Salary Negotiations: Gender Differences in Attitudes, Priorities, and Behaviors of Ophthalmologists.

PURPOSE: To investigate attitudes, priorities, and behaviors of ophthalmologists in salary negotiations. DESIGN: Cross-sectional study. METHODS: A Qualtrics survey was disseminated to U.S.-based practicing ophthalmologists between November 1, 2021 and March 31, 2022 and assessed attitudes, behaviors, and priorities surrounding salary negotiation during the respondents' first negotiation as a practicing physician and currently. Optional case-based scenarios were also included. RESULTS: Of 424 respondents, 155 (36.5%) identified as male (M) and 269 (63.3%) identified as female (F). Men were more likely to negotiate salary for their first position as an independent ophthalmologist (M 78.3%, F 68.2%; P = .04). Respondents of both genders assessed their success similarly; 85.0% of men and 75.7% of women (P = .07) felt that their negotiation was very successful or somewhat successful. Women were more likely to select "flexibility in clinic/OR schedule for personal commitments" as a priority during salary negation for their first position (M 14.8%, F 23.1%; P = .04). Women ophthalmologists reported feeling more uncomfortable (M 36.1%, F 49.1%; P = .01), intimidated (M 20.0%, F 43.5%; P < .01), and were less likely to feel well-trained (M 24.5%, F 13.0%; P < .01). Most respondents never received formal training in negotiation. CONCLUSIONS: We found significant gender differences among ophthalmologists in attitudes, priorities and behaviors surrounding salary negotiation. There were low reported levels of formal negotiation training, which appears to disadvantage women more than men. These gender disparities suggest that incorporating education about negotiation skills and career development early in training may be impactful.

Impact of a formal manual small-incision cataract surgery curriculum in an American ophthalmology residency program.

Purpose: Global ophthalmology educational activities often include the ability of ophthalmology residents to partake in low-resource clinical care at home and abroad. Low-resource surgical techniques have become a pillar of education during formalized global ophthalmology fellowships. A formal manual small-incision cataract surgery (MSICS) curriculum was started in the University of Colorado's residency training program to meet the growing demand for this surgical skill and to allow for more sustainable outreach work from our graduates. The survey was conducted to collect evaluations on the value of formal MSICS training within a United States-based residency program. Methods: This was a survey study in a US ophthalmology residency program. A formal MSICS curriculum was created that included didactic lectures on epidemiology of global blindness, MSICS technique, and how MISCS compared to phacoemulsification in terms of cost and sustainability in low-resource settings, followed by a formal wet lab experience. Residents were then exposed to MSICS procedures in the operating room (OR) under supervision of an experienced MSICS surgeon. An anonymous online survey was conducted on three consecutive cohorts of recently graduated senior ophthalmology residents from 2019 to 2021 with the aim of eliciting opinions about and outcomes from the new curriculum. Results: Fifteen graduating senior residents comprised the three cohorts with a 100% survey response rate. All residents agreed or strongly agreed that "MSICS is a valuable skill to have". Eighty percent of respondents agreed or strongly agreed that "exposure to MSICS has increased my likelihood of doing any type of outreach work in the future" and 86.67% agreed or strongly agreed that "exposure to MSICS increased my understanding about sustainable outreach work". The average number of cases assisted or performed per resident was 8.2 (SD 2.7, range 4-12). Conclusion: A formal MSICS curriculum for US-based ophthalmology residents was well-received by the trainees. The majority felt it increased their likelihood of pursuing and improved their understanding of sustainable outreach work. The curriculum, which included lectures, wet lab training, and formal teaching in the OR, could add value to a residency program's curriculum. Furthermore, a formal domestic program can avoid ethical pitfalls that can be seen with resident teaching during international mission work.

Subjective and Objective Measurement of Sleep Quality and Activity in Glaucoma.

