with ischemic heart disease. CONCLUSIONS: Surgeons without fellowship training can treat a similar volume of glaucoma patients as those with fellowship training. However, based on surgical procedures employed, their practices are skewed towards mild and moderate glaucoma and they are more limited in their breadth of procedures. In addition, ischemic heart disease was prevalent in the glaucoma patient population.

The Vision Detroit Project: Integrated Screening and Community Eye-Health Education Interventions Improve Eyecare Awareness.

PURPOSE: Poor eye-health knowledge and health literacy are pervasive, contributing to worse outcomes. This study aims to examine short- and long-term eye-health knowledge retention following eye-health education interventions in adults. METHODS: Vision Detroit was an outreach vision screening program that integrated a 5-Point Teaching Intervention (5PTI), at a Southwest Community Center (SW-CC) from 2015-2017. The 5PTI consists of eye-health learning points developed to verbally educate patients. During vision screenings, eye-health knowledge tests were administered before and after 5PTI (Test 1 and Test 2, respectively). In 2016, Community Eye-Health Education Interventions (CHEI) were initiated at the SW-CC. During CHEI, bilingual healthcare students taught voluntary SW-CC members the 5PTI learning points, regardless of participant interest to attend future screenings. CHEI sessions occurred on separate dates prior to vision screening events. Test 1 and Test 2 scores were compared for all participants. Test 1 scores were compared for those who underwent CHEI prior to vision screening (CHEI positive) versus those who did not (CHEI negative). RESULTS: Two-hundred-seventeen adult patients met inclusion criteria, with 75.8% women, 82.6% Hispanic, mean age 50.4 ± 16.2 years, 74.6% had high school or less education, and 49.2% had health insurance. Test 1 to Test 2 scores improved after 5PTI (71.2 ± 26.4% vs. 97.2 ± 9.9%, p < .00001). Forty-eight participants attended CHEI and subsequent vision screening. Test 1 scores were higher among those CHEI positive versus CHEI negative (81.1 ± 2.1% vs. 68.3 ± 3.4%, p = .0027). CONCLUSION: Simple eye-health education interventions, delivered during vision screenings and via community-based education, can improve eye-health knowledge.

Consensual Ophthalmotonic Reaction Following Selective Laser Trabeculoplasty.

Aim: "Consensual ophthalmotonic reaction" refers to changes in intraocular pressure (IOP) in one eye, which is accompanied by a corresponding change in IOP in the contralateral eye. This study evaluates whether monocular administration of selective laser trabeculoplasty (SLT) leads to a consensual ophthalmotonic reaction and how long this effect lasts. Materials and methods: A retrospective chart review was performed on patients receiving SLT at Kresge Eye Institute in Detroit, MI, from January 2015 to August 2016. Patients were excluded if they had previous history of glaucoma incisional and/or laser procedures; required additional laser trabeculoplasty; had glaucoma medication changes during the follow-up period; experienced no decrease in IOP during the follow-up period; or had a diagnosis of angle closure on gonioscopy. Various demographic, clinical, and surgical data were collected. IOP measurements were collected at baseline and postoperatively at 1-3 months, 4-9 months, and 12-15 months. Results: At all follow-up periods, the IOP of the treated eye was decreased from baseline IOP (p ≤ 0.05, paired t-test). For the fellow eye, there was a statistically significantly decrease from baseline up to the 4-9 months follow-up period (p ≤ 0.05, paired t-test). Linear regression analysis of the percent reduction in IOP from baseline in the SLT-treated eye with the fellow eye shows a mild correlation at all-time points: R2 = 0.284 (p < 0.001) at 1-3 months; R2 = 0.348 (p < 0.001) at 4-9 months; R2 = 0.118 (p = 0.054) at 12-15 months. Conclusion: This study showed that monocular administration of SLT results in a consensual ophthalmotonic reaction. The consensual ophthalmotonic reaction appears to last for up to 4-9 months. Clinical significance: Therefore, although SLT does lead to a consensual ophthalmotonic reaction, monocular administration of SLT is not a reliable method of long-term IOP control for the contralateral non-SLT-treated eye. How to cite this article: Nassiri N, Mei F, Tokko H, et al. Consensual Ophthalmotonic Reaction Following Selective Laser Trabeculoplasty. J Curr Glaucoma Pract 2022;16(1):36-40.

