Variation between surgeons in rate of reoperation after horizontal strabismus surgery among Medicare beneficiaries: associations with patient and surgeon characteristics and adjustable sutures.

Objective: To quantify variation between surgeons in reoperation rates after horizontal strabismus surgery, and to explore associations of reoperation rate with surgical techniques, patient characteristics, and practice type and volume. Methods: Fee-for-service payments in a national database to providers for Medicare beneficiaries having strabismus surgery on horizontal muscles between 2012 and 2020 were analyzed retrospectively to identify same calendar year reoperations. Multivariable linear regression was used to determine predictors of each surgeon's reoperation rate. Results: The reoperation rate for 1-horizontal muscle surgery varied between 0.0% and 30.8% among 141 surgeons. Just 7.8% of surgeons contributed over half of the reoperation events for 1-horizontal muscle surgery, due to the presence of high-volume surgeons with high reoperation rates. Surgeon seniority, gender, surgery volume, and use of adjustable sutures were not independently associated with surgeon reoperation rate. We explored associations of reoperation with patient characteristics, such as age and poverty. Surgeons in the South tended to have a higher reoperation rate (p=0.03) in a multivariable model. However, the multivariable model could only explain 16.3% of the inter-surgeon variation in reoperation rate for 1-horizontal muscle surgery. Discussion: Strabismus surgery is similar to other areas of medicine, in which large variations in outcomes between surgeons are observed. Future work can be directed towards explaining this variation. Conclusions: Patient-level analyses that fail to consider variation between surgeons will be dominated by a small number of high-reoperation, high-volume surgeons. Order-of-magnitude variations exist in reoperation rates among strabismus surgeons, the cause of which is largely unexplained.

Preliminary Analysis of Excess Mortality in India During the COVID-19 Pandemic.

We studied all-cause mortality during the COVID-19 pandemic in 19 Indian states (population 1.27 billion). Excess mortality was calculated by comparison with years 2015 to 2019. The known COVID-19 deaths reported for a state were assumed to be accurate, unless excess mortality data suggested a higher toll. Data from one state were excluded due to anomalies. In several regions, fewer deaths were reported in 2020 than expected. Areas in Andhra Pradesh, Delhi, Haryana, Karnataka, Madhya Pradesh, Tamil Nadu, and West Bengal saw spikes in mortality in Spring 2021. The pandemic-related mortality through August 31, 2021, in 18 Indian states was estimated to be 198.7 per 100,000 population (range 146.1-263.8 per 100,000). If these rates apply nationally, then 2.69 million people (range 1.98 to 3.57 million) may have perished in India as a result of the pandemic by August 31, 2021.

Ophthalmia neonatorum due to Escherichia coli: A rare cause or an emerging bacterial etiology of neonatal conjunctivitis?

Since the introduction of universal gonococcal and chlamydia prophylaxis, other etiologies for neonatal conjunctivitis such as Escherichia coli have become more common. Early eye culturing as part of the management plan could provide swifter treatment and preservation of vision potential in affected neonates.

The First Cataract Surgeons in the British Isles.

PURPOSE: To describe the entry of cataract surgery into the British Isles. METHODS: Handbills, books, and other historical sources were reviewed to determine when cataract surgery was first performed in the region. RESULTS: Roman artifacts suggest that couching was performed in the British Isles in antiquity. Seemingly miraculous cures of blindness during the early Middle Ages might be consistent with couching. However, there is no strong evidence of medieval cataract surgery in the region. Cataract couching probably arrived in England by the 1560s, in Scotland by 1595, in Ireland by 1684, and in Anglo-America by 1751. Before the 18th century, cataract surgery was taught within families, apprenticeships, and mountebank troupes. Beginning in the 17th century, congenital cataract surgery permitted surgeons to tout their skills and to explore visual perception. However, in some cases, such as the couching of the 13-year-old Daniel Dolins by surgeon William Cheselden in 1727, whether the cataracts were truly congenital, and whether vision improved in any way, remain in doubt. Beginning in the 1720s, cataract surgery began to be performed by traditional surgeons in hospitals. However, for most of the century, the highest-volume cataract surgeons continued to be itinerant oculists, including those who performed cataract extraction in the latter half of the century. CONCLUSIONS: Cataract surgery might have been performed in Roman Britain. Specific evidence of cataract surgery emerges in the region in the Elizabethan era. Cataract extraction was performed in the British Isles by 1753, but couching remained popular throughout the 18th century. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Peter the great and cataract surgery.

