Building a Culture of Safety in Ophthalmology.

Patient safety focused on a reduction in both procedural and diagnostic error is the number one concern of the United States healthcare system in the 21st century. The American Board of Ophthalmology has a longstanding interest in patient safety, and in 2015, teamed with the American Academy of Ophthalmology to convene all ophthalmology subspecialties and other prominent national organizations to address patient safety in ophthalmology. This article reviews the topic and highlights concerns for ophthalmologists.

Depression care management: impact of implementation on health system costs.

This study examined the mental health care costs associated with implementation of a collaborative care management (CCM) of treatment for depression in primary care. A retrospective review of all costs was performed over a 2-year period associated with providing care to adult patients at clinical sites with CCM versus those with usual care, comparing total and mental health per member per month (PMPM) costs for 2008 and 2009 (patient population = 103,000). The mental health-PMPM costs as a percentage of total health care costs at the clinic without CCM were 4.65% in 2008 and 4.5% in 2009 (p = .085). In the clinics with CCM, there was a significant difference between the 2 years with a decrease noted in 2009 of 4.91% compared with 4.36% in 2008 (p < .0001). This study demonstrated that, on a population basis with the implementation of CCM, the metric of mental health-PMPM (using the actual costs of delivering care) suggested that an increased short-term cost of care is not always realized. Collaborative care management treatment for depression may be a more cost-efficient method of care for the population as a whole, even in the short term.

Intravitreal alemtuzumab penetrates full-thickness retina in rabbit eyes.

PURPOSE: The purpose of this study was to assess whether alemtuzamab, a large antibody of 150 kDa, would be able to penetrate through the full-thickness retina of Dutch-belted rabbits. METHODS: Four Dutch-belted rabbits had intravitreal injections of alemtuzumab (1.5 mg in 0.05 mL). One rabbit each was killed at Day 1, Day 8, Day 15, and Day 29. The eyes were examined under frozen section and graded by immunostaining techniques for the degree of penetration of alemtuzumab into the retina. The degree of retinal staining was graded from 0 (no stain) to 4+ (marked stain). RESULTS: All study eyes showed antibody staining of the full-thickness retina as follows: 4+ at Day 1, 4+ at Day 8, 3+ at Day 15, and 2+ at Day 29. CONCLUSION: A 1.5-mg intravitreal dose of alemtuzumab was able to penetrate full-thickness retina throughout the full 29-day course of the study. Retinal toxicity studies are required before clinical use.

HIPAA costs and patient perceptions privacy safeguards Mayo Clinic.

BACKGROUND: A study was conducted to assess the costs of implementation of the Health Insurance Portability and Accountability Act (HIPAA) and to report patient awareness of Notices of Privacy Practices (NPP) content and HIPAA privacy protections. METHODS: All HIPAA start-up and implementation costs were collected prospectively. A random sample of 2,000 patients receiving services at the Mayo Clinic after HIPAA implementation (April 14, 2003) was surveyed about HIPAA knowledge, HIPAA content, and privacy concerns. RESULTS: Comprehensive measures of total HIPAA costs and costs related only to privacy practices were amortized over 7, 15, and 20 years. Patient knowledge of privacy protections and attitudes toward HIPAA were obtained from 1,309 (65.5%) respondents. The total HIPAA startup costs were $4,663,672. Fully amortized costs (annual plus start-up costs) were $1 per patient visit or $5 per patient per year. Costs for the privacy portion were $2,734,855. These costs were about $.90 per patient visit or about $4 per patient per year. Patients indicated high levels of awareness of HIPAA (71%), reading the NPP (79%), knowledge about HIPAA (80% with 6+ correct answers on a 10-item quiz), and improved feelings of privacy (44% versus 55% the same). DISCUSSION: Patients reported high levels of knowledge about HIPAA and confidence in privacy protections. HIPAA costs were modest per patient or per visit.

Pars planitis: a 20-year study of incidence, clinical features, and outcomes.

PURPOSE: To measure the incidence of pars planitis in a community-based population and to report clinical features, complications, and visual prognosis. DESIGN: Population-based, retrospective, 20-year cohort study. METHODS: Multicenter study using the Rochester Epidemiology Project medical records linkage system, which allows analysis of almost all patients within Olmsted County, Minnesota, with a given medical condition. Databases were searched to identify all patients with pars planitis from January 1, 1985 through December 31, 2004. Forty-six eyes of 25 patients were evaluated. RESULTS: Mean follow-up was 14.3 years. The incidence of pars planitis was 2.077 per 100,000 persons (95% confidence interval [CI], 1.43 to 2.62). The most common complications were epiretinal membrane (ERM) in 17 eyes (36%), cataract in 14 eyes (30.4%), and cystoid macular edema (CME) in 12 eyes (26.1%). Mean visual acuity after 10 years of follow-up was 20/30, with 18 of 24 patients maintaining a visual acuity of 20/40 or better. One-third of patients maintained normal visual acuity without requiring treatment. CONCLUSIONS: The visual prognosis of pars planitis is relatively good, with 75% of patients maintaining a visual acuity of 20/40 or better after 10 years. Many patients with mild disease do not require treatment. A subset of patients, however, experience severe disease with severe vision loss despite treatment. The rate of smoking and multiple sclerosis in patients with pars planitis is much higher than that of the general population.

