Comparative Effectiveness of Carotid Stenting to Medical Therapy Among Patients With Asymptomatic Carotid Stenosis.

BACKGROUND: No completed trials have compared carotid artery stenting (CAS) to medical therapy (MT). We examined the effectiveness of CAS compared with MT in patients with asymptomatic carotid stenosis. METHODS: We conducted a retrospective cohort study of 219 979 Veterans ≥65 years who received carotid imaging for asymptomatic carotid stenosis between 2005 and 2009 in the US Veterans Health Administration. We constructed a sample of patients who received MT (n=2509) and comparable patients who received CAS (n=551) and followed them for 5 years. Using target trial methodology, we computed weighted Kaplan-Meier curves and estimated the risk of fatal and nonfatal stroke in each group over 5 years of follow-up. We also estimated the cumulative incidence functions for fatal and nonfatal stroke accounting for nonstroke deaths as competing risks. RESULTS: Five hundred fifty-one patients received CAS, and 2509 patients received MT. The observed rate of stroke or death (perioperative complications) within 30 days in the CAS arm was 2.2%. Using the target trial methodology, the 5-year risk of fatal and nonfatal stroke was similar among patients assigned to CAS (6.9%) compared with patients assigned to MT (7.1%; risk difference, -0.1% [95% CI, -2.6% to 2.7%]). In an analysis that incorporated the competing risk of death, the risk difference between the two arms remained nonsignificant (risk difference, -1.5% [95% CI, -3.0% to 0.3%]). CONCLUSIONS: In this sample of older male adults, we found no difference between MT and CAS in the treatment of asymptomatic carotid stenosis. Future studies in other settings are needed to confirm these findings.

Effect of mitomycin c and 5-flurouracil adjuvant therapy on the outcomes of Ahmed glaucoma valve implantation.

BACKGROUND: To examine the effect of mitomycin c and 5-flurouracil on treatment outcomes following Ahmed glaucoma valve implantation. DESIGN: Retrospective consecutive case series. PARTICIPANTS: Fifty patients who received Ahmed glaucoma valve implantation from 1999 to 2013 in the San Francisco Veterans Administration Hospital. METHODS: The +INJECTION group received intraoperative mitomycin c followed by postoperative mitomycin c and/or 5-flurouracil, whereas the -INJECTION group did not. MAIN OUTCOME MEASURES: Primary outcome was treatment success at 1 year post-implantation. Intraocular pressure, hypertensive phase, and the number of glaucoma medications were also examined. RESULTS: Twenty-six patients/eyes in the +INJECTION group and 24 patients/eyes in the -INJECTION group were included. Treatment success was higher in the +INJECTION compared with the -INJECTION group (86 vs. 58%; P = 0.04). Intraocular pressure was lower in the +INJECTION compared with the -INJECTION group at 1, 3, 6 and 12 months (P ≪ 0.00001, P = 0.00003, 0.0008 and 0.024). Hypertensive phase occurred less often in the +INJECTION compared with the -INJECTION group (3.8 vs. 54%; P = 0.021). The +INJECTION group required fewer medications compared with the -INJECTION group (P = 0.02, 0.002, 0.003 and 0.008 at 1, 3, 6 and 12 months). Complication rates were comparable between groups (46.2 and 54.2%; P = 0.63). CONCLUSIONS: Adjuvant treatment with antifibrotics following Ahmed glaucoma valve implantation decreased the hypertensive phase and improved surgical outcomes without impacting complication rates at 1 year. This study postulates a role for antifibrotics in the postoperative management of Ahmed glaucoma valves.

Predictors of matching in an ophthalmology residency program.

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 one's 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 one's medical school.

FIAT: A Device for Objective, Optical Measures of Accommodation in Phakic and Pseudophakic Eyes.

Purpose: To present FIAT, a novel optical instrument and analysis package that is designed to elicit and optically record accommodation in human eyes. Methods: FIAT employs a Shack-Hartmann wavefront sensor and a retro-illumination pupil camera that records from a single eye at video rates. It is effective at eliciting accommodation by offering the subject a full-field binocular view of an alternating distant target and a near-eye display. FIAT analysis software computes wave aberrations for each video frame over full- or subpupil sizes and computes accommodative dynamics and accommodative range. Results: The system is validated by showing accurate refraction measurements in model eyes and human eyes with trial lenses. Robust accommodative responses are shown for young eyes, and a lack of accommodative response is shown for a known presbyopes. Accommodative stimulus-response curves from five phakic subjects over a range of ages show expected results. Results from two individuals with monofocal intraocular lenses are shown. Conclusions: FIAT is an effective instrument for making accurate, objective measures of accommodation in phakic and pseudophakic eyes. Translational Relevance: We present a device that can play an important role in the development and testing of accommodating intraocular lenses.

