Cost-utility analysis of prophylactic laser peripheral iridotomy for primary angle closure suspects.

PURPOSE: To assess the cost-utility of prophylactic laser peripheral iridotomy (LPI) for primary angle closure (PAC) suspects (PACS). DESIGN: Economic evaluation. METHODS: Our Markov model randomized PACS eyes to LPI or observation for 40 one-year cycles (100,000 iterations per strategy). Each cycle, an eye remained in its current health state, advanced linearly through PAC, mild, moderate, severe, and end-stage PAC glaucoma (PACG), or died. Transition rates were derived from the literature including the Zhongshan Angle Closure Prevention (ZAP) trial and the Singapore Asymptomatic Narrow Angles Laser Iridotomy Study (ANA-LIS). Eyes with acute-angle closure advanced to either PAC or directly to various PACG severities. A tracker monitored accumulated perimetric decibel reduction to progress PACG through increasing severities, with an annual probability of either stable or severity-dependent perimetry loss. We set a willingness to pay of an incremental cost-effectiveness ratio (ICER) <$50,000/quality-adjusted life years. RESULTS: At age 50, LPI was cost-saving using ZAP data and cost-effective using ANA-LIS data. The ZAP iterations became cost-effective from the societal perspective when the model started at age 55 and third-party perspective at age 70. LPI was no longer cost-effective from the societal perspective using ANA-LIS data at age 80 or from the societal perspective using ZAP data or third-party perspective with ANA-LIS data at age 85. Probabilistic sensitivity analyses favored LPI until starting age 85. CONCLUSIONS: Prophylactic LPI for PACS is cost-effective across a spectrum of ages and should be considered from a public health perspective.

Intraocular Pressure Spike Following Stand-Alone Phacoemulsification in the IRIS® Registry (Intelligent Research in Sight).

PURPOSE: To evaluate risk factors for intraocular pressure (IOP) spike after cataract surgery using the IRIS® Registry (Intelligent Research in Sight). DESIGN: Retrospective clinical cohort study. PARTICIPANTS: Adults with IRIS Registry data who underwent stand-alone phacoemulsification from January 1, 2013, through September 30, 2019. METHODS: Intraocular pressure spike was defined as postoperative IOP of > 30 mmHg and > 10 mmHg from the baseline within the first postoperative week. Odds ratios (ORs) for demographic and clinical characteristics were calculated with univariable and multivariable logistic regression analyses. MAIN OUTCOME MEASURES: Incidence and OR of IOP spike. RESULTS: We analyzed data from 1 191 034 eyes (patient mean age, 71.3 years; 61.2% female sex; and 24.8% with glaucoma). An IOP spike occurred in 3.7% of all eyes, 5.2% of eyes with glaucoma, and 3.2% of eyes without glaucoma (P < 0.0001). Multivariable analyses of all eyes indicated a greater risk of IOP spike with higher baseline IOP (OR, 1.57 per 3 mmHg), male sex (OR, 1.79), glaucoma (OR, 1.20), Black race (OR, 1.39 vs. Asian and 1.21 vs. Hispanic), older age (OR, 1.07 per 10 years), and complex surgery coding (OR, 1.22; all P < 0.0001). Diabetes (OR, 0.90) and aphakia after surgery (OR, 0.60) seemed to be protective against IOP spike (both P < 0.0001). Compared with glaucoma suspects, ocular hypertension (OR, 1.55), pigmentary glaucoma (OR, 1.56), and pseudoexfoliative glaucoma (OR, 1.52) showed a greater risk of IOP spike and normal-tension glaucoma (OR, 0.55), suspected primary angle closure (PAC; OR, 0.67), and PAC glaucoma (OR, 0.81) showed less risk (all P < 0.0001). Using more baseline glaucoma medications was associated with IOP spike (OR, 1.18 per medication), whereas topical ß-blocker use (OR, 0.68) was protective (both P < 0.0001). CONCLUSIONS: Higher baseline IOP, male sex, glaucoma, Black race, older age, and complex cataract coding were associated with early postoperative IOP spike, whereas diabetes and postoperative aphakia were protective against a spike after stand-alone phacoemulsification. Glaucomatous eyes demonstrated different risk profiles dependent on glaucoma subtype. The findings may help surgeons to stratify and mitigate the risk of IOP spike after cataract surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Glaucoma Tube Outcomes with and without Anti-VEGF in Patients with Age-related Macular Degeneration.