Topical ocular hypotensive medication and lens opacification: evidence from the ocular hypertension treatment study.

PURPOSE: To determine whether topical ocular hypotensive medication is associated with refractive changes, visual symptoms, decreased visual function, or increased lens opacification. DESIGN: Multi-center clinical trial. METHODS: We compared the medication and observation groups of the Ocular Hypertension Treatment Study (OHTS) during 6.3 years of follow-up with regard to the rate of cataract and combined cataract/filtering surgery, and change from baseline in visual function, refraction, and visual symptoms. A one-time assessment of lens opacification was done using the Lens Opacities Classification System III (LOCS III) grading system. RESULTS: An increased rate of cataract extraction and cataract/filtering surgery was found in the medication group (7.6%) compared with the observation group (5.6%) (hazard ratio [HR] 1.56; 95% confidence interval [CI] 1.05 to 2.29). The medication and observation groups did not differ with regard to changes from baseline to June 2002 in Humphrey visual field mean deviation, Humphrey visual field foveal sensitivity, Early Treatment of Diabetic Retinopathy Study (ETDRS) visual acuity, refraction, and visual symptoms. For the medication and observation groups, LOCS III readings were similar for nuclear color, nuclear opalescence, and cortical opacification. There was a borderline higher mean grade for posterior subcapsular opacity in the medication group (0.43 +/- 0.6 SD) compared with the observation group (0.36 +/- 0.6 SD) (P = .07). CONCLUSIONS: We noted an increased rate of cataract extraction and cataract/filtering surgery in the medication group as well as a borderline higher grade of posterior subcapsular opacification in the medication group on LOCS III readings. We found no evidence for a general effect of topical ocular hypotensive medication on lens opacification or visual function.

Changes in corneal thickness in patients with treated and untreated ocular hypertension.

PURPOSE: The elevated intraocular pressure (IOP) in eyes with ocular hypertension is often accompanied by increased corneal thickness. We tested the hypotheses that chronically elevated IOP causes a slow increase in corneal thickness and that lowering the IOP reverses this slow increase. METHODS: Fifty patients with ocular hypertension were randomized to medication and observation groups in the Mayo Clinic site of the Ocular Hypertension Treatment Study. Central corneal thickness was measured using an optical pachymeter at baseline and annually for 6 years. The rates of change of corneal thickness was compared between the groups. Epithelial thickness was measured by confocal microscopy 8 years after the baseline examination. RESULTS: Corneal thickness increased 1.5 +/- 3.3 microm/yr in the observation group (n = 23) and decreased -1.3 +/- 2.8 microm/yr in the medication group (n = 27, P = 0.002). Both rates were significantly different from zero (P = 0.04 and P = 0.02, respectively). Epithelial thickness was 46.4 +/- 4.9 microm in the observation group and 41.3 +/- 4.4 microm in the medication group (P = 0.008). CONCLUSION: Results of this single-center series imply that corneal thickness increases slowly in eyes with ocular hypertension and decreases slowly if the IOP is lowered by topical medications. These phenomena could be explained by a causal relationship between elevated IOP and a slow increase in corneal thickness. A decrease in epithelial thickness accounts for a portion of the thinning that occurs with treatment. If confirmed in a larger series, these findings indicate that the effects of previous treatment on thickness should be considered if corneal thickness is to be used as a discriminant factor in the management of patients with ocular hypertension.

Effects of glaucoma medications on corneal endothelium, keratocytes, and subbasal nerves among participants in the ocular hypertension treatment study.