PRCIS: Glaucoma patients exhibit worse indices of sleep function by both objective and subjective metrics compared with controls. PURPOSE: The purpose of this study is to characterize the sleep parameters and physical activity levels of glaucoma patients compared with controls. PATIENTS AND METHODS: A total of 102 patients with a diagnosis of glaucoma in at least 1 eye and 31 control subjects were enrolled in the study. Participants completed the Pittsburgh Sleep Quality Index (PSQI) during enrollment and then wore wrist actigraphs for 7 consecutive days to characterize circadian rhythm, sleep quality, and physical activity. The primary outcomes of the study were subjective and objective metrics of sleep quality using the PSQI and actigraphy devices, respectively. The secondary outcome was physical activity, measured by the actigraphy device. RESULTS: From the PSQI survey, glaucoma patients had higher (worse) scores compared with controls for sleep latency, sleep duration, and subjective sleep quality, whereas scores for sleep efficiency were lower (better), suggesting more time spent in bed asleep. By actigraphy, time in bed was significantly higher in glaucoma patients as was time awake after sleep onset. Interdaily stability, quantifying the synchronization to the 24-hour light-dark cycle, was lower in glaucoma patients. There were no other significant differences between glaucoma and control patients with regard to rest-activity rhythms or physical activity metrics. In contrast to the survey data, findings from the actigraphy demonstrated that there were no significant associations between the study group and controls regarding sleep efficiency, onset latency, or total sleep time. CONCLUSIONS: In this study, patients with glaucoma demonstrated several subjective and objective differences in sleep function when compared with controls, whereas physical activity metrics were similar.

Comparison of Outcomes of Phacoemulsification Combined with Endoscopic Cyclophotocoagulation, iStent, or Both in the Management of Open-Angle Glaucoma.

INTRODUCTION: To compare outcomes of phacoemulsification combined with endoscopic cyclophotocoagulation (phaco/ECP), first generation iStent implantation (phaco/iStent), or both (phaco/iStent/ECP) in patients with open-angle glaucoma. METHODS: A retrospective chart review was performed on patients at the University of Colorado Department of Ophthalmology. Outcomes included intraocular pressure (IOP), medication use, best corrected visual acuity (BCVA), and surgical complications were analyzed. Success was defined as IOP reduction of ≥ 20% and/or reduction by at least one glaucoma medication. RESULTS: A total of 394 eyes were included in the study. There were 170 eyes (43.1%) in the phaco/ECP group, 175 eyes (44.4%) in the phaco/iStent group, and 49 eyes (12.4%) in the phaco/iStent/ECP group. The mean pre-operative IOP was 15.9 mmHg for phaco/ECP, 15.8 mmHg for phaco/iStent, and 15.2 mmHg for phaco/iStent/ECP. At 24 months, the mean IOP was 13.7 mmHg (p < 0.0001), 14.2 mmHg (p = 0.0001), and 13.0 mmHg (p = 0.0007), respectively. The mean pre-operative number of glaucoma medications was 2.0 for phaco/ECP, 1.4 for phaco/iStent, and 2.2 for phaco/iStent/ECP and at 24 months post-surgery decreased to, 1.8 (p = 0.011), 0.9 (p < 0.0001), and 1.7 (p = 0.01), respectively. The success rate at 24 months was 54.4% for phaco/ECP, 75.3% for phaco/iStent, and 55.6% for phaco/iStent/ECP. CONCLUSION: Phacoemulsification when combined with ECP, iStent, or both, lowered IOP and glaucoma medication reliance at 24 months. The success rate for phaco/iStent was significantly higher than phaco/ECP. When iStent was added to phaco/ECP, the success rate was higher at earlier postoperative visits compared to the phaco/ECP alone.

The Role of Technology in Ophthalmic Surgical Education During COVID-19.

