Assessing Resident Cataract Surgery Outcomes Using Medicare Physician Quality Reporting System Measures.

OBJECTIVES: To assess resident cataract surgery outcomes at an academic teaching institution using 2 Physician Quality Reporting System (PQRS) cataract measures, which are intended to serve as a proxy for quality of surgical care. DESIGN: A retrospective review comparing cataract surgery outcomes of resident and attending surgeries using 2 PQRS measures: (1) 20/40 or better best-corrected visual acuity following cataract surgery and (2) complications within 30 days following cataract surgery requiring additional surgical procedures. SETTING: An academic ophthalmology center. PARTICIPANTS: A total of 2487 surgeries performed at the Massachusetts Eye and Ear Infirmary from January 1, 2011 to December 31, 2012 were included in this study. RESULTS: Of all 2487 cataract surgeries, 98.95% achieved a vision of at least 20/40 at or before 90 days, and only 0.64% required a return to the operating room for postoperative complications. Of resident surgeries, 98.9% (1370 of 1385) achieved 20/40 vision at or before 90 days follow-up. Of attending surgeries, 99.0% (1091 of 1102) achieved 20/40 vision at or before 90 days (p = 1.00). There were no statistically significant differences between resident and attending cases regarding postoperative complications needing a return to the operating room (i.e., 0.65%, or 9 of 1385 resident cases vs 0.64%, or 7 of 1102 attending cases; p = 1.00). CONCLUSIONS: Using PQRS Medicare cataract surgery criteria, this study establishes new benchmarks for cataract surgery outcomes at a teaching institution and supplemental measure for assessing resident surgical performance. Excellent cataract outcomes were achieved at an academic teaching institution, with results exceeding Medicare thresholds of 50%. There appears to be no significant difference in supervised trainee and attending cataract surgeon outcomes using 2 PQRS measures currently used by Medicare to determine physician reimbursement and quality of care.

The sensitivity of the bielschowsky head-tilt test in diagnosing acquired bilateral superior oblique paresis.

PURPOSE: To determine the sensitivity of the Bielschowsky head-tilt test and other commonly used criteria in identifying patients with true bilateral superior oblique paresis. DESIGN: A retrospective chart review was performed to identify patients seen between 1978 and 2009 who were diagnosed with acquired bilateral superior oblique paresis. METHODS: All patients had a confirmed history of head trauma or brain surgery with altered consciousness followed by symptomatic diplopia. Bilateral superior oblique paresis was defined and diagnosed by the above history, including the presence of greater extorsion in downgaze than upgaze on Lancaster red-green testing, a V-pattern strabismus, and bilateral fundus extorsion. We analyzed findings of the Bielschowsky head-tilt test, the Parks 3-step test, and reversal of the hypertropia from straight-ahead gaze to the other 8 diagnostic positions of gaze to determine these tests' sensitivity in identifying true bilateral superior oblique paresis. RESULTS: Twenty-five patients were identified with the diagnosis of true bilateral superior oblique paresis. The Bielschowsky head-tilt test had a 40% sensitivity, the Parks 3-step test had a sensitivity of 24%, and reversal of the hypertropia had a sensitivity of 60% in making the diagnosis of true bilateral superior oblique paresis. CONCLUSIONS: What previously has been described as masked bilateral superior oblique paresis simply may be a reflection of inherent poor sensitivity of the Bielschowsky head-tilt test, the Parks 3-step test, and reversal of the hypertropia in diagnosing bilateral superior oblique paresis. Hence, none of these tests should be relied on exclusively to make this diagnosis.

Differentiating bilateral superior oblique paresis from sensory extorsion.

PURPOSE: To determine whether patients historically diagnosed with bilateral superior oblique paresis (BSOP) categorized into (1) immediate-onset and (2) gradual-onset torsional diplopia groups are also distinguishable on the basis of patterns of subjective misalignment in various directions of gaze, consistent with the gradual-onset group being caused by sensory extorsion rather than by BSOP. METHODS: The medical records of all patients diagnosed with BSOP, V-pattern esotropia, or V-pattern exotropia between 1978 and 2009 were retrospectively reviewed. Those patients with torsional diplopia were classified into immediate- or gradual-onset diplopia groups. The torsional misalignments measured by Lancaster red-green plots were compared, and the surgical outcomes were evaluated. RESULTS: Of 38 patients identified, 27 had immediate-onset and 11 gradual-onset diplopia. There was a statistically significant difference in the increase in extorsion from up- to downgaze between the immediate- versus gradual-onset group (17.8° versus -1.5°, P < 0.001). Patients in the immediate-onset group fared significantly better with bilateral Harada-Ito procedures than with bilateral inferior oblique-weakening procedures (P = 0.02), whereas patients in the gradual-onset group fared equally well with either procedure (P = 0.72). CONCLUSIONS: Extorsion in upgaze is largely absent in patients with immediate-onset BSOP but is present in both up- and downgaze in patients with gradual-onset sensory extorsion. Lancaster red-green testing aids in distinguishing these two groups. The bilateral Harada-Ito procedure is a better procedure for true BSOP, whereas a bilateral inferior oblique-weakening procedure may be preferred for patients with sensory extorsion.