Factors Associated with 5-year Glaucomatous Progression in Glaucoma Suspect Eyes: A Retrospective Longitudinal Study.

Purpose: Using demographic, clinical, visual field, and optical coherence tomography (OCT) variables to study the association of 5-year glaucomatous progression in glaucoma suspect eyes. Patients and methods: This is a retrospective longitudinal clinical study. Inclusion criteria consisted of glaucoma suspect eyes (i.e., concerning cup-to-disk ratio and/or intraocular pressure (IOP) >21 mm Hg), age ≥ 30 years old, follow-up time of 5 years, best-corrected visual acuity (BCVA) of 20/100 or better, spherical equivalent (SE) higher than 8 diopters and an astigmatism less than 3 diopters. Eyes with glaucoma-determined by two consecutive, reliable visual field tests-were excluded, as well as any eyes with any clinically significant retinal or neurological disease. The percentage of glaucoma suspect eyes, which progressed to glaucoma within a 5-year period, was calculated. Study subjects were divided into the following groups: eyes that progressed to glaucoma and those that did not. Results: In the 288 patients which we looked at, 365 total eyes, 323 eyes had concerning cup-to-disk ratio and 42 had ocular hypertension. Bivariate analysis showed that the eyes which progressed to glaucoma had significantly worse mean deviation, increased pattern standard deviation (PSD), and less visual field index (VFI). Our bivariate analysis also showed a thinner average, superior and inferior retinal nerve fiber layer thickness (RNFL), and more severe average, superior, and inferior RNFL damages (i.e., color grading scale) at baseline. Logistic regression analysis showed that only PSD and severe inferior RNFL damage (i.e., red color) to be significantly associated with 5-year glaucomatous progression. Conclusion: Segmental RNFL damage and pattern standard deviation are associated with 5-year glaucomatous progression in glaucoma suspect eyes. How to cite this article: Nassiri N, Das S, Patel V, et al. Factors Associated with 5-year Glaucomatous Progression in Glaucoma Suspect Eyes: A Retrospective Longitudinal Study. J Curr Glaucoma Pract 2022;16(1):11-16.

The Vision Detroit Project: Visual Burden, Barriers, and Access to Eye Care in an Urban Setting.

PURPOSE: Vision loss and blindness are among the top ten disabilities in the United States, yet access and utilization of eye care remains low. Vision Detroit aimed to address eye-care disparities via community-based screenings. By investigating burden of eye disease and barriers to eye-care utilization in an underserved urban community, we may direct efforts to improve access. METHODS: Twenty-three screenings were conducted from March 2015-November 2017. Patient information gathered at screenings were demographics, medical and social history, eye exam/referral history, insurance status, primary care physician (PCP) status, and patient-perceived eye-care barriers. RESULTS: Three-hundred-eighty patients were screened, 42% African American and 51% Hispanic. Average age was 53 ± 16.4 years, 70% reported vision problems, 50% reported over two years of vision problems, and average habitual visual acuity in best-seeing eye was 20/37. Eye-care underutilization was reported in 61% of type-2 diabetics. Older age and PCP recommendations/referrals were associated with increased utilization in all patients. Insurance was the most common barrier (53%); of the 55% insured, 31% reported financial barriers. Employed patients were more likely than unemployed to report a time barrier (odds ratio = 1.76, 95% confidence interval 1.03-3.01). Those with high school or less education reported "unaware of need", "unsure where to go", "transportation", and "insurance" as barriers more often. CONCLUSION: Visual burden was pervasive, yet access was suboptimal. Financial, logistical, and awareness barriers were common. PCP referral and older age were associated with increased utilization. Those less educated reported more barriers, highlighting the need to address fiscal concerns and eye-health education.

Comparison of Povidone-Iodine and Gentamicin Soak as Scleral Buckle Infection Prophylaxis.