Tsar Peter Alekseyevich Romanov (1672-1725), often called Peter the Great, modernized Russia in many areas, including in the field of medicine. Peter I attended medical lectures and demonstrations and may have even performed some medical procedures himself. In Paris, he witnessed a cataract couching performed by Englishman John Thomas Woolhouse (1664-1733/4) and requested that Woolhouse train a Russian student in ophthalmology.

The history of cataract surgery: from couching to phacoemulsification.

Where and when cataract surgery started have been a mystery. Indian tradition and the Persian author Zarrin-Dast attributed the procedure to the Indians, while pseudo-Galen suggested an Egyptian origin. Certain idiosyncratic practices are common to early Greek and Sanskrit descriptions of cataract couching, e.g., the requirement for maturity of the cataract, the preference for patients of intermediate ages, comparison of some eyes to glass, rubbing the eye, having a wide portion of the couching instrument shaft, pars-plana puncture with avoidance of the vein, and immediate vision testing. In ancient Greece and India, the words describing the color of a healthy blue eye (glaukos and nila, respectively) could also characterize a poorly-seeing eye not curable by surgery. In both regions, the lens (or pupillary region) was compared to a lentil, and colored entoptic phenomena were noted. The sitting posture of the patient, ocular convergence towards the nose, the more systematized integration of the humoral theory with cataract surgery, and possibly blowing on the eye and putting cotton on the eye are all consistent with an Indian origin for the procedure. On the other hand, the emphasis on surgical ambidexterity could suggest an origin close to the Mediterranean. Thus, the question of where cataract surgery started has not been resolved. Various authors have suggested that multiple types of cataract surgery were practiced in the ancient and medieval periods: (I) couching, (II) discission (division), (III) aspiration through a tube, (IV) extraction through a limbal incision, and (V) expulsion of lens remnants around an embedded probe. We review the evidence in favor (and against) each of these types of surgery.

Association of Country-wide Coronavirus Mortality with Demographics, Testing, Lockdowns, and Public Wearing of Masks.

We studied sources of variation between countries in per-capita mortality from COVID-19 (caused by the SARS-CoV-2 virus). Potential predictors of per-capita coronavirus-related mortality in 200 countries by May 9, 2020 were examined, including age, gender, obesity prevalence, temperature, urbanization, smoking, duration of the outbreak, lockdowns, viral testing, contact-tracing policies, and public mask-wearing norms and policies. Multivariable linear regression analysis was performed. In univariate analysis, the prevalence of smoking, per-capita gross domestic product, urbanization, and colder average country temperature were positively associated with coronavirus-related mortality. In a multivariable analysis of 196 countries, the duration of the outbreak in the country, and the proportion of the population aged 60 years or older were positively associated with per-capita mortality, whereas duration of mask-wearing by the public was negatively associated with mortality (all P < 0.001). Obesity and less stringent international travel restrictions were independently associated with mortality in a model which controlled for testing policy. Viral testing policies and levels were not associated with mortality. Internal lockdown was associated with a nonsignificant 2.4% reduction in mortality each week (P = 0.83). The association of contact-tracing policy with mortality was not statistically significant (P = 0.06). In countries with cultural norms or government policies supporting public mask-wearing, per-capita coronavirus mortality increased on average by just 16.2% each week, as compared with 61.9% each week in remaining countries. Societal norms and government policies supporting the wearing of masks by the public, as well as international travel controls, are independently associated with lower per-capita mortality from COVID-19.

Clinical predictors of the optimal spectacle correction for comfort performing desktop tasks.