A multicenter analysis of the ophthalmic knowledge assessment program and American Board of Ophthalmology written qualifying examination performance.

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.

Cataract surgery after refractive surgery.

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.

Comparative Effectiveness of Carotid Endarterectomy vs Initial Medical Therapy in Patients With Asymptomatic Carotid Stenosis.

Importance: Carotid endarterectomy (CEA) among asymptomatic patients involves a trade-off between a higher short-term perioperative risk in exchange for a lower long-term risk of stroke. The clinical benefit observed in randomized clinical trials (RCTs) may not extend to real-world practice. Objective: To examine whether early intervention (CEA) was superior to initial medical therapy in real-world practice in preventing fatal and nonfatal strokes among patients with asymptomatic carotid stenosis. Design, Setting, and Participants: This comparative effectiveness study was conducted from August 28, 2018, to March 2, 2020, using the Corporate Data Warehouse, Suicide Data Repository, and other databases of the US Department of Veterans Affairs. Data analyzed were those of veterans of the US Armed Forces aged 65 years or older who received carotid imaging between January 1, 2005, and December 31, 2009. Patients without a carotid imaging report, those with carotid stenosis of less than 50% or hemodynamically insignificant stenosis, and those with a history of stroke or transient ischemic attack in the 6 months before index imaging were excluded. A cohort of patients who received initial medical therapy and a cohort of similar patients who received CEA were constructed and followed up for 5 years. The target trial method was used to compute weighted Kaplan-Meier curves and estimate the risk of fatal and nonfatal strokes in each cohort in the pragmatic sample across 5 years of follow-up. This analysis was repeated after restricting the sample to patients who met RCT inclusion criteria. Cumulative incidence functions for fatal and nonfatal strokes were estimated, accounting for nonstroke deaths as competing risks in both the pragmatic and RCT-like samples. Exposures: Receipt of CEA vs initial medical therapy. Main Outcomes and Measures: Fatal and nonfatal strokes. Results: Of the total 5221 patients, 2712 (51.9%; mean [SD] age, 73.6 [6.0] years; 2678 men [98.8%]) received CEA and 2509 (48.1%; mean [SD] age, 73.6 [6.0] years; 2479 men [98.8%]) received initial medical therapy within 1 year after the index carotid imaging. The observed rate of stroke or death (perioperative complications) within 30 days in the CEA cohort was 2.5% (95% CI, 2.0%-3.1%). The 5-year risk of fatal and nonfatal strokes was lower among patients randomized to CEA compared with patients randomized to initial medical therapy (5.6% vs 7.8%; risk difference, -2.3%; 95% CI, -4.0% to -0.3%). In an analysis that incorporated the competing risk of death, the risk difference between the 2 cohorts was lower and not statistically significant (risk difference, -0.8%; 95% CI, -2.1% to 0.5%). Among patients who met RCT inclusion criteria, the 5-year risk of fatal and nonfatal strokes was 5.5% (95% CI, 4.5%-6.5%) among patients randomized to CEA and was 7.6% (95% CI, 5.7%-9.5%) among those randomized to initial medical therapy (risk difference, -2.1%; 95% CI, -4.4% to -0.2%). Accounting for competing risks resulted in a risk difference of -0.9% (95% CI, -2.9% to 0.7%) that was not statistically significant. Conclusions and Relevance: This study found that the absolute reduction in the risk of fatal and nonfatal strokes associated with early CEA was less than half the risk difference in trials from 20 years ago and was no longer statistically significant when the competing risk of nonstroke deaths was accounted for in the analysis. Given the nonnegligible perioperative 30-day risks and the improvements in stroke prevention, medical therapy may be an acceptable therapeutic strategy.

Risk factors for intraoperative complications in resident-performed phacoemulsification surgery.