PURPOSE: To compare glaucoma tube outcomes of wet age-related macular degeneration (AMD) eyes receiving anti-VEGF injections versus dry AMD eyes and no anti-VEGF. DESIGN: Retrospective clinical cohort study. PARTICIPANTS: Patients with wet AMD and a history of anti-VEGF within a year prior or after stand-alone glaucoma tube surgery and eyes with dry AMD and no history of anti-VEGF with at least 6 months of follow-up. Eyes with neovascular glaucoma or anti-VEGF for reason other than wet AMD were excluded. METHODS: A Kaplan-Meier analysis compared survival for wet versus dry AMD eyes. Failure was defined as intraocular pressure (IOP) > 21 mmHg or < 20% IOP reduction from baseline or IOP ≤ 5 mmHg for 2 consecutive postoperative visits starting at month 3, additional glaucoma surgery, or no light perception. Complete success was defined as no failure or medications at final follow-up. Hypertensive phase was defined for valved tubes as IOP > 21 mmHg within 3 months of surgery after a reduction to < 22 mmHg during the first postoperative week. Intraocular pressure, percent reduction in IOP, number of glaucoma medications, and early (< 1 year) and late (> 1 year) complications were compared through 5 years. MAIN OUTCOME MEASURES: Survival analysis, IOP, number of medications. RESULTS: Baseline IOP, number of medications, or tube type were not significantly different between wet (n = 24) and dry AMD eyes (n = 54). No wet AMD eyes failed versus 10 (18%) dry AMD eyes (P = 0.03). Five-year survival was estimated as 100% for wet AMD and 72% for dry AMD (P = 0.04). Wet AMD eyes had lower IOP (10.6 vs. 12.7 mmHg, P = 0.05), greater IOP reduction (60% vs. 49%, P = 0.04), fewer medications (1.2 vs. 2.1, P = 0.02), and more complete success (50% vs. 15%, P = 0.001) at final follow-up (32 vs. 36 months, P = 0.42). Fewer wet than dry AMD eyes experienced hypertensive phase (0/10 [0%] vs. 4/10 [40%], P = 0.04). There were no significant differences in early or late complications. CONCLUSIONS: Exposure to anti-VEGF may influence postoperative wound healing and capsule formation which may improve glaucoma tube surgical outcomes. Prospective data is needed to consider perioperative administration of anti-VEGF for glaucoma tube surgery. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Assessing Factors That May Impact Physician-based Decisions for Placing Indwelling Pleural Catheters.

INTRODUCTION: Malignant pleural effusion is a common finding in patients with advanced cancer and is a frequent cause of dyspnea. Current guidelines indicate thoracentesis for symptomatic patients, while indwelling pleural catheters (IPC) are recommended for patients who develop pleural fluid re-accumulation. IPC maintenance, however, requires a significant level of financial and social support. This study aims to analyze potential influencing factors that may play a role in the decision for placing IPCs in patients with recurrent malignant pleural effusions. METHODS: This study retrospectively collected baseline sociodemographic and laboratory data in patients who underwent thoracentesis for malignant pleural effusion from August 2016 to October 2021, and selected patients who presented with re-accumulation of pleural fluid within 30 days or had a pulmonary physician's note documenting that IPC is a potential management option. Of these selected patients (IPC candidates), we stratified patients who underwent IPC placement and those who did not, and performed statistical analysis between these 2 groups. RESULTS: One hundred seventy-six patients who underwent thoracentesis were regarded as IPC candidates. Almost all baseline sociodemographic characteristics, including ethnicity ( P =0.637), sex ( P =0.655), and marital status ( P =0.773) were similar between the 2 groups, but significantly higher ECOG scores ( P =0.049) were noted in the IPC group. No statistically significant differences were noted in age, body mass index, platelet, PTT, international normalized ratio, creatinine, white blood cell, red blood cells, fluid protein, or fluid lactate dehydrogenase. Fluid albumin ( P =0.057) and serum neutrophil:lymphocyte ratio ( P =0.003) were significantly higher in patients without IPC placement. CONCLUSION: This study did not recognize any baseline sociodemographic factors that may contribute to the decision to place IPCs.

