Postoperative Corneal Injuries: Incidence and Risk Factors.

BACKGROUND: Previous studies of postoperative corneal injury rates relied on provider-initiated incident reports, which may underestimate the true incidence. Postoperative administration of proparacaine eye drops is used almost exclusively to diagnose corneal injury; therefore, identifying instances of administration may provide a better estimate of corneal injuries. We compared proparacaine administration versus provider-initiated reports to determine rates of corneal injury. In addition, potential associations between clinical variables and injury were assessed with a matched case-control study. METHODS: The health records of 132,511 sequential adult postanesthesia recovery room admissions (January 1, 2011 to June 30, 2017) were reviewed to identify postoperative proparacaine administration and incident reports of corneal injury. Patients with corneal injury were matched with control patients at a 1:2 ratio to assess factors associated with injury. RESULTS: Proparacaine drops were administered to 442 patients (425 patients received proparacaine for diagnosis and 17 patients received proparacaine for unrelated reasons). Incident reports identified 320 injuries, and the aggregate corneal injury count was 436 (incidence, 3.3 injuries [95% confidence interval {CI}, 3.0-3.6] per 1000 cases of general anesthesia). Proparacaine administration had a greater case ascertainment percentage than incident reporting (97.5% vs 73.4%; P < .001). The matched case-control analysis found greater risks associated with longer duration of anesthesia (odds ratio, 1.05 [95% CI, 1.03-1.07] per 10 minutes of anesthesia; P < .001) and nonsupine surgical position (odds ratio, 3.89 [95% CI, 2.17-6.98]; P < .001). Patients with injuries also had more evidence of sedation and agitation during anesthesia recovery. CONCLUSIONS: Calculation of incidence by using the administration of a medication (proparacaine eye drops) that is almost exclusively used to diagnose a specific injury (corneal injury) showed higher case ascertainment percentage than incident-reporting methods. Similar strategies could be used to monitor the rates of other adverse events.

String Technique for Anterior Orbital Fish Hook Removal.

Removing fish hooks is a common procedure performed by many emergency department providers. There are several techniques that are commonly employed to aid in successful removal. However, when a fish hook becomes embedded within the orbit, there are limited options as to avoid damaging vital surrounding structures. The authors report the removal of a fish hook within the anterior orbit using the string technique in a 25-year-old patient. The procedure was performed under general anesthesia with the aid of size 5 polyglactin suture wrapped around the hook. The procedure itself took less than 10 seconds and was successful in swiftly and safely removing the hook without damaging surrounding orbital structures. The patient recovered well without any permanent sequelae.

Comparing Access to Laser Capsulotomy Performed by Optometrists and Ophthalmologists in Oklahoma by Calculated Driving Distance and Time.

PURPOSE: To quantify Medicare beneficiary proximity to his or her yttrium-aluminum-garnet (YAG) laser capsulotomy-providing ophthalmologist and optometrist in Oklahoma by calculating driving distances and times. DESIGN: Cross-sectional cohort study using 2014 Oklahoma Medicare 100% and 5% data sets and Google Maps distance and travel time application programming interfaces. PARTICIPANTS: U.S. fee-for-service Medicare beneficiaries and Oklahoma ophthalmologist and optometrist laser capsulotomy providers. METHODS: The 2014 Medicare Provider Utilization and Payment Limited 100% and 5% datasets from the Centers for Medicare and Medicaid (CMS) were obtained to identify the office street addresses of Oklahoma ophthalmologists and optometrists who submitted claims to Medicare for a YAG laser capsulotomy, and the county addresses of the corresponding Medicare beneficiaries who received the laser capsulotomy. The shortest travel distances and travel times between the beneficiary and the laser provider were calculated by using Google Maps distance and travel time application programming interfaces. MAIN OUTCOME MEASURES: Beneficiary driving distances and times to his or her YAG laser capsulotomy-providing Oklahoma ophthalmologist and optometrist. RESULTS: In 2014, 90 (57%) of 157 Oklahoma ophthalmologists and 65 (13%) of 506 Oklahoma optometrists submitted a total of 7521 and 3751 YAG laser capsulotomy claims to Medicare, respectively. By using the Medicare Limited 5% dataset, there was no difference in driving distance between beneficiaries who received a laser capsulotomy from an ophthalmologist (median, 39 miles; interquartile range [IQR], 13-113 miles) compared with an optometrist (median, 46 miles; IQR, 13-125 miles; P = 0.93) or in driving time to an ophthalmologist (median, 47 minutes; IQR, 19-110 minutes) compared with an optometrist (median, 50 minutes; IQR, 17-117 minutes; P = 0.76). CONCLUSIONS: For Medicare beneficiaries, there was no difference in geographic access to YAG laser capsulotomy whether performed by an Oklahoma ophthalmologist or optometrist as determined by calculated driving distances and times.