Purpose of Review: To describe the effect of COVID-19 on ophthalmic training programs and to review the various roles of technology in ophthalmology surgical education including virtual platforms, novel remote learning curricula, and the use of surgical simulators. Recent Findings: COVID-19 caused significant disruption to in-person clinical and surgical patient encounters. Ophthalmology trainees worldwide faced surgical training challenges due to social distancing restrictions, trainee redeployment, and reduction in surgical case volume. Virtual platforms, such as Zoom and Microsoft Teams, were widely used during the pandemic to conduct remote teaching sessions. Novel virtual wet lab and dry lab curricula were developed. Training programs found utility in virtual reality surgical simulators, such as the Eyesi, to substitute experience lost from live patient surgical cases. Summary: Although several of these described technologies were incorporated into ophthalmology surgical training programs prior to COVID-19, the pandemic highlighted the importance of developing a formal surgical curriculum that can be delivered virtually. Novel telementoring, collaboration between training institutions, and hybrid formats of didactic and practical training sessions should be continued. Future research should investigate the utility of augmented reality and artificial intelligence for trainee learning.

Outcomes of Kahook Dual Blade Goniotomy for Uveitis Associated Open Angle Glaucoma or Ocular Hypertension.

PRCIS: Kahook Dual Blade (KDB) goniotomy can successfully lower intraocular pressure in some patients with uveitis-associated ocular hypertension or glaucoma. PURPOSE: The purpose of this study was to report a case series of patients that underwent KDB goniotomy at a single institution for uveitis-associated ocular hypertension or glaucoma with an open angle. METHODS: We performed a retrospective chart review of all patients with uveitis-associated ocular hypertension or glaucoma who underwent KDB goniotomy with trabecular meshwork excision alone or in combination with phacoemulsification cataract surgery at a single center between August 2017 and February 2020. The case series included 45 eyes of 37 patients. All eyes developed ocular hypertension refractory to maximum-tolerated medical therapy and required surgical intervention. Two eyes were excluded as they were lost to follow-up before 5 months postoperatively. Surgical success was defined as reaching the goal intraocular pressure or lower for each patient, including ongoing medical therapy. RESULTS: At most recent follow-up, 25 (55.6%) of 45 eyes had an intraocular pressure that was at goal. Mean follow-up time was 15.2±12.1 months ranging from 0.5 to 36 months postoperatively, considering that patients were eliminated from the data analysis once they required a second surgery. The mean number of preoperative medications, including oral carbonic anhydrase inhibitors was 3.7±1.2 medications. The mean number of postoperative medications through the last clinic visit was 2.5±1.9 medications for a mean reduction of 1.2±1.6 medications ( P -value <0.0001*). CONCLUSIONS: This larger case series shows that some patients with uveitis-associated ocular hypertension or glaucoma with an open angle may have success with KDB goniotomy.

Selective Laser Trabeculoplasty and Outcomes of Subsequent Phacoemulsification Combined with Kahook Dual Blade Goniotomy.

INTRODUCTION: To investigate the relationship between intraocular pressure (IOP)-lowering success of selective laser trabeculoplasty (SLT) and combined phacoemulsification/Kahook Dual Blade (phaco/KDB) goniotomy in eyes with mild to severe open angle glaucoma (OAG). METHODS: Eyes undergoing combined phaco/KDB goniotomy and that had previously undergone SLT were analyzed. Data collected included demographics, glaucoma type and severity, IOP, and topical IOP-lowering medications before and after both procedures. Eyes were divided into two groups based on success of SLT, defined as IOP reduction of at least 20% maintained on at least two consecutive follow-up visits without any subsequent medication additions or interventions. Phaco/KDB goniotomy success was defined as IOP reduction of at least 20% and/or reduction in the number of IOP-lowering medications of at least one up to 12 months of follow-up. RESULTS: Overall, SLT was successful in 20 of 43 eyes (46.5%), of which 63.6% (7/11) had successful phaco/KDB goniotomy at 12 months follow-up. Among eyes with unsuccessful SLT, 60.0% (9/15) had successful phaco/KDB at 12 months follow-up. Phaco/KDB success rate was similar in patients regardless of their previous response to SLT at all postoperative time points up to 12 months follow-up (p = 0.87). CONCLUSIONS: The presence or lack of IOP-lowering response to SLT did not influence the success rate of subsequent phaco/KDB goniotomy in eyes with mild to severe OAG. Patients who did not respond to SLT still benefited from phaco/KDB goniotomy at a later date.