Intraocular Pressure Changes Following Stand-Alone Phacoemulsification: An IRISɌ Registry Analysis.

PURPOSE: To describe real-world intraocular pressure (IOP) changes following stand-alone cataract surgery by comparing postoperative IOP to phakic fellow eyes. DESIGN: Retrospective clinical cohort study. METHODS: A total of 1,334,868 patients (336,060 with glaucoma and 998,808 without glaucoma) in the IRIS® Registry (Intelligent Research in Sight) underwent stand-alone phacoemulsification from 1 January 2013 to 30 September 2019 with a fellow eye that had subsequent cataract surgery. Postoperative daily mean IOP was compared between surgical and control eyes from postoperative day 1 to 90. A generalized linear model determined when the postoperative daily mean IOP stabilized to calculate a final mean IOP, which was then compared to baseline IOP. RESULTS: Postoperative daily mean IOP was initially greater for surgical than for control eyes because of an early postoperative IOP spike. By postoperative day 13, postoperative daily mean IOP was significantly lower for surgical than for control eyes every day through postoperative day 90 (P < .001). There was a mean (SD) decrease from baseline to final mean IOP of 1.55 (3.52) mm Hg or 7.79% for all surgical eyes, 1.91 (3.93) mm Hg or 8.89% for surgical eyes with glaucoma, and 1.37 (3.28) mm Hg or 7.24% for surgical eyes without glaucoma, respectively. There was a statistically significant decrease from baseline to the final mean IOP for all surgical eyes, surgical eyes without glaucoma, and all categories of pre-glaucoma and glaucoma (P < .0001 for all, excluding uveitic glaucoma [P = .0016]). CONCLUSIONS: Eyes both with and without glaucoma that underwent stand-alone phacoemulsification had a significant decrease in IOP through the 90-day postoperative period compared to baseline and phakic fellow eyes.

The Effect of Changing Fellowship Interview Format on Candidate Ranking Variabilities: The COVID-19 Experience.

Purpose: This study investigated the effect of interview format changes (in-person to virtual, one-to-one to multiple-to-one) necessitated by the COVID-19 travel restrictions on preliminary fellowship candidate ranking variabilities. Design: Cross-sectional observational study. Method: In 2018 and 2019, the glaucoma fellowship interviews were conducted in-person in a one-to-one format, whereas in 2020, interviews were virtual and in a multiple (interviewers)-to-one (candidate) format. We compared ranking ranges of interviewers within the same virtual room (WSR) and not within the same virtual room (NWSR) to assess the effect of WSR versus NWSR on ranking variabilities. We also compared ranking categories ("accept," "alternate," and "pass") agreements between 2018, 2019, and 2020 to assess the effect of virtual versus in-person interviews on ranking variabilities. Results: NWSR and WSR mean rankings differed by 1.33 (95% confidence interval difference 0.61 to 2.04, p = 0.0003), with WSR interviewers having less variability than NWSR pairs. The variability between 2018/2019 (in-person interviews) and 2020 (virtual interviews) showed no differences between in-person and virtual interviews (weighted Kappa statistic 0.086 for 2018, 0.158 for 2019, and 0.101 for 2020; p < 0.05 for all years). The overall least attractive candidate has the lowest variability; the most attractive candidate has the second lowest variability. Conclusion: Grouping interviewers WSR during the interview decreased ranking variabilities compared to NWSR, while a change from in-person to virtual interview format did not increase the ranking variabilities. This suggests that the decreased nonverbal interactions in virtual interviews do not decrease interviewers' perceptions as applied to preliminary rankings.