PURPOSE: To determine the risk factors for intraoperative complications in resident-performed phacoemulsification surgery and the effect of complications on postoperative visual acuity. DESIGN: Retrospective case series. PARTICIPANTS: A total of 320 consecutive eyes of predominantly male (96.6%) and elderly patients (mean age +/-1 standard deviation = 73.1+/-10.0 years) undergoing phacoemulsification surgery by ophthalmology residents at a Veterans Administration Hospital between January 2006 and 2007. There were no exclusion criteria for type of cataract undergoing phacoemulsification surgery. METHODS: Data were collected by review of patients' electronic medical records. Collected data included the patient demographics, ocular comorbidities, cataract features, resident, resident experience, attending, right or left eye, anesthesia type, wound type, phacoemulsification technique, preoperative and postoperative visual acuities, and presence of any intraoperative complication. Multivariate models were constructed to determine potential risk factors for intraoperative complications. MAIN OUTCOME MEASURES: Major intraoperative complication rate, risk factors for major intraoperative complications, and best-corrected postoperative visual acuity. RESULTS: The major intraoperative complication rate was 4.7%, which included 3.1% of cases with vitreous loss. The strongest association with a major complication was the presence of a case identified as challenging preoperatively, which had an odds ratio of 6.0 (95% confidence interval [CI], 1.5-24.1, P=0.01). The challenging features most strongly associated with major complications were mature 4+ nuclear sclerotic cataracts and zonular pathology (antecedent trauma and pseudoexfoliation), which had odds ratios of 18.9 (95% CI, 3.1-117, P=0.002) and 26.2 (95% CI, 4.3-159, P=0.003), respectively. A major complication decreased the likelihood of achieving 20/40 or better visual acuity within 90 days of surgery (95% of uncomplicated eyes vs. 71% of complicated eyes; P=0.009). CONCLUSIONS: Residents performing phacoemulsification surgery achieved a low overall rate of major complications. However, specific features of cataracts, such as mature nuclei and zonular pathology, carried increased intraoperative risk. Anticipating risk may help to decrease surgical complications further and to counsel patients appropriately.

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 $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.

Resident-performed prophylactic retinopexy and the risk of retinal detachment.

BACKGROUND AND OBJECTIVE: To examine the natural history of retinopexies performed by ophthalmology residents at university-affiliated clinics and to determine the rate of progression to rhegmatogenous retinal detachment. PATIENTS AND METHODS: Charts of patients receiving prophylactic thermal coagulation between 1997 and 2006 were reviewed retrospectively. Outcome measures included subsequent rhegmatogenous retinal detachment and additional prophylactic treatments. RESULTS: Review of the medical records identified 166 eyes with peripheral retinal lesions treated by residents, with an average follow-up of 2.4 +/- 0.2 years. At presentation, only 43.4% of patients were symptomatic. Two (1.2%) eyes developed rhegmatogenous retinal detachment during follow-up, with each arising in a previously healthy area of retina in a patient with a history of detachment of the fellow retina. Twenty-five eyes (15%) received at least one additional prophylactic procedure. CONCLUSION: The rate of rhegmatogenous retinal detachment following prophylactic retinopexy performed by residents at hospital-based clinics is low, supporting this standard practice.

Gender Differences in Case Volume Among Ophthalmology Residents.

IMPORTANCE: Although almost equal numbers of male and female medical students enter into ophthalmology residency programs, whether they have similar surgical experiences during training is unclear. OBJECTIVE: To determine differences for cataract surgery and total procedural volume between male and female residents during ophthalmology residency. DESIGN, SETTING, PARTICIPANTS: This retrospective, longitudinal analysis of resident case logs from 24 US ophthalmology residency programs spanned July 2005 to June 2017. A total of 1271 residents were included. Data were analyzed from August 12, 2017, through April 4, 2018. MAIN OUTCOMES AND MEASURES: Variables analyzed included mean volumes of cataract surgery and total procedures, resident gender, and maternity or paternity leave status. RESULTS: Among the 1271 residents included in the analysis (815 men [64.1%]), being female was associated with performing fewer cataract operations and total procedures. Male residents performed a mean (SD) of 176.7 (66.2) cataract operations, and female residents performed a mean (SD) of 161.7 (56.2) (mean difference, -15.0 [95% CI, -22.2 to -7.8]; P < .001); men performed a mean (SD) of 509.4 (208.6) total procedures and women performed a mean (SD) of 451.3 (158.8) (mean difference, -58.1 [95% CI, -80.2 to -36.0]; P < .001). Eighty-five of 815 male residents (10.4%) and 71 of 456 female residents (15.6%) took parental leave. Male residents who took paternity leave performed a mean of 27.5 (95% CI, 13.3 to 41.6; P < .001) more cataract operations compared with men who did not take leave, but female residents who took maternity leave performed similar numbers of operations as women who did not take leave (mean difference, -2.0 [95% CI, -18.0 to 14.0]; P = .81). From 2005 to 2017, each additional year was associated with a 5.5 (95% CI, 4.4 to 6.7; P < .001) increase in cataract volume and 24.4 (95% CI, 20.9 to 27.8; P < .001) increase in total procedural volume. This increase was not different between genders for cataract procedure volume (ß = -1.6 [95% CI, -3.7 to 0.4]; P = .11) but was different for total procedural volume such that the increase in total procedural volume over time for men was greater than that for women (ß = -8.0 [95% CI, -14.0 to -2.1]; P = .008). CONCLUSIONS AND RELEVANCE: Female residents performed 7.8 to 22.2 fewer cataract operations and 36.0 to 80.2 fewer total procedures compared with their male counterparts from 2005 to 2017, a finding that warrants further exploration to ensure that residents have equivalent surgical training experiences during residency regardless of gender. However, this study included a limited number of programs (24 of 119 [20.2%]). Future research including all ophthalmology residency programs may minimize the selection bias issues present in this study.