A Third-Year Medical School Ophthalmology Curriculum for a Longitudinal Integrated Clerkship Model.

Background Longitudinal Integrated Clerkships (LICs) are innovative educational models that allow medical student continuity with patients, preceptors, colleagues, and health care systems. Given their benefits, the number of LICs continues to increase. We share a pilot model for an ophthalmology LIC curriculum at the University of Colorado School of Medicine targeted for students to see patients through transitions of care. Methods A needs assessment was performed including literature search, interviews with expert faculty, and a precurricular student questionnaire. Based on our findings, we developed a pilot two-part curriculum consisting of an introductory lecture and a half-day clinical experience designed to integrate patient eye care into the LIC model. At the end of the year, students completed a questionnaire assessing attitude, confidence, and knowledge. Precourse data were collected from students in the academic year (AY) 2018/2019 to aid with the needs assessment. Postcourse data were collected after completion of the curriculum from students in AY 2019/2020. Data from questionnaire were intended to improve our curricular experience. Results Our curriculum was piloted between the 2019 and 2020 AY. The completion rate of our curriculum was 100%. The questionnaire response rate was 90% in pre- and postcurricular groups ( n =15/17 and n =9/10, respectively). Hundred percent of students from both groups responded that it is "very important"/"important" for all physicians to be able to identify when ophthalmology referral is indicated. After the intervention, there were significant differences in the rate of students responding that they were "confident" diagnosing acute angle-closure glaucoma (36 vs. 78%, p =0.04), treating a chemical burn (20 vs 67%, p =0.02), and diagnosing viral conjunctivitis (27 vs. 67%); 90% of students reported increased confidence in longitudinal care of patients in the eye clinic. Conclusions Medical students believe in the importance of ophthalmic education regardless of their specialty of choice. We present a pilot model to introduce ophthalmology within an LIC model. Future studies with a larger sample are needed to determine the impact of this model in terms of knowledge acquisition and relationship between curriculum and ophthalmology interest among students. Our curriculum can be adapted to other underrepresented specialties in the medical school curriculum and is easily exportable to other LICs.

A Comparison of Clinical Outcomes After XEN Gel Stent and EX-PRESS Glaucoma Drainage Device Implantation.

PRECIS: Although the XEN stent offers a lower risk of hypotony and choroidal effusions with fewer clinic visits postoperatively, its surgical success rate was inferior to the EX-PRESS shunt. PURPOSE: To compare the clinical efficacy and safety outcomes of the XEN stent and EX-PRESS glaucoma drainage device in glaucomatous eyes. MATERIALS AND METHODS: One hundred eyes from 88 patients underwent ab interno XEN stent or EX-PRESS shunt implantation (52 XEN and 48 EX-PRESS) for uncontrolled glaucoma at the University of Colorado Eye Center. The primary outcome was surgical success defined as intraocular pressure (IOP) ≥6 and ≤18 mm Hg, without reoperation for uncontrolled glaucoma, loss of light perception, or use of glaucoma medications (complete success). Secondary outcomes were the same requirements allowing for medications (qualified success), mean IOP, medication use, adverse events, and number of postoperative clinic visits in the first 3 months. RESULTS: Baseline characteristics including glaucoma type and severity were similar between groups, with the exception of XEN patients having fewer men (17% vs. 46%), older patients (median age, 78 vs. 68), and a higher percentage of white patients (89% vs. 69%). Adjusted hazard ratio of failure of XEN relative to EX-PRESS was 3.94 (95% confidence interval, 1.73-9.00, P=0.001) for complete success and 1.61 (95% confidence interval, 0.40-6.38, P=0.501) for qualified success. There were significantly fewer postoperative clinic visits during the first 3 months in the XEN group (5.3 vs. 9.1 visits, P<0.001). The incidence of serous choroidal effusions and hypotony was significantly less after XEN compared with EX-PRESS (1 vs. 9, P=0.02 and 15 vs. 25, P=0.023, respectively). Three XEN stents (5.8%) required removal. CONCLUSIONS: In this population, although the XEN stent offers a better safety profile and fewer postoperative clinic visits, complete surgical success was inferior to the EX-PRESS shunt.