Glaucoma Cascade Screening in a High Risk Afro-Caribbean Haitian Population: A Pilot Study.

PRCIS: Glaucoma cascade screening in first-degree relatives (FDRs) of young Haitian glaucoma patients had high yield for diagnosing manifest and suspected glaucoma in 30.8% of those screened despite modest participation. PURPOSE: To evaluate the outcomes of glaucoma cascade screening in FDRs (parents, siblings, and offspring) of Haitian juvenile open-angle glaucoma (JOAG) patients. PATIENTS AND METHODS: Consecutive index patients (Haitians with JOAG) were identified, and the number/type of FDRs residing in South Florida were recorded. These FDRs were invited for free glaucoma screening, which included a comprehensive ophthalmic exam, gonioscopy, automated visual field testing and optical coherence tomographic analysis of the retinal nerve fiber layers. FDR characteristics and clinical findings from screening are reported. RESULTS: A total of 77 FDRs were invited, 26 (33.8%) agreed to undergo screening (18 females, 9 males), which revealed 2 (7.7%) with manifest glaucoma (mean age 77.5 y; one of whom was previously unaware of his glaucoma diagnosis), 6 (23.1%) with suspected glaucoma (mean age 29.8±18.3 y), and 18 (69.2%) without manifest or suspected glaucoma (mean age 37.2±21.8 y). Siblings of index patients were least likely to participate in cascade glaucoma screening when compared with index patients' parents or offspring. FDR eyes with manifest glaucoma had significantly worse best-corrected visual acuities, higher intraocular pressures, thinner central corneal thicknesses, and thinner circumferential papillary retinal nerve fiber layer thicknesses than those without glaucoma. CONCLUSION: Glaucoma cascade screening of Haitian JOAG patients' FDRs revealed that 30.8% had suspected or manifest glaucoma. Future efforts centered on provider-initiated recruitment and improving public glaucoma awareness and education may increase screening participation.

Abnormal Pulmonary Function Testing as an Independent Risk Factor for Procedural Complications During Transthoracic Needle Biopsies.

BACKGROUND: Computed tomography (CT)-guided transthoracic needle biopsy is an important diagnostic tool for pulmonary nodules, offering a less invasive alternative to surgical procedures. This study aims to better risk stratify patients undergoing this procedure by analyzing the pulmonary function testing (PFT), imaging characteristics, and patient demographics most associated with complications. PATIENTS AND METHODS: This retrospective study involved 254 patients undergoing transthoracic needle biopsies at 3 hospitals between October 2016 and December 2019. Demographic data, extent of emphysema, and target lesion characteristics were recorded. Complications were defined as minor (small pneumothorax, mild hemoptysis, or pulmonary hemorrhage) and major (pneumothorax requiring chest tube, hemothorax, rapid atrial fibrillation, or postprocedure hypotension or hypoxia). RESULTS: There were 50 minor (20%) and 18 major complications (7%). As seen with prior studies, older age, increased distance to pleura, and smaller nodule size correlated with an increased risk of complications. Uniquely to our study, emphysema severity, seen on CT (P=0.008) and with decreased forced expiratory volume/forced vital capacity ratio, conferred an increased risk (62.94 vs. 68.74, P=0.05) of complications. Decreased Hounsfield unit of surrounding lung (a surrogate measure of emphysema) and decreased diffusion capacity (11.81 vs. 14.93, P=0.05) were associated with increased risk of major complications. Interestingly, body mass index and comorbidities had no correlation with complications. CONCLUSION: In addition to previous well-described characteristics, we described physiological data (abnormal PFTs), imaging findings, and nodule location as risk factors of procedural complications. Obtaining preprocedural PFT, in addition to reviewing CT imaging and demographic data, may aid clinicians in better risk stratifying patients undergoing transthoracic needle biopsies.

Pediatric intraoperative ciliary block.