PURPOSE: To compare subbasal corneal nerve and keratocyte density and endothelial characteristics of ocular hypertensive patients treated with medications or observation. METHODS: Participants in the Ocular Hypertensive Treatment Study (OHTS) randomized at Mayo Clinic to medication or observation were evaluated with specular microscopy annually for 6 years. Confocal microscopy was performed 78 to 108 months after enrollment. Subbasal nerve density was calculated by manual tracing and digital image analysis. Keratocyte density was determined by manual counting methods. Data were compared using a t test and a rank sum test. RESULTS: After 6 years, corneal endothelial cell density, percent hexagonal cells, and coefficient of variation of cell area for the observation (n = 21) and medication groups (n = 26) were similar (2415 +/- 300 vs. 2331 +/- 239 cells/mm; 63% +/- 11% vs. 65% +/- 10%; and 0.32 +/- 0.07 vs. 0.30 +/- 0.06, respectively). Of 38 participants undergoing confocal examination, the medication group (n = 19) had fewer nerves (3.8 +/- 2.1 vs. 5.9 +/- 2.0 nerves/frame; P = 0.02) and a lower nerve density (5643 +/- 2861 vs. 9314 +/- 3743 mum/mm; P = 0.007) than the observation patients (n = 10). An additional 9 patients in the observation group, who began medication before confocal scanning, had intermediate nerve densities. Full-thickness keratocyte density was similar, with 22,257 +/- 2419 and 23,430 +/- 3285 cell/mm in the observation and medication groups, respectively. CONCLUSIONS: Chronic administration of glaucoma medications causes a decrease in the number and density of corneal subbasal nerve fiber bundles but does not affect keratocyte density or corneal endothelial characteristics.

Effect of ibopamine on aqueous humor production in normotensive humans.

PURPOSE: Ibopamine is a prodrug of epinine (deoxyepinephrine) that exhibits activity at dopaminergic and adrenergic receptors. Topical ocular application has been shown to cause mydriasis without cycloplegia and to increase the rate of aqueous humor flow in normotensive human eyes. Mydriasis can interfere with the measurement of aqueous flow. In this study ibopamine's effect on aqueous humor production was measured while making allowance for the potential artifact caused by its mydriatic effect. METHODS: The effects of topical ibopamine on pupillary diameter, aqueous humor flow measured by fluorophotometry, and intraocular pressure were studied in 24 healthy, blue-eyed humans. Ibopamine was administered with and without the alpha-adrenergic antagonist dapiprazole, and its effects were compared with those of tropicamide, with and without dapiprazole in a double-masked, randomized, crossover design. RESULTS: Ibopamine dilated the pupil from a diameter of 3.7 +/- 0.64 (mean +/- SD, n=24) to 7.7 +/- 0.70 mm. Ibopamine, during its peak mydriasis, was associated with a very large increase in the rate of clearance of topically applied fluorescein from the cornea and anterior chamber, an effect that was not associated with tropicamide during its peak mydriasis. The mydriatic effect of ibopamine was completely blocked by dapiprazole, and the increase in fluorescein clearance was partially blocked. When mydriasis was blocked, ibopamine increased fluorescein clearance by 13% (P<0.0001), which was interpreted as an increased rate of aqueous humor production. Compared with placebo and with the tropicamide control, ibopamine decreased intraocular pressure, despite its stimulation of aqueous humor flow. CONCLUSIONS: Ibopamine is in a specific class of drug, along with pilocarpine, epinephrine, and bimatoprost that in humans increases the rate of aqueous humor flow as measured by fluorophotometry. This effect is partly responsible for its ability to increase intraocular pressure in persons suspected to have abnormally low aqueous humor outflow facility. The transient apparent doubling of aqueous humor flow, measured by fluorescein clearance after administration of ibopamine is an artifact of increased fluorescein clearance through the dilated pupil while accommodation is active.

Validity of overall self-rated health as an outcome measure in small samples: a pilot study involving a case series.

OBJECTIVE: A single-item measure of overall self-rated health (SRH) commonly is used in population surveys, but has not been used in small pilot projects. The purpose of this study was to assess the validity of SRH in small samples. DESIGN: We used data from a prospective, observational weight-loss project to compare change in SRH with change in body weight and physical activity (PA) (minutes) over 30 days (n = 34). Body mass index at baseline ranged from 25.5 to 50.4 (mean = 36.1, median = 34.6). SRH was self-assessed using the following question: How would you rate your health overall? Results An increase in weight was associated with a reduction in SRH (r = 0.37, P = 0.03). An increase in PA was associated with improved SRH (r = 0.39, P = 0.02). CONCLUSIONS: A single-item SRH measure may be an efficient method for measuring programme outcomes, and may also be useful for comparing the relative effectiveness of different programmes in pilot projects and quality improvement studies.

Incidence and outcomes of uveitis in juvenile rheumatoid arthritis, a synthesis of the literature.