Trends in Ophthalmology Resident Operative Experience and the Early Impact of the COVID-19 Pandemic.

Purpose This study aimed to evaluate trends in ophthalmology resident operative experience and the early impact of the novel coronavirus disease 2019 (COVID-19) pandemic. Design Present study is a retrospective analysis of the Accreditation Council for Graduate Medical Education (ACGME) Case Log System. Participants Anonymized graduating resident case logs from 2011 to 2020 academic years (AYs) were examined for this study. Methods Regression analysis for each procedure category was performed to identify trends between 2011 and 2019 AYs. Unpaired two-tailed t -test compared 2018 to 2019 and 2019 to 2020 AY's for each category surgeon (S) and as surgeon and assistant (S + A). Main Outcome Measures Mean and median cases as (S) and (S + A) during 2011 to 2019 AYs. Comparison between 2018 to 2019 and 2019 to 2020 AY's for each category as (S) and (S + A) to evaluate the impact of the COVID-19 pandemic. Results Total ophthalmology procedures as (S) rose from a mean of 479.6 to 601.3 ( p < 0.001; R 2 = 0.96; Δ/year = 16.9) and a median of 444 to 537 ( p < 0.001; R 2 = 0.97; Δ/year = 13.1). Total procedures as (S + A) rose from a mean of 698.1 to 768 ( p < 0.01; R 2 = 0.83; Δ/year = 9.07) and a median of 677 to 734 ( p < 0.05; R 2 = 0.61; Δ/year = 6.64). Cataract procedures as (S) rose from a mean of 152.8 to 208 ( p < 0.001; R 2 = 0.99; Δ/year = 7.98) and a median of 146 to 197 ( p < 0.001; R 2 = 0.97; Δ/year = 7.87). Cataract procedures as both (S + A) rose from a mean 231.4 to 268.7 ( p < 0.001; R 2 = 0.95; Δ/year = 5.5) and a median of 213 to 254 ( p < 0.001; R 2 = 0.93; Δ/year = 5.33). Between 2018 to 2019 and 2019 to 2020 AYs, the first pandemic year was associated with significant reductions in total procedures (601.3-533.7 [ p < 0.0001]) as (S) and 768.0 to 694.4 ( p < 0.0001) as (S + A), cataract surgery (208-162.2 [ p < 0.0001]) as (S) and 268.7 to 219.1 ( p < 0.0001) as (S + A), and glaucoma surgery (16.3-14.2 [ p = 0.0068]) as (S) and 25.6 to 22.6 ( p = 0.0063) as (S + A). Conclusion During 2011 to 2019 AYs, cataract, intravitreal injections, glaucoma, and total procedures increased significantly. During the early period of the COVID-19 pandemic (2019-2020 AY), national halting of elective procedures had a precipitous effect on resident cataract surgery experience to volumes similar to 2013 to 2014 AY where the mean was twice the current required minimum number. With few exceptions, other procedure volumes remained stable.

Utilizing a Professionalism Mentor to Address Sexual Harassment in Academic Ophthalmology.