OBJECTIVE: To determine the best method of antimicrobial prophylaxis against implanted material-associated infections in the setting of scleral buckle surgery. DESIGN: Experimental study. PARTICIPANTS: Scleral buckle elements were soaked in either gram-positive or polymicrobial broth, while control buckle elements were soaked in PBS only. METHODS: Solid silicone and sponge scleral buckle elements were inoculated with common pathogens of the ocular surface, and then soaked in either 1% or 5% povidone-iodine, 1 mg/mL gentamicin solution, or sterile saline for 1, 5, 10, or 15 minutes. Bacteria were then isolated from the buckle elements and cultured for 24 hours. RESULTS: In all gram-positive bacterial conditions, gentamicin solution decreased the bacterial load from 451,666.67 colony-forming units (CFU)/mL to 171,611.11 CFU/mL (p=0.0004). The fractional bacterial survival after soaking in gentamicin was higher for the silicone sponge than band (0.357 vs 0.079, p=0.038). Both 1% and 5% povidone-iodine were able to completely eradicate all gram-positive bacteria of both buckle elements. Only 5% povidone-iodine was able to completely sterilize all microbes on the buckle after soaking in a polymicrobial solution consisting of gram-positive, gram-negative bacteria, and fungi. CONCLUSION: Povidone-iodine solution was significantly more effective at bacterial eradication compared to gentamicin solution. For all scleral buckle procedures, we recommend soaking the buckle element in 2-3% povidone-iodine solution before placement and rinsing the ocular surface with the same solution after placement.

Comprehensive Analysis to Uncover Determinants of Patient Appointment Compliance in Ophthalmology at the Kresge Eye Institute, USA.

INTRODUCTION: Appointment compliance (AC) has a significant impact on patient care; however, determinants of AC in Ophthalmology and its subspecialties remains elusive. METHODS: We performed a five-year retrospective analysis across Kresge Eye Institute (KEI) and its affiliated Michigan locations. A total of 597,364 appointments across >13 subspecialties were included. AC was the primary outcome of interest. Compliant (CO) and non-compliant (NC) groups were compared to the following variables: patient characteristics (gender, race, age, insurance), appointment rank (relative to patient history), scheduling location, month, and ophthalmic specialty, in regard to arrival and no-show. RESULTS: Among all appointments, 59.77% were associated with a female patient and 79.16% of the total number of appointments depicted patient compliance. AC differed concerning specialty, with retina representing the highest compliance across all appointments. Among 200+ insurance providers, Medicare was most frequently used and represented the highest share of CO appointments. African Americans were the primary ethnicity served by KEI and had the highest number of NC appointments. CONCLUSION: Our study demonstrates the impact of patient demographics, appointment characteristics, and ophthalmic subspecialty on AC. A better understanding of these determinants could allow for an increased CO for Ophthalmology practices.

Three-year outcomes of trabeculectomy and Ahmed valve implant in patients with prior failed filtering surgeries.

PURPOSE: To compare three-year surgical outcomes of trabeculectomy versus Ahmed valves in patients with prior failed trabeculectomy. METHODS: This is a longitudinal retrospective comparative study of one-hundred twenty adult patients with prior failed trabeculectomy who underwent a repeat trabeculectomy or Ahmed valve implant. Demographic and clinical data were collected up to 3 years on all study participants at the Kresge Eye Institute from 2004 to 2016. Visual acuity, intraocular pressure, number of intraocular pressure reducing medications, and success rates at various time points up to 3 years after repeat surgery were the main outcome variables. RESULTS: Sixty-five and sixty eyes were included in the trabeculectomy and the Ahmed valve groups, respectively. Baseline intraocular pressure significantly decreased in both groups at 3 years (p < 0.01). The number of medications was relatively similar to baseline in both study groups at 3 years (p > 0.05). There was no statistically significant difference between the two groups in visual acuity, percentage of intraocular pressure reduction, number of medications, or success rates at any follow-up time points (p > 0.05 for all). CONCLUSIONS AND RELEVANCE: After 3 years, both trabeculectomy and Ahmed valves significantly reduced intraocular pressure from baseline, but with relatively similar number of medications compared to baseline. There was no significant difference in any outcome measure between trabeculectomy and Ahmed valves at any follow-up time points. These results may suggest neither trabeculectomy or Ahmed valves are superior in patients with previously failed trabeculectomies.