Joint Management of Cataract Surgery by Ophthalmologists and Optometrists.

PURPOSE: To estimate the rate and geographic variation of cataract surgery that is managed jointly by ophthalmologists and optometrists in aging Americans. DESIGN: Database study. PARTICIPANTS: United States fee-for-service (FFS) Medicare Part B beneficiaries and their providers. METHODS: Medicare Provider Utilization and Payment Data furnished by the Centers for Medicare and Medicaid were used to identify cataract surgery claims among FFS Medicare Part B beneficiaries in all 50 states and the District of Columbia in 2012 and 2013. Payments and joint management rates of cataract surgery by ophthalmologists and optometrists were calculated for each United States state. Geographic variations were evaluated by using the extremal quotient and coefficient of variation (CV). MAIN OUTCOME MEASURES: Medicare allowed payments for cataract surgery (Current Procedural Terminology codes 66982 and 66984) and number of unique FFS Medicare Part B beneficiaries undergoing cataract surgery. RESULTS: The overall national rate of joint management of cataract surgery by ophthalmologists and optometrists among FFS Medicare Part B beneficiaries was 10.9% (range by state, 0%-75%) in 2012 and 11.1% (range by state, 0%-63%) in 2013. In 2013, the mean extremal quotient was 67 and the CV was 82.2, demonstrating very high variation in joint management between states. The Medicare allowed payment to optometrists in the joint management of cataract surgery was 2.1% of the total Medicare allowed payments for cataract surgery codes in 2012 and 2013. Twenty percent and 24% of all Medicare-participating optometrists submitted 10 or more Medicare claims in the joint management of cataract surgery in 2012 and 2013, respectively. CONCLUSIONS: The overall rate of joint management of cataract surgery by ophthalmologists and optometrists among Medicare beneficiaries was 10.9% in 2012 and 11.1% in 2013. Very high geographic variation was documented, with joint management rates ranging from 0% to 63% across states in 2013.

High Variation of Intravitreal Injection Rates and Medicare Anti-Vascular Endothelial Growth Factor Payments per Injection in the United States.

PURPOSE: To estimate geographic variation of intravitreal injection rates and Medicare anti-vascular endothelial growth factor (VEGF) drug costs per injection in aging Americans. DESIGN: Observational cohort study using 2013 Medicare claims database. PARTICIPANTS: United States fee-for-service (FFS) Part B Medicare beneficiaries and their providers. METHODS: Medicare Provider Utilization and Payment Data furnished by the Centers for Medicare and Medicaid Services was used to identify all intravitreal injection claims and anti-VEGF drug claims among FFS Medicare beneficiaries in all 50 states and the District of Columbia in 2013. The rate of FFS Medicare beneficiaries receiving intravitreal injections and the mean Medicare-allowed drug payment per anti-VEGF injection was calculated nationally and for each state. Geographic variations were evaluated by using extremal quotient, coefficient of variation, and systematic component of variance (SCV). MAIN OUTCOME MEASURES: Rate of FFS Medicare Part B beneficiaries receiving intravitreal injections (Current Procedural Terminology [CPT] code, 67028), nationally and by state; mean Medicare-allowed drug payment per anti-VEGF injection (CPT code, 67028; and treatment-specific J-codes, J0178, J2778, J9035, J3490, and J3590) nationally and by state. RESULTS: In 2013, the rate of FFS Medicare beneficiaries receiving intravitreal injections varied widely by 7-fold across states (range by state, 4 per 1000 [Wyoming]-28 per 1000 [Utah]), averaging 19 per 1000 beneficiaries. The mean SCV was 8.5, confirming high nonrandom geographic variation. There were more than 2.1 million anti-VEGF drug claims, totaling more than $2.3 billion in Medicare payments for anti-VEGF agents in 2013. The mean national Medicare drug payment per anti-VEGF injection varied widely by 6.2-fold across states (range by state, $242 [South Carolina]-$1509 [Maine]), averaging $1078 per injection. Nationally, 94% of injections were office based and 6% were facility based. CONCLUSIONS: High variation was observed in intravitreal injection rates and in Medicare drug payments per anti-VEGF injection across the United States in 2013. Identifying factors that contribute to high variation may help the ophthalmology community to optimize further the delivery and use of anti-VEGF agents.

Effect of a 7.0 mm intraocular lens optic on peripheral retinal illumination with implications for negative dysphotopsia.