BACKGROUND: The best strategy for spectacle correction of presbyopia for near tasks has not been determined. METHODS: Thirty volunteers over the age of 40 years were tested for subjective accommodative amplitude, pupillary size, fusional vergence, interpupillary distance, arm length, preferred working distance, near and far visual acuity and preferred reading correction in the phoropter and trial frames. Subjects performed near tasks (reading, writing and counting change) using various spectacle correction strengths. Predictors of the correction maximising near task comfort were determined by multivariable linear regression. RESULTS: The mean age was 54.9 years (range 43 to 71) and 40 per cent had diabetes. Significant predictors of the most comfortable addition in univariate analyses were age (p<0.001), interpupillary distance (p=0.02), fusional vergence amplitude (p=0.02), distance visual acuity in the worse eye (p=0.01), vision at 40 cm in the worse eye with distance correction (p=0.01), duration of diabetes (p=0.01), and the preferred correction to read at 40 cm with the phoropter (p=0.002) or trial frames (p<0.001). Target distance selected wearing trial frames (in dioptres), arm length, and accommodative amplitude were not significant predictors (p>0.15). The preferred addition wearing trial frames holding a reading target at a distance selected by the patient was the only independent predictor. Excluding this variable, distance visual acuity was predictive independent of age or near vision wearing distance correction. The distance selected for task performance was predicted by vision wearing distance correction at near and at distance. CONCLUSIONS: Multivariable linear regression can be used to generate tables based on distance visual acuity and age or near vision wearing distance correction to determine tentative near spectacle addition. Final spectacle correction for desktop tasks can be estimated by subjective refraction with trial frames.

Prediction of postoperative astigmatism in cataract surgery.

BACKGROUND: The purpose of this study was to predict postoperative astigmatism using refraction, keratometry, and other preoperative information after phacoemulsification with posterior chamber intraocular lens (IOL) implantation. METHODS: A retrospective study was conducted of 176 eyes of 161 patients undergoing phacoemulsification for visually significant cataract with capsular bag or sulcus IOL fixation at the Hunter Holmes McGuire Veterans Administration Medical Center, Richmond, Va. Eyes with complications and final-corrected visual acuity of less than 20/60 were excluded. Keratometric and refractive astigmatism were described by Jackson cross-cylinder with-the-rule (J0) and oblique (J45) components. Preoperative predictors of postoperative refractive J0 and J45 were determined by univariate and multivariate regression analysis. RESULTS: The final multivariate model to predict postoperative with-the-rule astigmatism was J0Postoperative = 0.24 x J0Preoperative 0.46 x J0Keratometric (-0.08 )(coefficient of determination [r2] = 0.51, all p < 0.001). The multivariate model based on expected predictors of oblique astigmatism was J45Postoperative = 0.10 x J45Preoperative + 0.23 x J45Keratometric + 0.01, (r2 = 0.05, p = 0.09 for J45Preoperative and 0.03 for J45Keratometric). Temporal clear cornea (as opposed to superior scleral tunnel) incisions, and use of sutures in scleral tunnel incisions, were not predictive of postoperative astigmatism. INTERPRETATION: Postoperative astigmatism can be estimated from preoperative astigmatism using the following weighted average: two-thirds keratometric and one-third refractive astigmatism. Preoperative refraction may predict postoperative astigmatism independent of keratometry because keratometry reflects only the paracentral anterior (not posterior) corneal curvature.

Cataract couching and the goat's eye.

At the start of the third century, a story told by Claudius Aelianus, Leonidas of Alexandria and pseudo-Galen held that couching originated when a goat with cataract punctured its eye with a thorn. The significance of this story is unknown. We reviewed Graeco-Roman texts to identify the relevance of the goat to the eye. In the works of Hippocrates, Aristotle and Galen, the goat's eye was an eye with intermediate brightness or colour. A dark brown eye with a black pupil was healthy and required no treatment. A bright glaukos eye, with extensive corneal edema or scarring, was not amenable to couching. An eye with a white cataract behind an undilated pupil would appear to have an intermediate brightness and was potentially amenable to couching. The origin myth probably arose when an instructor explained that couching works best for a goat's eye, that is, an eye with intermediate brightness.

Interpretation of uniocular and binocular trials of glaucoma medications: an observational case series.