Pediatric patients who undergo intraocular surgery are at risk for many of the same perioperative complications as adults. The same methodical approach to assessing perioperative shallowing of the anterior chamber that presents in the adult population should be followed for children. We present a rare case of intraoperative ciliary block in a 3-year-old boy undergoing a second glaucoma drainage device implantation that was successfully treated with pars plana vitrectomy and hyaloid-zonulo-iridectomy.

Virtual Versus In-Person Surgical Fellowship Interviews and Ranking Variability: the COVID-19 Experience.

Objective: To investigate the effect of interview format changes (in-person to virtual, one-to-one to multiple-to-one) necessitated by the COVID-19 travel restrictions on candidate ranking variabilities. Method: In 2018/2019, the glaucoma fellowship interviews were conducted in-person and one-to-one, whereas in 2020, interviews were virtual and multiple (interviewers)-to-one (candidate). We compared ranking ranges of interviewers within the same virtual room (WSR) and not within the same virtual room (NWSR) to assess the effect of this change on ranking variabilities. We also compared ranking categories ("accept," "alternate," and "pass") agreements between in-person and virtual interviews to assess the effect of this change on ranking variabilities. Results: NWSR and WSR mean rankings differed by 1.33 (95% confidence interval difference 0.61 to 2.04, p = 0.0003), with WSR interviewers having less variability than NWSR pairs. The variability of in-person interviews and later virtual interviews showed no differences (weighted Kappa statistic 0.086 for 2018, 0.158 for 2019, and 0.101 for 2020; p < 0.05 for all years). The overall least attractive candidate has the lowest variability; the most attractive candidate has the second lowest variability. Conclusion: Grouping interviewers decreased ranking variabilities, while a change from in-person to virtual interview format did not increase the ranking variabilities.

Effect of Nylon Wick Technique on Early Intraocular Pressure Control in Nonvalved Aqueous Shunt Surgery.

PRECIS: The use of nylon wicks with fenestrations in nonvalved aqueous shunt surgery significantly reduces intraocular pressure (IOP) and glaucoma medication usage in the immediate postoperative period compared with the use of fenestrations alone. PURPOSE: To compare early postoperative IOP and medication usage in patients undergoing implantation of a nonvalved aqueous shunt device with fenestrations only or fenestrations with nylon wicks. METHODS: A retrospective review of all nonvalved aqueous shunt insertions completed by one surgeon (L.W.H.) was completed using current procedure terminology. Patients undergoing Baerveldt or ClearPath 350 mm2 aqueous shunt insertion with fenestrations only (n=37) or fenestrations with 2 nylon wicks were identified (n=92). All devices were ligated with 7-0 Vicryl (polyglactin) suture, and either 4 fenestrations or 2 fenestrations and two 9-0 nylon wicks were placed anterior to the ligature. Data regarding visual acuity (VA), IOP, number of glaucoma medications, and complications were collected from the preoperative visit just before surgery, postoperative day 1, week 3 (POW3), week 5, and month 2 (POM2). The main outcome measures were VA, IOP, number of glaucoma medications, and complications at all postoperative time points. RESULTS: There was no difference in logMAR VA between the 2 groups at any time point. At POW3, IOP was significantly lower in the wick group (14.6±7.7 vs. 18.1±8.7 mm Hg, P=0.03). Number of glaucoma medications used was significantly reduced in the wick group at POW3 (0.5±0.9 vs. 1.0±1.2, P=0.02) and POM2 (0.7±1.0 vs. 1.4±1.3, P=0.02). There was no significant increase in the overall rate of complications in the wick group, but there was a higher rate of transient hyphema (28% vs. 8%, P=0.02). CONCLUSIONS: The use of 2 nylon wicks with fenestrations in nonvalved aqueous shunt device implantation can significantly lower IOP and medication burden while awaiting the dissolution of the ligature suture.

A Service Coverage Analysis of Primary Congenital Glaucoma Care Across the United States.