PURPOSE: To use optical modeling to compare a 6.0 mm and 7.0 mm intraocular lens (IOL) optic diameters on peripheral retinal illumination with implications for negative dysphotopsia. SETTING: Mayo Clinic, Rochester, Minnesota, and Simpson Optics LLC, Arlington, Texas. DESIGN: Model eye. METHODS: Ray-tracing software was used to simulate retinal illumination from an extended light source for a pseudophakic eye with in-the-bag biconvex IOLs (refractive index [n] = 1.46 and 1.55) and a 2.5 mm pupil. Ray-tracing diagrams and simulated retina illumination profiles were compared using the 6.0 mm and 7.0 mm optic diameter IOLs. Retinal locations were scaled to relative visual angles from 70 to 110 degrees horizontally. RESULTS: A 7.0 mm optic (n = 1.46) expands the image field by 2.8 degrees compared with a 6.0 mm optic. High-angle input light misses a 7.0 mm optic at a larger visual angle than a 6.0 mm optic, shifting illumination of the peripheral retina by this light anteriorly by 5.6 degrees. Consequently, a region of nonilluminated peripheral nasal retina is enlarged and shifted peripherally using a 7.0 mm optic (visual angle, 86.3 to 96.3 degrees) compared with a 6.0 mm optic (visual angle, 83.5 to 90.7 degrees). Similar illumination changes were seen modeling a 1.55 n IOL. CONCLUSIONS: A narrow dark region in the nasal retina when using a 6.0 mm optic is changed to a broader, more peripheral dark region when using a 7.0 mm optic. An extended, more peripheral dark nasal region may make a temporal shadow less bothersome and explain lower negative dysphotopsia rates using a 7.0 mm optic.

Prevalence of pseudophakia: U.S. population-based study.

PURPOSE: To determine the current prevalence and trends of pseudophakia in a well-defined U.S. population, calculating values for Olmsted County, Minnesota, from 1988 through 2018. SETTING: Mayo Clinic, Rochester, Minnesota. DESIGN: Population-based cohort study. METHODS: Rochester Epidemiology Project (REP) databases were used to identify all cases of pseudophakia in Olmsted County, Minnesota, between January 1, 1988, and December 31, 2018. Age- and sex-specific prevalence rates were calculated in 1988, 1998, 2008, and 2018 using REP census population estimates and mortality counts. Poisson regression analysis was used to assess changes in prevalence over time. Mortality rates were estimated by Kaplan-Meier analysis. RESULTS: In 2018, 10 024 county residents were pseudophakic in at least 1 eye, for a total population prevalence of 6.5%. The prevalence increased 67% in the last 10 years and 590% in the last 30 years (P < .001). By 2018, 51% of residents aged 75 years and 88% of residents aged 85 years and older were pseudophakic in at least 1 eye, 53% of residents with pseudophakia aged 65 years and older were bilaterally pseudophakic, and 29% of residents with pseudophakia had lived with pseudophakia for more than 10 years. The prevalence was higher among women than men and increased with age (P < .001). Overall, pseudophakia had a lower all-cause mortality compared with the general Minnesota population (P < .001). CONCLUSIONS: In 2018, most residents aged 75 years and older were pseudophakic in at least 1 eye. These numbers underscore the changing visual status of older adults and the large number of adults who benefit from cataract surgery.

Cancer Risk in Patients With Fuchs Endothelial Corneal Dystrophy.

PURPOSE: The purpose of this study is to quantify cancer risk in patients with Fuchs endothelial corneal dystrophy (FECD). METHODS: Using the 2014 to 2016 Medicare Limited 5% Data Sets-Carrier Line File, US Medicare fee-for-service beneficiaries (aged 65 years or older) with FECD and cancer were identified through International Classification of Diseases , ninth and 10th Revision diagnostic codes from January 1, 2014, to December 31, 2016. The main outcome measures were odds ratios (ORs) of cancer at various anatomic locations in patients with versus without FECD. RESULTS: Of the 1,462,740 Medicare beneficiaries, 15,534 patients (1.1%) had an International Classification of Disease code for FECD. Compared with US Medicare beneficiaries without FECD, patients with FECD were at increased risk for the following malignancies: breast [OR: 1.32; 95% confidence interval (CI): 1.22-1.43; P < 0.001], cutaneous basal cell (OR: 1.42; 95% CI: 1.35-1.49; P < 0.001), cutaneous melanoma (OR: 1.20; 95% CI: 1.03-1.40; P = 0.02), cutaneous squamous cell (OR: 1.45; 95% CI: 1.38-1.53; P < 0.001), ovarian (OR: 1.84; 95% CI: 1.48-2.30; P < 0.001), and thyroid (OR: 1.32; 95% CI: 1.04-1.68; P = 0.02). By contrast, FECD cases were at lower odds of having lung (OR: 0.81; 95% CI: 0.71-0.93; P = 0.003) and prostate cancer diagnoses (OR: 0.88; 95% CI: 0.81-0.96; P = 0.002). CONCLUSIONS: Patients with FECD aged 65 years or older may be at increased risk for cancer at several anatomic locations. Follow-up studies are needed to further explore the association of FECD and malignancy, elucidate potential disease mechanisms, and identify genetic and/or environmental risk factors.