BACKGROUND: To predict the effectiveness of topical glaucoma medications based on initial uniocular and binocular treatment. To test a traditional hypothesis that effectiveness following a uniocular trial is associated with the change in IOP in the initially treated eye minus the change in the initially untreated eye. To determine whether uniocular or binocular treatment trials are superior. METHODS: Based on a review of medical records, we identified 168 instances in 154 patients with bilateral primary open angle glaucoma of initial uniocular use of a topical glaucoma medication with well-documented intraocular pressure (IOP) readings at baseline (IOP(A)), during the trial (IOP(B)), and at follow-up (IOP(C)). Abstracted data included demographic data, IOP, and medication use. Predictors of the IOP following the trial (IOP(C)) in each eye were identified by multivariable linear regression. In 70 cases, the predictive ability of initial uniocular and binocular treatment could be directly compared. RESULTS: In a multivariable analysis, the follow-up pressure in the initially treated eye (IOP(1C)) was directly correlated with treated eye IOP during initial uniocular use (IOP(1B), p < 0.001). In a multivariable analysis, the follow-up pressure in the initially untreated eye (IOP(2C)) was directly correlated with its baseline IOP(2A) (p < 0.001), and also tended to be associated with treated IOP(1B) (p = 0.07). The multivariable regression coefficient (b) for the IOP change in the initially untreated eye was generally not close to the value of -1 expected by the classic teaching (for eye 1, b = 0.04, p = 0.35; for eye 2, b = 0.07, p = 0.50). In 70 cases, the uniocular and binocular trials predicted a similar fraction of the variance in follow-up IOP(1C) (r(2) = 0.56 and 0.57, respectively) and IOP(2C) (r(2) = 0.39 and 0.38, respectively). CONCLUSION: 1) For uniocular trials, the IOP change in the untreated eye should not be subtracted from that in the treated eye. 2) Uniocular and binocular trials have similar predictive value when interpreted correctly. Either may be selected based on clinical circumstances.

A Family of Early English Oculists (1600-1751), With a Reappraisal of John Thomas Woolhouse (1664-1733/1734).

INTRODUCTION: John Thomas Woolhouse (1666-1733/1734), who practiced in Paris, was part of a family with 5 generations of English oculists. Some historians have derided him as a "charlatan" and have criticized him for adhering to the old notion that a cataract was a membrane anterior to the lens. METHODS: We reviewed treatises and digital records related to Woolhouse and his family and the handwritten notes of his 1721 lecture series at the Royal Society of Medicine. RESULTS: We have identified 5 generations of oculists in Woolhouse's family, by the names of Atwood, Stepkins, Ivy, and Beaumont. Woolhouse taught students from across Europe. He was one of the early proponents in Europe, inspired by Asian medical practices, to perform paracentesis to release aqueous for a new condition called hydrophthalmia. In Woolhouse's system, some of these cases probably described angle-closure glaucoma. He was the first to attach the name glaucoma to the palpably hard eye in 1707. He may also have been the first to teach that a soft eye was unlikely to recover vision. Credit for these teachings has traditionally gone to one of his students, Johannes Zacharias Platner, in 1745. Some historians have stated that he proposed iridectomy as a theoretical procedure, which was later performed by Cheselden. In fact, Woolhouse described techniques he had performed which today would be called pupilloplasty, synechiolysis, or pupillary membrane lysis. He was also a pioneer in dacryocystectomy for chronic dacryocystitis and in congenital cataract surgery. His writings from 1716 onward repeatedly (and correctly) stressed that most of the patients with visual disorders required depression of the crystalline lens (for what he called glaucoma), as opposed to removal of an anterior membrane (which he called cataract). CONCLUSIONS: Woolhouse was a bold ophthalmic innovator and teacher who made major contributions which have lasted to this day. Although he did not admit it, he ultimately adopted much of the evolving understanding of the nature of lens opacities. However, his stubborn refusal to adopt the newer semantics has detracted from a full appreciation of his contributions.

American Insight Into Strabismus Surgery Before 1838.

English surgeon John Taylor attempted to perform strabismus surgery in the 18th century. The field languished until, in Germany, treatment of strabismus by cutting an extraocular muscle was proposed by Louis Stromeyer in 1838 and performed by Johann Friedrich Dieffenbach in 1839. According to traditional teaching, there has never been any proof that anyone in the United States thought of the idea of strabismus surgery before Stromeyer's report. In 1841, American surgeon William Gibson wrote that he had cut extraocular muscles to treat strabismus several times beginning in 1818 but never published his cases. Gibson's former trainee Alexander E Hosack of New York confirmed Gibson's memory. Interestingly, Hosack's family had a connection with the family of New York oculist John Scudder Jr (1807-1843), whose reported cure of strabismus by cutting some of the fibers of an extraocular muscle was described in newspapers throughout the United States in 1837. Thus, Scudder's report preceded that of Stromeyer. Scudder's claim cannot be verified, but his description could have influenced Stromeyer, and demonstrates that the idea of strabismus surgery did exist in America before 1838.