PURPOSE: To assess the number of infants at risk of delayed primary congenital glaucoma (PCG) evaluation due to long travel times to specialists. DESIGN: Cross-sectional geospatial service coverage analysis. METHODS: All American Glaucoma Society (AGS) and American Association for Pediatric Ophthalmology and Strabismus (AAPOS) provider locations were geocoded using each organization's member directory. Sixty-minute drive time regions to providers were generated using ArcGIS Pro (Esri). The geographic intersection of AGS and AAPOS service areas was computed because patients typically require visits to both types of specialists. American Community Survey data were then overlaid to estimate the number of infants within and beyond the AGS/AAPOS service areas. RESULTS: One thousand twenty-nine AGS and 1,040 AAPOS provider locations were geocoded. The analysis yielded 944,047 infants age 0-1 year (23.6%) who live beyond the AGS/AAPOS service areas. Therefore, approximately 14-94 new PCG cases/year may be at risk of delayed diagnosis as a result of living in a potential service desert. Compared with children living within the AGS/AAPOS service areas, children aged <6 years in these potential service deserts were more likely to live in households earning below the US federal poverty level, lack health insurance, and live in a single-parent home. These communities are disproportionately likely to experience other rural health disparities and are more prevalent across the Great Plains. CONCLUSION: Service coverage analysis is a useful tool for identifying underserved regions for PCG referrals and evaluation. These data may assist in targeting screening programs in low access areas for pediatric glaucoma care.

A Geodemographic Service Coverage Analysis of Travel Time to Glaucoma Specialists in Florida.

PRECIS: Approximately 1 in 9 Florida residents over the age of 65 years (438,642 people) live more than an hour away from a glaucoma specialist, which represents a significant barrier to care. PURPOSE: To describe access to glaucoma care for Florida's elderly population using travel time to American Glaucoma Society (AGS) member offices. METHODS: For this cross-sectional service coverage analysis, a list of AGS member locations was extracted from the AGS website, and addresses were geocoded using ArcGIS Online. Driving time regions were created using the service area tool in ArcGIS Pro 2.4 and overlaid with 2010 United States Census and 2016 American Community Survey data for all Florida residents age 65 or older. RESULTS: Fifty-eight AGS member providers with 65 locations were identified and geocoded. There were 3,797,625 individuals aged over 65 years in Florida, of which 1,153,320 (30.4%) lived within 15 minutes of driving time from an AGS provider's office, 2,586,825 (68.1%) within 30 minutes, 3,358,983 (88.4%) within 60 minutes, and 3,491,815 (91.9%) within 120 minutes. The areas with the lowest access include rural areas near Lake Okeechobee and the Florida Panhandle. The population living beyond a 60-minute drive was more likely to be White, non-Hispanic and older, but less likely to be living below the federal poverty level or receiving public assistance than the population living within a 60-minute drive. CONCLUSIONS: There is a significant travel burden for the elderly community of Florida to reach AGS providers. Additional studies could help identify other social barriers to accessing glaucoma providers in Florida and beyond in an effort to improve patient compliance and, ultimately, vision outcomes.

Sex Differences in Presentation, Treatment Patterns, and Clinical Outcomes in Central Retinal Vein Occlusion.

BACKGROUND AND OBJECTIVE: To evaluate the impact of sex differences on the presenting features, treatment patterns, and clinical outcomes in patients with central retinal vein occlusions (CRVO). PATIENTS AND METHODS: This retrospective, longitudinal cohort study included 476 patients diagnosed with CRVO over a 7-year period. Charts were reviewed and clinical data were abstracted. RESULTS: The average age at CRVO onset was lower in males (63.8 years vs. 66.1 years; P = .048). More males (104/224, 54%) had an ischemic CRVO compared to females (113/252, 45%) at 12 months (P = .05). Males with CRVO had a greater central subfield thickness at the baseline (546.7 ± 306.8 µm vs. 438.4 ± 252.9 µm; P = .003) and final visits (343 ± 179.5 µm vs. 304.6 ± 176.2 µm; P = .005). Foveal avascular zone enlargement was more likely in males (39/102, 38% vs. 29/116, 25%; P = .04). CONCLUSIONS: Sex differences exist in presenting features of patients with CRVO. Further inquiry may help provide individualized recommendations for management of CRVO. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:279-285.].

