Increased rate of ptosis following glaucoma drainage device placement and other anterior segment surgery: a prospective analysis.

PURPOSE: To determine the degree and rate of ptosis in patients undergoing glaucoma and cataract surgery. METHODS: Patients undergoing cataract extraction (CE), trabeculectomy, or glaucoma drainage device (GDD) placement, or a combination, were consecutively enrolled by a sole surgeon. Eyelid measurements, including margin reflex distance 1 (MRD1) and levator function, were obtained preoperatively and at 1 and 3 months postoperatively. Primary outcome measures were the change in MRD1 pre- vs postoperatively; percentage of patients with ptosis (defined as MRD1 < 2 mm pre- vs postoperatively). Secondary measures were the absolute change in MRD1 between groups, decrease in MRD1 of ≥ 2 mm, and change in levator function. RESULTS: In total, 104 eyes of 73 patients underwent CE, trabeculectomy, or GDD placement and completed at least 1-month follow-up; 93 eyes of 65 patients completed 3-month follow-up. MRD1 decreased significantly in trabeculectomy and GDD groups at 1 and 3 months postoperatively, while it did not change in the CE group. The GDD group had a significant increase in percentage of patients with ptosis at 3 months postoperatively. CONCLUSION: Patients who underwent glaucoma surgery, especially those who underwent GDD placement, were more likely to have postoperative ptosis than patients undergoing CE alone. High ptosis rates in patients undergoing glaucoma surgery may warrant preoperative counseling and post-operative referral to oculoplastic surgeons.

Nd:YAG capsulotomy for the management of posterior capsular amyloidosis.

PURPOSE: To describe the accumulation of amyloid in Berger's space. OBSERVATIONS: A 35-year-old man with autosomal-dominant, familial transthyretin-associated amyloidosis and bilateral vitreous opacities had a recurrence of amyloidosis following vitrectomy. The recurrent amyloid was attached to the posterior capsule of the lens. Phacoemulsification followed by neodymium:yttrium-aluminum-garnet (Nd:YAG) capsulotomy was helpful in restoring vision. CONCLUSIONS AND IMPORTANCE: Amyloid can reaccumulate in Berger's space, which is difficult to reach in phakic eyes during vitrectomy and can then cause decreased vision. Recognition of this interesting anatomic problem will allow for faster visual rehabilitation of the patient.

Healthcare Utilization by Glaucoma Patients in a Team Care Model.

PURPOSE: To determine the effect of a glaucoma team care model on resource utilization and efficiency in glaucoma management. METHODS: Retrospective cohort study of 358 patients diagnosed and treated for glaucoma. Analysis included number of patient visits, diagnostic tests, and glaucoma procedures performed before (2005-2007) and after (2008-2010) implementation of a team care model in 2008. Patients not involved in the model served as controls. RESULTS: Number of patient visits did not change significantly after model implementation (p > .05). Diagnostic tests significantly increased in comprehensive ophthalmologist and glaucoma subspecialist groups 25 months after diagnosis (p = .03 and p = .001). Procedures increased for glaucoma subspecialists but was not statistically significant (p = .06). Optometrists used billing codes with significantly lower reimbursement than other providers (p < .001). CONCLUSIONS: Team care model had neutral effect on patient visits and increased testing. Continued evaluation of this model is required to determine its effect on disease progression and outcomes.

Variations in Trabeculectomy and Glaucoma Drainage Device Use for the Treatment of Glaucoma in the United States.

PURPOSE: To estimate geographic variations and surgeon and patient characteristics associated with the use of trabeculectomy and glaucoma drainage devices (GDDs) to treat glaucoma among US Medicare fee-for-service (FFS) beneficiaries. DESIGN: Observational cohort study of a Medicare claims database. PARTICIPANTS: US Medicare Part B FFS patients (age ≥65 years) and their glaucoma surgeons. METHODS: Analysis of Limited Data Set claims for the 5% sample from Medicare Provider and Utilization and Payment Data was used to identify trabeculectomy and GDD claims with diagnosis codes for patients treated in the United States from January 1, 2014, to September 30, 2015. The number of patients who underwent trabeculectomy or GDD placement was calculated for each US census region. Regional variations were evaluated with the extremal quotient. Multivariate binomial logistic regression was performed to analyze surgeon (career stage and sex), patient (age, race, sex, and ICD-9-CM diagnosis code), and regional characteristics associated with trabeculectomy and GDD placement. MAIN OUTCOME MEASURES: Rates of trabeculectomy and GDD placement performed for Medicare Part B FFS patients by US census region. RESULTS: From January 1, 2014, to September 30, 2015, the odds that patients received trabeculectomy versus GGD placement varied by region. Patients in the South (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.74-2.66; P < 0.001) and Midwest (OR, 1.42; 95% CI, 1.11-1.83; P < 0.01) were significantly more likely to receive GDD placement than patients in the Northeast. The extremal quotient was 2.16, which confirmed high regional variation. Characteristics associated with increased odds of receiving GDD placement were age greater than 84 years (OR, 1.47; 95% CI, 1.11-1.95), African American race (OR, 1.37; 95% CI, 1.11-1.69), and ICD-9-CM diagnosis of glaucoma associated with vascular disorders (OR, 5.87; 95% CI, 2.78-12.41). CONCLUSIONS: High regional variation in trabeculectomy and GDD placement was observed. Placement of a GDD was more likely to be performed in the South. Placement of a GDD was more likely in African American patients and patients with glaucoma associated with vascular disorders, and was more likely performed by early-career surgeons.

Analysis of a Physician-led, Team-based Care Model for the Treatment of Glaucoma.

PURPOSE: To determine the effect of a protocol for a new physician-led, team-based glaucoma care model implemented in 2008 at Mayo Clinic's campus in Rochester, Minnesota (MCR), to increase conformance with the American Academy of Ophthalmology (AAO) Preferred Practice Pattern guidelines for treatment of primary open-angle glaucoma. METHODS: Records of 591 patients with newly diagnosed glaucoma were assessed retrospectively for the completion of 9 AAO Preferred Practice Pattern recommended metrics including measured corneal thickness, intraocular pressure (IOP), cup to disk ratio, visual acuity, recorded IOP target, gonioscopy, fundus photos, ocular coherence tomography, and visual field in the 3 years before and 3 years after protocol implementation. Treatment by the glaucoma care team at MCR was compared with treatment at a community-based general ophthalmology practice and with a group of comprehensive ophthalmologists at MCR without team care, which served as controls. RESULTS: Adherence to AAO recommendations increased for the documentation of target IOP (+24%, 42.6% to 66.7%; P=0.007), gonioscopy (+27%, 66.7% to 93.3%; P≤0.001), fundus photos (+29%, 44.4% to 73.3%; P≤0.001), and ocular coherence tomography (+20%, 48.1% to 68.0%; P=0.02) after protocol initiation. No change in pattern of testing occurred in the control groups without team care during the same time period. Type and severity of glaucoma were similar between MCR and community practice. CONCLUSIONS: An increase in compliance with AAO guidelines was found after implementation of our protocol for a physician-led, team-based care model to standardize glaucoma care among providers.