Factors Associated with the Development of Posterior Capsule Opacification Requiring Yttrium Aluminum Garnet Capsulotomy.

SIGNIFICANCE: Determining risk factors for posterior capsule opacification will allow for further interventions to reduce the risk of development and thus additional procedures. PURPOSE: The purpose of this study was to investigate risk factors associated with development of clinically significant posterior capsule opacification requiring yttrium aluminum garnet (YAG) capsulotomy. METHODS: Medical records of patients (≥18 years) who underwent cataract surgery between January 1, 2011, and March 31, 2014, at Kresge Eye Institute were reviewed. Three hundred eyes requiring YAG capsulotomy up to 3 years after cataract surgery were included in the YAG capsulotomy group. Three hundred eyes not requiring YAG capsulotomy up to 3 years after cataract surgery were selected via age-matched simple randomization (control group). RESULTS: The YAG capsulotomy group included patients with younger age (65.8 ± 11.3 vs. 70.1 ± 10.6 years, P < .001), more men (42.67 vs. 34.67%, P = .04), fewer patients with hypertension (73.00 vs. 83.00%, P < .001), and more patients with hydrophilic intraocular lenses (74.67 vs. 47.00%, P < .001). Logistic regression analysis demonstrated a negative association between YAG capsulotomy and age (coefficient, -0.04; 95% confidence interval [CI], 0.95 to 0.98; P < .001) and hydrophobic intraocular lenses (coefficient, -1.50; 95% CI, 0.15 to 0.33; P < .001), and a positive association with presence of glaucoma (coefficient, 0.88; 95% CI, 1.39 to 4.17; P = .002). Elapsed time to YAG capsulotomy was sooner in patients with a history of uveitis (95% CI, 5.10 to 9.70 months; P = .02) and insertion of hydrophilic intraocular lenses (95% CI, 18.67 to 21.57 months; P < .001). CONCLUSIONS: Results of this study suggest that development of visually significant posterior capsule opacification is associated with younger age, glaucoma, and hydrophilic intraocular lenses, and it occurs earlier among those with hydrophilic intraocular lenses and a history of uveitis.

Zika Virus Infects Trabecular Meshwork and Causes Trabeculitis and Glaucomatous Pathology in Mouse Eyes.

Zika virus (ZIKV) infection during pregnancy leads to devastating fetal outcomes, including neurological (microcephaly) and ocular pathologies such as retinal lesions, optic nerve abnormalities, chorioretinal atrophy, and congenital glaucoma. Only clinical case reports have linked ZIKV infection to causing glaucoma, a major blinding eye disease. In the present study, we have investigated the role of ZIKV in glaucoma pathophysiology using in vitro and in vivo experimental models. We showed that human primary trabecular meshwork (Pr. TM) cells, as well as a human GTM3 cell line, were permissive to ZIKV infection. ZIKV induced the transcription of various genes expressing pattern recognition receptors (TLR2, TLR3, and RIG-I), cytokines/chemokines (TNF-α, IL-1ß, CCL5, and CXCL10), interferons (IFN-α2, IFN-ß1, and IFN-γ), and interferon-stimulated genes (ISG15 and OAS2) in Pr. TM cells. ZIKV infection in IFNAR1-/- and wild-type (WT) mouse eyes resulted in increased intraocular pressure (IOP) and the development of chorioretinal atrophy. Anterior chamber (AC) inoculation of ZIKV caused infectivity in iridocorneal angle and TM, leading to the death of TM cells in the mouse eyes. Moreover, anterior segment tissue of infected eyes exhibited increased expression of inflammatory mediators and interferons. Furthermore, ZIKV infection in IFNAR1-/- mice resulted in retinal ganglion cell (RGC) death and loss, coinciding with optic nerve infectivity and disruption of anterograde axonal transport. Because of similarity in glaucomatous pathologies in our study and other experimental glaucoma models, ZIKV infection can be used to study infectious triggers of glaucoma, currently an understudied area of investigation.IMPORTANCE Ocular complications due to ZIKV infection remains a major public health concern because of their ability to cause visual impairment or blindness. Most of the previous studies have shown ZIKV-induced ocular pathology in the posterior segment (i.e., retina) of the eye. However, some recent clinical reports from affected countries highlighted the importance of ZIKV in affecting the anterior segment of the eye and causing congenital glaucoma. Because glaucoma is the second leading cause of blindness worldwide, it is imperative to study ZIKV infection in causing glaucoma to identify potential targets for therapeutic intervention. In this study, we discovered that ZIKV permissively infects human TM cells and evokes inflammatory responses causing trabeculitis. Using a mouse model, we demonstrated that ZIKV infection resulted in higher IOP, increased RGC loss, and optic nerve abnormalities, the classical hallmarks of glaucoma. Collectively, our study provides new insights into ocular ZIKV infection resulting in glaucomatous pathology.