Objective This study assesses a new departmental role-a professionalism mentor-who receives sexual harassment reporting, liaisons with campus resources, and organizes educational sessions. Study Design Multicenter randomized controlled survey study. Methods Academic ophthalmology departments in the United States were randomized to a professionalism mentor group ( n = 9) and a control group ( n = 7). Among both pre- and postsurveys, 605 faculty and trainee responses were received and 546 were complete. The intervention group was assigned a professionalism mentor with educational session for a 6- to 10-month period. Sexual harassment and reporting rate change over time were compared between the two groups. Results Among 546 anonymous responses, 16% experienced workplace sexual harassment during the prior 10 months. Location in the South or Midwest was a risk factor ( p < 0.001). Victims were mostly women (76%), including residents/fellows (46%) and academic attendings (49%); perpetrators included patients (35%) and academic attendings (35%). Departments with and without a professionalism mentor had stable harassment from pre- to postsurvey ( p = 0.95 comparing change). The professionalism mentor group had an increase in reporting to an authority from pre- to postsurvey (7-23%), whereas the control group had a decrease (27-12%; p = 0.07 comparing change). Most faculty and trainees in the interventional arm of this study recommended instituting a professionalism mentor with educational session (66% presurvey and 68% postsurvey), compared with educational session alone (25% presurvey and 23% postsurvey), or neither (9% presurvey and 9% postsurvey). Residency program directors in the professionalism mentor group even more strongly supported instituting both a professionalism mentor and educational program (100% presurvey and 100% postsurvey) as opposed to educational program alone (0% presurvey and 0% postsurvey) or neither (0% presurvey and 0% postsurvey). Conclusion This study identified a high sexual harassment rate in academic ophthalmology departments over a brief period. The presence of a professionalism mentor was viewed favorably and may lead to increased reporting.

Gender Compensation Gap for Ophthalmologists in the First Year of Clinical Practice.

PURPOSE: To identify the role of gender and other factors in influencing ophthalmologists' compensation. DESIGN: Cross-sectional study. PARTICIPANTS: U.S. practicing ophthalmologists. METHODS: Between January and March 2020, an anonymous survey was sent to U.S. residency program directors and practicing ophthalmologists who recently completed residency training. Respondents who completed residency ≤ 10 years ago and responded to questions about gender, fellowship training, state of practice, and salary were included. Propensity score match (PSM) analysis was performed with age, academic residency, top residency, fellowship, state median wage, practice type, ethnicity, and number of workdays. Multivariate linear regression (MLR) analysis controlled for additional factors along with the aforementioned variables. MAIN OUTCOME MEASURES: Base starting salary with bonus (SWB) received in the first year of clinical position was the main outcome measure. A multiplier of 1.2 (20%) was added to the base salary to account for bonus. RESULTS: Of 684 respondents, 384 (56% were female, 44% were male) from 68 programs were included. Female ophthalmologists received a mean initial SWB that was $33 139.80 less than that of their male colleagues (12.5%, P = 0.00). The PSM analysis showed an SWB difference of -$27 273.89 (10.3% gap, P = 0.0015). Additionally, SWB differences were calculated with the number of workdays substituted by operating room (OR) days (-$27 793.67 [10.5% gap, P = 0.0013]) and clinic days (-$23 597.57 [8.90% gap, P = 0.0064]) in separate PSM analyses. The SWB differences between genders were significant using MLR analyses, which also controlled for work, clinic, and OR days separately (-$22 261.49, $-18 604.65, and $-16 191.26, respectively; P = 0.017, P = 0.015, P = 0.002, respectively). Gender independently predicted income in all 3 analyses (P < 0.05). Although an association between gender and the attempt to negotiate was not detected, a greater portion of men subjectively reported success in negotiation (P = 0.03). CONCLUSIONS: Female ophthalmologists earn significantly less than their male colleagues in the first year of clinical practice. Salary differences persist after controlling for demographic, educational, and practice type variables with MLR and PSM analyses. These income differences may lead to a substantial loss of accumulated earnings over an individual's career.

Effect of Novel Design Modifications on Fibrotic Encapsulation: An In Vivo Glaucoma Drainage Device Study in a Rabbit Model.