Risk Factors for Return to the Operating Room after Resident-Performed Cataract Surgery.

OBJECTIVE: Investigate risk factors for unplanned return to the operating room after resident-performed cataract surgery. DESIGN: Retrospective case-control study. SETTING: Institutional. METHODS: Study population: All patients with reoperation within 90 days of resident-performed phacoemulsification were matched to four control eyes which had surgery within 30 days of the reoperation at the same institution. OBSERVATION PROCEDURE: Billing codes were used to identify all patients who underwent resident-performed intended phacoemulsification with intraocular lens placement from January 2005 to December 2010. MAIN OUTCOME MEASURES: Investigated risk factors for reoperation included cataract characteristics and preexisting ocular co-morbidities, including diabetic retinopathy, retinal detachment history, glaucoma, corneal pathology, and uveitis. Additional preoperative risk factors studied included resident training year, history of tamsulosin use, phacodonesis, pupillary dilation, presence of pseudoexfoliation, myopia, history of trauma, visual acuity, and monocular status. Intraoperative variables were the use of iris expansion devices, use of capsular stain, attending type, incision type, use of sutures, vitreous loss, anesthesia type, and phacoemulsification technique. RESULTS: There were 67 returns to the operating room (i.e., cases) over five years that were assigned to 268 control eyes. In preoperative multivariate analysis, phacoemulsification done by a first- or second-year resident (OR 3.2, 95% CI: 1.7-6.0, p < 0.001) was associated with an increased risk of reoperation. In postoperative multivariate analysis, only the use of the divide-and-conquer technique (OR 4.0, 95% CI:1.7-9.2, p = 0.001) was associated with an increased risk of reoperation. CONCLUSIONS: Phacoemulsification done by a junior resident or using the divide-and-conquer technique had the highest risk of reoperation.

The clear corneal tongue: a mechanism for wound incompetence after phacoemulsification.

PURPOSE: To describe a mechanism for wound incompetence after phacoemulsification with corneal incisions resulting in early postoperative wound leakage. DESIGN: Observational case series. METHODS: Three patients who had uneventful phacoemulsification through a clear corneal incision were identified because of a postoperative wound leak. A corneal tongue, consisting of an everted triangular flap of posterior corneal stroma, the Descemet membrane, and endothelium, was observed in the wounds of all cases. RESULTS: One wound leak resolved after pressure patching. The other two necessitated wound revisions. None of the patients developed endophthalmitis. CONCLUSIONS: In phacoemulsification with corneal incisions, an everted flap of posterior corneal tissue, a corneal tongue, may prevent normal anatomical apposition of the surgical wound edges leading to potential wound incompetence. This event may increase the risk of endophthalmitis after clear corneal phacoemulsification.

Early Reoperation Rate, Complication, and Outcomes in Resident-performed Glaucoma Surgery.

PURPOSE OF THE STUDY: The purpose of the study was to examine reoperation rate and complications of resident-performed glaucoma surgeries within the first 90 postoperative days. MATERIALS AND METHODS: A retrospective study of resident-performed glaucoma filtering surgeries at the San Francisco Veterans Affairs Medical Center between 2002 and 2014 was performed. Patients requiring reoperation within 90 days of the initial surgery were included in our study. Combined surgeries were excluded. Complications and the rates of reoperation within the first 90 days were evaluated. Clinical outcomes for those who needed reoperations were evaluated at the 1-year follow-up. RESULTS: Total of 180 cases were reviewed [34 trabeculectomy, 85 Ex-PRESS shunt, and 61 Ahmed glaucoma valve (AGV)]. One hundred and four eyes developed complications, most commonly choroidal effusion (65.3%), followed by hypotony (45.2%) and wound leak (32.7%). Complications were comparable among the 3 groups, except that filtering surgery had significantly more wound leak than AGV (P<0.001). Seven (3.9%) cases required reoperation within first 90 days. There was no reoperation for trabeculectomy group. Reoperation rate was 4.7% for Ex-PRESS and 4.9% for AGV (P=0.74). Indications for reoperation were persistent wound leak (4 cases) and tube occlusion/revision (3 cases). For the 7 patients who required reoperations, their intraocular pressure at 1-year postreoperation was significantly decreased compared with intraocular pressure before the initial glaucoma surgery (P<0.001) with similar number of glaucoma medications and stable visual acuity. CONCLUSIONS: Glaucoma incisional surgeries performed by third-year ophthalmology residents had acceptable and comparable reoperation rates and complication rates for patients with trabeculectomy, Ex-PRESS, and AGV. Clinical outcomes for the patients requiring reoperation were favorable.

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.

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

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.