Factors Associated with Conjunctival Erosions after Ahmed Glaucoma Valve Implantation.

PURPOSE: To investigate the frequency of conjunctival erosions in a series of patients who underwent Ahmed valve implantation in a tertiary referral center and to study risk factors associated with the conjunctival erosions. METHODS: This is a single-center, retrospective case-control study of all patients who underwent Ahmed valve implantation between October 2006 and July 2016 at the Kresge Eye Institute in Detroit, Michigan. The series consisted of 306 eyes (277 patients) that underwent Ahmed valve implantation. The rate of conjunctival erosions was determined. Univariate, bivariate, and Cox-proportional hazard analyses were performed to identify factors associated with conjunctival erosions. RESULTS: During the study period, 23 erosions occurred in 306 eyes (7.52%). Aphakia was significantly more common in eyes with erosions (P < 0.05). Aphakia (P = 0.02), uveitic glaucoma (P = 0.03), and longer post-operative use of topical steroids (P < 0.04) significantly increased the risk of erosions based on the Cox model. There were similar rates of erosions with each type of patch graft. No conjunctival erosion was observed after using the modified scleral tunnel method (n = 10). CONCLUSIONS: The overall erosion rate was 7.52% in our series. Uveitic glaucoma, aphakia, and longer post-operative use of topical steroids were significantly associated with conjunctival erosions.

Effect of phenylephrine 1.0%-ketorolac 0.3% injection on tamsulosin-associated intraoperative floppy-iris syndrome.

PURPOSE: To determine the effect of phenylephrine 1.0%-ketorolac 0.3% injection (Omidria) on different components of intraoperative floppy-iris syndrome (IFIS). SETTING: Silverstein Eye Centers, Kansas City, Missouri, USA. DESIGN: Prospective case series. METHODS: Men treated with tamsulosin having standard cataract extraction surgery were placed in a treatment group that received phenylephrine 1.0%-ketorolac 0.3% injection in the irrigation solution and a control group) that received basic saline solution. Every procedure was video recorded using an endocyclophotocoagulation (ECP) probe and microscopic view. Pupil dilation, iris billowing, and iris prolapse were measured using a micrometer, ECP recording grading scale, and microscopic recordings, respectively. RESULTS: Each group (treatment and control) comprised 25 eyes of 25 patients. Although both groups had a decrease in pupil diameter before and after cataract extraction and before cataract extraction and after intraocular lens implantation, the changes were statistically significantly greater in the treatment group. Iris prolapse occurred in 3 patients (12.0%) in the treatment group and 14 patients (56.0%) in the control group (P < .001). Stage 3 (severe) pupil billowing occurred in 1 eye (4.0%) in the treatment group and 10 eyes (40.0%) in the control group (P < .001). CONCLUSIONS: The use of the phenylephrine 1.0%-ketorolac 0.3% injection combination added to the irrigating solution during cataract surgery in patients at risk for IFIS led to significantly better prevention of miosis, less pupil billowing, and a reduced incidence of iris prolapse. A new grading scale for intraoperative iris abnormalities might be used for future evaluation.

Assessment of Neurotrophins and Inflammatory Mediators in Vitreous of Patients With Diabetic Retinopathy.