PURPOSE: To quantify the effects of modified Ahmed glaucoma valves® (AGV) with anti-fibrotic plate coatings or a plate surface micro-pattern on outflow resistance and tissue response. METHODS: Twelve New Zealand rabbits were divided into four groups: commercially available AGV implants (n = 3), AGV with hydrophilic coating (n = 3), AGV with heparin coating (n = 3), and AGV with a plate surface micro-pattern (n = 3). After 6 weeks, the anterior chamber silicone tube was cannulated in situ and perfused with 2.5 µL/min of saline. The pressures were recorded with a perfusion system to measure outflow resistance. The rabbits were then euthanized followed by enucleation of all eyes for bleb histological analyses. RESULTS: Hydrostatic pressures were significantly lower in AGVs with the hydrophilic plate coating (mean difference -9.6 mm Hg; p < 0.001), heparin-coated plates (mean difference -4.4 mm Hg; p < 0.001), and micro-patterned plates (mean difference -18.6 mm Hg, p < 0.001), indicating lower outflow resistance compared to control AGV models. Fibrotic encapsulation was lower in hydrophilic plate coating (84.2 µm; mean difference -6.2 µm, p = 0.425), micro-patterned surface (63.7 µm; mean difference -26.7 µm, p = 0.003), and heparin plate coating (49.3 µm; mean difference -41.1 µm, p = 0.006) when compared to control AGV models. CONCLUSIONS: Modified AGVs with plate coatings and AGVs with micro-patterned plates both appear to reduce postoperative fibrotic encapsulation and aqueous outflow resistance by altering the tissue response to implanted materials. Further studies are needed to characterize the safety and role of plate surface modifications on glaucoma drainage devices.

Refractive outcomes among glaucoma patients undergoing phacoemulsification cataract extraction with and without Kahook Dual Blade goniotomy.

BACKGROUND: Glaucoma patients undergoing phacoemulsification alone have a higher rate of refractive surprise compared to patients without glaucoma. This risk is further increased with combined filtering procedures. Indeed, there are few and conflicting reports on the effect of combined phacoemulsification and micro-invasive glaucoma surgery (MIGS). Here, we look at refractive outcomes of glaucoma patients undergoing phacoemulsification with and without Kahook Dual Blade (KDB) goniotomy. METHODS: Retrospective chart review of 385 glaucomatous eyes of 281 patients, which underwent either phacoemulsification alone (n = 309) or phacoemulsification with KDB goniotomy (n = 76, phaco-KDB) at the University of Colorado. The main outcome was refractive surprise defined as the difference in target and postoperative refraction spherical equivalent greater than ±0.5 Diopter (D). RESULTS: Refractive surprise greater than ±0.5 D occurred in 26.3% of eyes in the phaco-KDB group and 36.2% in the phacoemulsification group (p = 0.11). Refractive surprise greater than ±1.0 D occurred in 6.6% for the phaco-KDB group and 9.7% for the phacoemulsification group (p = 0.08). There was no significant difference in risk of refractive surprise when pre-operative IOP, axial length, keratometry or performance of KDB goniotomy were assessed in univariate analyses. CONCLUSION: There was no difference between refractive outcomes of glaucomatous patients undergoing phacoemulsification with or without KDB goniotomy.

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.

Efficacy of Goniotomy With Kahook Dual Blade in Patients With Uveitis-associated Ocular Hypertension.