Influence of head-of-bed elevation on the measurement of inferior vena cava diameter and collapsibility.

PURPOSE: Inferior vena cava (IVC) diameter and variation are commonly measured in the supine position to estimate intravascular volume status of critically ill patients. Many scientific societies describe the measurement of IVC diameter in the supine position. However, critically ill patients are rarely placed supine due to concerns for aspiration risk, worsened respiratory mechanics, increases in intracranial pressure, and the time it takes to change patient position. We assessed the influence of head-of-bed (HOB) elevation on IVC measurements. METHODS: We conducted a prospective observational study of critically ill patients undergoing critical care ultrasound. With HOB at 0°, IVC maximum (IVCmax0°) and minimum (IVCmin0°) diameters were measured. Measurements were then repeated with HOB elevated to 30° and 45°. Collapsibility index (CI), defined as (IVCmax - IVCmin)/IVCmax, was calculated for each HOB elevation. Mean differences were then compared. RESULTS: A convenience sample of 95 patients was studied, of whom 45% were on vasopressors and 44% were spontaneously breathing. The CI did not significantly differ between the three positions. We found a significant difference (P ≤ .0001) between IVCmax at 45° (2.09 cm) and 0° (1.96 cm), IVCmin at 45° (1.75 cm) and 0° (1.59 cm), IVCmax at 45° (2.09 cm) and 30° (1.97 cm), and IVCmin at 45° (1.75 cm) and 30° (1.61 cm). CONCLUSIONS: In a population of critically ill patients undergoing goal-directed ultrasound examinations, elevating HOB to 30° did not significantly alter IVC measurements or CI. At 45°, however, IVCmax and IVCmin diameters increased significantly, albeit with no significant change in CI. Performing ultrasound measurements of the IVC with HOB elevated to 30° is unlikely to produce clinically meaningful changes.

Treatment Outcomes Following Resident Performed Nonvalved (Baerveldt 350) Glaucoma Drainage Device Implantation.

PRECIS: When compared with outcomes by glaucoma specialists in several prospective studies, residents at the Durham Veterans Affairs Medical Center achieved comparable reductions in intraocular pressure (IOP) and failure rates during the year following Baerveldt drainage device implantation. PURPOSE: To review the outcomes of resident performed Baerveldt implantation through 1 year of postoperative management in a resident-run clinic. MATERIALS AND METHODS: The medical records of all veterans at the Durham Veterans Affairs Medical Center were searched to identify those with Baerveldt implantation by resident physicians from July 1, 2007 to June 30, 2017. Exclusion criteria include previous glaucoma tube or concurrent surgical intervention, including cataract extraction. All postoperative visits were reviewed and clinical data were collected. Failure was defined as 2 consecutive visits, starting at postoperative month (POM) 3, with IOP ≤5 mm Hg, or with IOP >21 mm Hg or <20% IOP reduction from baseline, reoperation for glaucoma, or loss of light perception. RESULTS: A total of 48 eyes were included with mean (SD) IOP and number of medications: baseline, 23.1 (6.7) mm Hg on 3.7 (1.0) medications; postoperative day 1, 20.5 (11.7) mm Hg on no medications; postoperative week 1, 14.3 (6.9) mm Hg and 1.9 (1.7) medications; POM1, 16.7 (6.4) mm Hg and 2.2 (1.5) medications; POM3, 15.1 (5.2) mm Hg and 2.1 (1.6) medications; POM6 12.8 (4.9) mm Hg and 2.8 (1.3) medications; POM12, 13.0 (4.0) mm Hg and 2.8 (1.4) medications. IOP decreased at all time intervals (P<0.01) but postoperative day 1 (P=0.15) while medication burden was reduced at every visit (P<0.01). Through 12 months, 8 patients (17%) failed with a time to failure of 9.2 (0.3) months. No patients underwent additional glaucoma surgical interventions or lost light perception. CONCLUSIONS: Residents can safely and efficaciously perform Baerveldt implantation, providing reassurance regarding the autonomy afforded residents in the operating room and clinic.