Purpose: To assess vitreous levels of inflammatory cytokines and neurotrophins (NTs) in diabetic retinopathy (DR) and elucidate their potential roles. Methods: A prospective study was performed on 50 vitreous samples obtained from patients with DR (n = 22) and the nondiabetic controls (n = 28). All patients were candidates for vitrectomy. Inflammatory cytokine and NT levels were determined with ELISA. Potential source and role of NTs was determined by using human retinal Müller glia and mouse photoreceptor cells and challenging them with TNF-α or IL-1ß, followed by detection of NTs and cell death. Results: Vitreous NT levels of all DR patients were significantly higher than those of nondiabetic controls (nerve growth factor [NGF, P = 0.0001], brain-derived neurotrophic factor [BDNF, P = 0.009], neurotrophin-3 [NT-3, P < 0.0001], neurotrophin-4 [NT-4, P = 0.0001], ciliary neurotrophic factor [CNTF, P = 0.0001], and glial cell-derived neurotrophic factor [GDNF, P = 0.008]). Similarly, the levels of inflammatory mediators IL-1ß (P < 0.0001), IL-6 (P = 0.0005), IL-8 (P < 0.0001), and TNF-α (P < 0.0001) were also higher in eyes with DR. Interestingly, inflammatory cytokine and NT levels, particularly TNF-α (P < 0.05), IL-8 (P < 0.004), NT-3 (P = 0.012), NGF (P = 0.04), GDNF (P = 0.005), and CNTF (P = 0.002), were higher in eyes with nonproliferative diabetic retinopathy (NPDR) than in eyes with active proliferative diabetic retinopathy (PDR). Cytokine stimulation of Müller glia resulted in production of NTs, and GDNF treatment reduced photoreceptor cell death in response to inflammation and oxidative stress. Conclusions: Together, our study demonstrated that patients with DR have higher levels of both inflammatory cytokines and NTs in their vitreous. Müller glia could be the potential source of NTs under inflammatory conditions to exert neuroprotection.

The effect of electronic health record software design on resident documentation and compliance with evidence-based medicine.

This study aimed to determine the role of electronic health record software in resident education by evaluating documentation of 30 elements extracted from the American Academy of Ophthalmology Dry Eye Syndrome Preferred Practice Pattern. The Kresge Eye Institute transitioned to using electronic health record software in June 2013. We evaluated the charts of 331 patients examined in the resident ophthalmology clinic between September 1, 2011, and March 31, 2014, for an initial evaluation for dry eye syndrome. We compared documentation rates for the 30 evidence-based elements between electronic health record chart note templates among the ophthalmology residents. Overall, significant changes in documentation occurred when transitioning to a new version of the electronic health record software with average compliance ranging from 67.4% to 73.6% (p < 0.0005). Electronic Health Record A had high compliance (>90%) in 13 elements while Electronic Health Record B had high compliance (>90%) in 11 elements. The presence of dialog boxes was responsible for significant changes in documentation of adnexa, puncta, proptosis, skin examination, contact lens wear, and smoking exposure. Significant differences in documentation were correlated with electronic health record template design rather than individual resident or residents' year in training. Our results show that electronic health record template design influences documentation across all resident years. Decreased documentation likely results from "mouse click fatigue" as residents had to access multiple dialog boxes to complete documentation. These findings highlight the importance of EHR template design to improve resident documentation and integration of evidence-based medicine into their clinical notes.

The Impact of the Medicare Access and CHIP Reauthorization Act on the Field of Ophthalmology.

PURPOSE: To analyze the impact of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) on the field of ophthalmology. DESIGN: A perspective on the effects of MACRA's Quality Payment Program after analysis of the proposed rule, final rule, and commentary submitted by relevant stakeholders. RESULTS: Physicians will need to use 1 of 2 payment structures: Merit-Based Incentive Payment Systems (MIPS) or Alternative Payment Models (APMs). APMs and MIPS will focus on bundling payments and reimbursing based on "fee-for-service-plus" models, which take into account clinical outcomes, coordination of care, clinical improvement, and electronic information exchange and security. APMs have substantial advantages, with eligible participants receiving a bonus and a higher rate of annual adjustment over the program's life. For most ophthalmology practices, MIPS may be more appropriate owing to its broader applicability and the current paucity of APMs for ophthalmologists. CONCLUSION: The Quality Payment Program is a substantial improvement over the negative adjustments under the repealed Substantial Growth Rate model. Ophthalmologists will likely use the MIPS system; however, its comparatively lower reimbursements, as well as its cost, quality, and other reporting measures, may prove problematic.