PRECIS: In a small case series of patients with uveitis-associated ocular hypertension (OHTN) or glaucoma, goniotomy with Kahook Dual Blade (KDB) was an effective surgical treatment option for lowering intraocular pressure (IOP). PURPOSE: The purpose of this study is to review the success of goniotomy using the KDB with trabecular meshwork (TM) excision in lowering the IOP of patients with uveitis-associated OHTN or glaucoma. MATERIALS AND METHODS: A retrospective chart review was completed for all patients with uveitis-associated OHTN or glaucoma who underwent KDB goniotomy with TM excision alone or in combination with phacoemulsification cataract surgery at a single institution. The study included 12 patients (16 eyes). Patients were followed for a minimum of 5 months postoperatively. The main outcome measures of this case series included postoperative IOPs, percent IOP reduction, and reduction of glaucoma medications. RESULTS: The mean maximum IOP of the patients before maximum-tolerated medical therapy or surgery was 35.6±5.8 mm Hg. The mean preoperative IOP at the clinical office visit before surgery of these patients was 28.1±8.5 mm Hg on maximum-tolerated medical therapy. Ten eyes (62.5%) have maintained an IOP at or below their goal through their most recent follow-up visit (mean follow-up time of 9.6±5.6 mo). The mean number of glaucoma medications was significantly reduced from 3.6±0.9 medications to 2.1±1.7 medications, for a mean reduction of 1.5±1.4 medications (P=0.004). CONCLUSIONS: On the basis of this small case series, KDB goniotomy may be a safe, less invasive, and effective first-line surgical alternative for patients with uveitis-associated OHTN or glaucoma refractory to medical therapy.

Optimum time for angle visualization during ab interno glaucoma surgery: Before or after phacoemulsification.

PURPOSE: To determine whether it is more advantageous to perform ab interno glaucoma surgeries involving the angle before or after phacoemulsification. SETTING: University of Colorado Health Eye Center, Aurora, USA. DESIGN: Retrospective case series. METHODS: Video recordings were taken of eyes having phacoemulsification with or without angle surgery. From the videos, still images of the angle before and after cataract surgery were obtained. Four glaucoma physicians independently reviewed the images and were masked to whether the images presented side-by-side were captured before or after cataract surgery. The reviewers used a 5-point rating scale to assess which of the 2 presented images showed the best visualization of the angle. Patient and ocular characteristics were analyzed to determine predictive factors for better view before or after phacoemulsification. RESULTS: Twenty side-by-side comparisons (20 eyes of 20 patients) were reviewed and rated. The mean rating of all surgeons was 2.93, nearing the "3-no difference" response. The most common response was "3-no difference" between each photograph (32.5%), followed by "4-post phacoemulsification image somewhat better" (30%), and "2-pre-phacoemulsification image somewhat better" (27.5%). No ocular characteristic, including anterior chamber depth, angle pigmentation, or cumulative dissipation energy, was found to be predictive of surgeon preference. CONCLUSION: In combination phacoemulsification and angle-based glaucoma procedures, there appears to be no significant angle visualization difference whether the surgeon chooses to complete angle surgery before or after phacoemulsification; therefore, the decision of surgical order should rely on surgeon preference.

Histopathologic Examination of Trabecular Meshwork Changes After Trabecular Bypass Stent Implantation.

PURPOSE: The purpose of this article was to evaluate how human trabecular meshwork (TM) is influenced by the chronic presence of trabecular bypass implants. METHODS: Human TM samples were obtained intraoperatively from 3 patients who had previously undergone implantation of a trabecular micro-bypass stent. Trabecular strips were obtained with a goniotomy blade from areas directly adjacent to the stent after stent removal. Tissue samples were preserved, processed, cut, and stained according to standardized laboratory protocol. Harvested samples were compared with human cadaveric TM from an eye without ocular disease as well as TM obtained from a glaucomatous eye without prior stent placement. RESULTS: In all samples, a significant increase in the amount of fibrous material compared with cellular material was noted when compared with controls. In a single strip, a basement membrane-like structure was noted, which correlated with a semiopaque membrane noted intraoperatively overlying the stent and adjacent TM. Further, TM cells were absent from areas adjacent to the stent implantation site with related collapse of collagen beams. CONCLUSIONS: These findings indicate that inflammatory and fibrotic changes are present surrounding the device with clear differences noted when compared with both healthy and glaucomatous controls. These changes suggest a possible etiology for device failure over time. Further studies are necessary to tease out differences in TM tissue reaction to various implant materials as well as to make comparisons to procedures that excise TM.