Anesthesia Care for Cataract Surgery in Medicare Beneficiaries.

Importance: Cataract surgery in the US is routinely performed with anesthesia care, whereas anesthesia care for other elective, low-risk, outpatient procedures is applied more selectively. Objective: To identify predictors of anesthesia care in Medicare beneficiaries undergoing cataract surgery and evaluate anesthesia care for cataract surgery compared with other elective, low-risk, outpatient procedures. Design, Setting, and Participants: This population-based, retrospective observational cohort study included Medicare beneficiaries 66 years or older who underwent cataract surgery in 2017. The data were analyzed from August 2020 through May 2021. Interventions (for clinical trials) or Exposures (for observational studies): Anesthesia care during elective, low-risk, outpatient procedures. Main Outcomes and Measures: Prevalence of anesthesia care during cataract surgery compared with other low-risk procedures; association of anesthesia care with patient, clinician, and health system characteristics; and proportion of patients experiencing a systemic complication within 7 days of cataract surgery compared with patients undergoing other low-risk procedures. Results: Among 36 652 cataract surgery patients, the mean (SD) age was 74.7 (6.1) years; 21 690 (59.2%) were female; 2200 (6.6%) were Black and 32 049 (87.4%) were White. Anesthesia care was more common among patients undergoing cataract surgery compared with patients undergoing other low-risk procedures (89.8% vs range of <1% to 70.2%). Neither the patient's age (adjusted odds ratio, 1.01; 95% CI, 1.00-1.02; P = .01) nor Charlson Comorbidity Index (CCI) score (CCI of ≥3: adjusted odds ratio, 1.06; 95% CI, 0.95-1.18; P = .28; reference, CCI score of 0-1) was strongly associated with anesthesia care for cataract surgery, but a model comprising a single variable identifying the ophthalmologist predicted anesthesia care with a C statistic of 0.96. Approximately 6.0% of ophthalmologists never used anesthesia care, 76.6% always used anesthesia care, and 17.4% used it for only a subset of patients. Fewer cataract surgery patients experienced systemic complications within 7 days (2833 [7.7%]), even when limited to patients of ophthalmologists who never used anesthesia care (108 [7.4%]), than patients undergoing other low-risk procedures (range, 13.2%-52.2%). Conclusions and Relevance: The results of this cohort study suggest that systemic complications occurred less frequently after cataract surgery compared with other elective, low-risk, outpatient procedures during which anesthesia care was less commonly used. Anesthesia care was not associated with patient characteristics, such as older age or worse health status, but with the ophthalmologists' usual approach to cataract surgery sedation. The study findings suggest an opportunity to use anesthesia care more selectively in patients undergoing cataract surgery.

Visualization of changes in the foveal avascular zone in both observed and treated diabetic macular edema using optical coherence tomography angiography.

BACKGROUND: Central vision loss in diabetic retinopathy is commonly related to diabetic macular edema (DME). The objective of this study was to describe changes between consecutive visits on optical coherence tomography angiography (OCTA) of the foveal avascular zone (FAZ) in eyes with DME. METHODS: 20 eyes from 14 patients with DME were imaged on 2 successive clinic visits separated by at least 1 month. The mean interval between visits was 3.2 months. The only intervention used was intravitreal anti-VEGF in 11 eyes; the others were observed over time without treatment. Two different readers measured FAZ area using a pseudo-automated tool in comparison to a manual tracing tool. Qualitative changes in the appearance of the vasculature surrounding the FAZ were also recorded. The retinal capillary plexus was segmented into deep and superficial plexuses, and FAZ measurements were done on the superficial, deep, and summated plexuses. RESULTS: Pseudo-automated and manual measurements of FAZ area decreased significantly (p < 0.05) between visits in the deep, superficial, and summated plexuses. Qualitative analysis of vasculature surrounding the FAZ showed that most of the vascular changes (65%) over time were visible in the deep plexus, compared to 30 and 20% in the superficial and summated plexuses, respectively. CONCLUSIONS: The most significant differences in FAZ size over time were in the summated plexus (p < 0.001), while changes in FAZ appearance were most prominent in the deep plexus. Absolute decrease in FAZ size over visits was largest in the deep plexus. Our results demonstrate that OCTA can effectively be used to measure FAZ area in patients with DME, visualize qualitative changes in retinal vasculature, and visualize the segmentation levels at which these changes can be best appreciated. However, larger studies are needed to evaluate the reproducibility of manual and pseudo-automated measuring techniques.

Articular osteotomy of the distal humerus and excision of extensive heterotopic ossification.

Prior case series of corrective osteotomy of substantial intra-articular malunion after a fracture of the distal humerus described concomitant heterotopic ossification in a subset of patient, but only in mild forms. We present our experience in treating two patients with malunited articular fractures of the distal humerus with extensive heterotopic ossification and near ankylosis where the lateral articular fragments were encased in heterotopic bone. Although osteotomy of articular malunion after distal humeral fracture along with excision of extensive HO is challenging and risky due to potential devitalization of the fragments, articular deterioration during the delay to osteotomy, and recurrence of heterotopic bone among other concerns, restoring articular congruity in these patients using articular fracture fragments extracted from heterotopic ossification can lead to improved function of the elbow.