Zika virus infects cells lining the blood-retinal barrier and causes chorioretinal atrophy in mouse eyes.

Zika virus (ZIKV) is an important pathogen that causes not only neurologic, but also ocular, abnormalities. Thus, it is imperative that models to study ZIKV pathogenesis in the eye are developed to identify potential targets for interventions. Here, we studied ZIKV interactions with human retinal cells and evaluated ZIKV's pathobiology in mouse eyes. We showed that cells lining the blood-retinal barrier (BRB), the retinal endothelium, and retinal pigment epithelium (RPE) were highly permissive and susceptible to ZIKV-induced cell death. Direct inoculation of ZIKV in eyes of adult C57BL/6 and IFN-stimulated gene 15 (ISG15) KO mice caused chorioretinal atrophy with RPE mottling, a common ocular manifestation of congenital ZIKV infection in humans. This response was associated with induced expression of multiple inflammatory and antiviral (IFNs) response genes in the infected mouse retina. Interestingly, ISG15 KO eyes exhibited severe chorioretinitis, which coincided with increased retinal cell death and higher ZIKV replication. Collectively, our study provides the first evidence to our knowledge that ZIKV causes retinal lesions and infects the cells lining the BRB and that ISG15 plays a role in retinal innate defense against ZIKV infection. Our mouse model can be used to study mechanisms underlying ZIKV-induced chorioretinitis and to gauge ocular antiviral therapies.

Resident Compliance With the American Academy of Ophthalmology Preferred Practice Patterns for Primary Open-Angle Glaucoma Suspect.

PURPOSE: To study resident compliance with the American Academy of Ophthalmology (AAO) Preferred Practice Patterns (PPPs) for primary open-angle glaucoma suspect (POAGS) in a resident ophthalmology clinic. PATIENTS AND METHODS: Two hundred charts were selected for analysis of adult patients with the International Classification of Diseases diagnosis code for POAGS during their initial visit between November 2, 2010 and May 6, 2014 at the Kresge Eye Institute resident clinic. Electronic medical records of clinic visits for POAGS patients were evaluated for documentation and compliance with 17 elements of AAO PPPs. RESULTS: The overall mean compliance was 73.8% for all charts (n=200), 74.4% for first-year residents (n=53), 74.5% for second-year residents (n=38), and 73.3% for third-year residents (n=109). Documentation rates were high (>90%) for 9 elements, which included most elements of physical examination and history. Documentation of ocular history, central corneal thickness, gonioscopy, optic nerve head and retinal nerve fiber layer analysis, and visual field ranged from 40% to 80%. Documentation was lowest for patient education elements which ranged from 0% to 10%. Compliance was not significantly different (P>0.05) between residents or between different resident years for any element. CONCLUSIONS: Residents' compliance was high for most elements of the PPPs for POAGS. We identified elements with poor compliance especially regarding patient education. Adherence to AAO PPPs can be a helpful method of assessing resident performance.

Photosensitive disorders of the skin with ocular involvement.

Patients with photosensitive disorders of the skin may present with ocular manifestations that are evident at birth or may be manifested later with progression of the disorder. Dermatologists should be able to recognize these and appropriately refer patients for further management. Ocular involvement associated with immunologically mediated photodermatoses, drug- and chemical-induced photosensitivity, photodermatoses associated with defective DNA repair/chromosome instability, and photoaggravated dermatoses are reviewed. Photodermatoses are commonly classified into four general groups: (1) immunologically mediated photodermatoses; (2) drug- and chemical-induced photosensitivity; (3) photodermatoses associated with defective DNA repair/chromosome instability; and (4) photoaggravated dermatoses. Photodermatoses in these groups with ocular involvement will be discussed. In addition, skin diseases associated with photophobia are also described.