BACKGROUND: Juvenile rheumatoid arthritis (JRA) is the most common systemic cause of pediatric uveitis in Europe and North America. Uveitis is commonly perceived as a frequent sequela of JRA and JRA-associated uveitis is commonly considered to have a complicated course with frequent adverse visual outcomes. METHODS: We performed a systematic literature search for series of consecutive patients with JRA (as defined by the American College of Rheumatology criteria) reporting on the frequency of uveitis and/or complications of uveitis, published between January 1980 and December 2004. The main outcome measures were: the cumulative incidence of uveitis in JRA, the cumulative incidence of adverse visual outcome and that of complications in JRA-associated uveitis. Additionally, the influence of gender, presence of antinuclear antibody (ANA) and disease onset subtype to the likelihood of developing uveitis were examined. RESULTS: Analysis of pooled data from the 26 eligible series suggested a cumulative incidence of uveitis in JRA of 8.3% [95% confidence intervals (CI), 7.5-9.1%]. The cumulative incidence of uveitis varied according to geographic location, being highest in Scandinavia, then the US, then Asia and lowest in India. JRA-associated uveitis was more common in pauciarticular than polyarticular onset patients [odds ratio (OR) = 3.2, 95% CI, 2.33-4.36] and in ANA-positive than ANA-negative patients (OR = 3.18, 95% CI, 2.22-4.54). Female gender was only a weak risk factor for the development of uveitis in JRA patients (OR = 1.69, 95% CI 1.09-2.62) and was not statistically significant after considering disease onset subtypes. In JRA-associated uveitis the cumulative incidence of cumulative incidence of adverse outcome (visual acuity < 20/40 OU) was 9.2% (95% CI: 4.7-15.8) of cataracts 20.5% (95% CI: 15.5-26.3), of glaucoma 18.9% (95% CI: 14.4-24.2) and of band keratopathy 15.7% (95% CI: 10.9-21.7). CONCLUSION: The cumulative incidence of uveitis in JRA varies according to geographic location, presence of ANA, type of JRA onset and gender. Uveitis, adverse visual outcome, and complications in JRA are less frequent than commonly accepted.

Ocular manifestations of juvenile rheumatoid arthritis in Olmsted County, Minnesota: a population-based study.

BACKGROUND: Juvenile rheumatoid arthritis (JRA) is the most common systemic cause of uveitis in Europe and North America. The cumulative incidence of uveitis in JRA has been reported at between 8.5% and 25% in series from referral centers in the USA. There have been no population-based studies of the cumulative incidence of uveitis in JRA in the USA. METHODS: We performed a population-based, retrospective cohort study of patients residing in Olmsted County, Minnesota between 1 January 1960 and 31 December 2000 who met American College of Rheumatology diagnostic criteria for JRA. The patients were identified using the Rochester Epidemiology Project (REP), a surveillance and medical records-linkage system which provides access to medical records of residents of Olmsted County. Patient histories were reviewed and information regarding rheumatic and ocular disease was extracted and analyzed. The main outcome measures were: cumulative incidence of uveitis, of complications of uveitis, of keratoconjunctivitis sicca (KCS) and of adverse visual outcome. RESULTS: Of the 88 patients identified, three patients developed uncomplicated uveitis [3.4%; 95% confidence intervals [CI] 0.7-9.6%), all with pauciarticular onset JRA. Two patients developed KCS (2.3%; 95% CI 0.3-8.0%). The visual acuity of these five patients at last follow-up (mean length of follow-up 22.6 years, range 8-36 years) was 20/20. There were no patients with visual loss attributable to JRA. CONCLUSIONS: In a population-based study of JRA in the United States, uveitis occurred at a lower frequency than expected. In the limited number of cases in this cohort with JRA-associated ophthalmologic complications there was no resulting loss of visual acuity.

Iris and anterior chamber involvement in acute lymphoblastic leukemia.

The authors describe a 6-year-old child, with a history of acute lymphoblastic leukemia, who presented with leukemic infiltration of the anterior segment of one eye mimicking anterior uveitis. After tissue diagnosis, administration of radiation therapy to the affected eye resulted in dramatic improvement of the condition. Involvement of the iris and anterior chamber is a recognized but unusual manifestation of leukemia. In the absence of systemic relapse, local radiation therapy without chemotherapy is highly effective, although the prognosis in these patients may be guarded.

Perioperative visual changes.

BACKGROUND: The goal of this project was to describe the frequency and natural history of perioperative changes in vision. METHODS: The authors performed a prospective evaluation of changes in visual accommodation and acuity in adult patients undergoing various surgical procedures. Patients were evaluated preoperatively and at 1 and 3 days postoperatively. For patients who had persistent blurring of vision on the third postoperative day, surveillance was extended to 1.5 yr to determine how long the visual changes persisted and if the patients required eye-care provider attention for the condition. RESULTS: Twenty-eight of 671 patients (4.2%) reported new onset of blurred vision lasting at least 3 days after surgery. Seven of these 28 patients (1% of total) required either new corrective lens or changes in eyeglass or contact prescriptions because of persistent blurry vision. Most of the remaining patients reported resolution of blurry vision within 1 to 2 months. No significant risk factors for this problem were identified. CONCLUSIONS: In this surgical population, changes in visual acuity manifest primarily by blurred vision were reported at a surprisingly high frequency. For many of these patients, the blurring resolved within 2 months without complication, but 25% of patients who had blurred vision for 3 days or longer required visits to eye-care providers and either new corrective lens or changes in existing prescriptions.