Outcomes of Patients With Active Diabetic Macular Edema at the Time of Cataract Surgery Managed With Intravitreal Anti-Vascular Endothelial Growth Factor Injections.

PURPOSE: To investigate the outcomes of cataract surgery in patients with active diabetic macular edema (DME) who are receiving active treatment with intravitreal anti-vascular endothelial growth factor (VEGF) injections in the perioperative period. DESIGN: Retrospective clinical cohort study. METHODS: We reviewed all patients who underwent cataract surgery and were receiving intravitreal anti-VEGF injections from January 1, 2012 through December 31, 2017. Thirty-seven eyes underwent cataract surgery and received ≥1 intravitreal anti-VEGF injection for a diagnosis of DME within 6 months before surgery. Outcome measures included the development of subretinal or intraretinal fluid in the 6 months after surgery, timing of injections, number of injections, best-corrected visual acuity, and central subfield thickness. RESULTS: There was a significant improvement between pre- and postoperative best-corrected visual acuity when comparing all eyes (Ps < .0001) and no significant difference in central subfield thickness before and after surgery (P > .05). There were 30 eyes (81.1%) that had fluid on the preoperative optical coherence tomography scan. Seventeen eyes (45.9%) developed new or worsening postoperative DME. Comparing the eyes that did or did not develop worsening DME, there were no differences in postoperative visual acuities (P > .05). Eyes that did develop new fluid had significant increases in postoperative central subfield thickness at both 1 month (350 vs 320 µm, P = .036) and 6 months (342 vs 305 µm, P = .013). CONCLUSION: In a real-world setting, patients with cataracts and actively treated DME may undergo cataract surgery but may see a worsening of DME not immediately affecting the best-corrected visual acuity.

Angle alpha orientation and magnitude distribution in a cataract surgery population.

PURPOSE: To report normative angle alpha orientation and magnitude distribution in a cataract surgery patient population. SETTING: U.S. academic medical center. DESIGN: Retrospective review. METHODS: A total of 11 871 wavefront aberrometer/corneal topographer angle alpha measurements were performed over 40 months, yielding 8773 bilateral measurements (73.9%) with zero bad wavefront datapoints. The analysis was limited to the first right-eye scan for 3382 unique patients. The angle alpha magnitudes (millimeters) and orientations (degrees) were analyzed for these unique right eyes. RESULTS: For the 3,382 unique patients, the mean angle alpha magnitude was 0.44 ± 0.15 mm (median, 0.44 mm; 25th and 75th percentiles 0.34 mm, 0.53 mm). Angle alpha orientation was predominantly horizontal (P < .01), with a mean of 186 ± 32 degrees. The expected point of intraocular lens (IOL) centration (EPIC) based on the geometric center of the corneal limbus was temporal to the visual axis in 3212 eyes (95%), nasal in 92 eyes (2.7%), inferior in 56 eyes (1.7%), and superior in 22 eyes (0.6%). The mean angle alpha magnitude was 0.3 mm or less in 607 eyes (18%) and 0.5 mm or greater in 1089 eyes (32%). CONCLUSIONS: Angle alpha is a predominantly horizontal phenomenon with a mean EPIC of 0.44 mm temporal to the visual axis. This information may assist in determining eligibility for patients in multifocal IOL implantation.

Visual and Anatomic Outcomes following Cataract Surgery in Patients with Pre-operative Macular Edema Due to Retinal Vein Occlusions Managed with Intravitreal anti-VEGF.

PURPOSE: The purpose of this study was to investigate the visual and anatomic outcomes in patients with macular edema due to retinal vein occlusions (RVO) who were actively managed with intravitreal anti-vascular endothelial growth factor (VEGF) before and after cataract surgery. METHODS: Retrospective, cohort study of all patients with RVO who underwent cataract surgery and were receiving intravitreal anti-VEGF injections from January 1st, 2012 through October 31st, 2018. There were 31 eyes that underwent cataract surgery and received at least one intravitreal anti-VEGF injection for a diagnosis of RVO within 6 months prior to surgery. Data collected included the development of subretinal or intraretinal macular fluid in the 6 months following surgery, timing of injections, number of injections, best corrected visual acuity (BCVA), and central subfield thickness (CST). RESULTS: There was a significant improvement between pre- and post-operative BCVA when comparing all eyes (p values < .0001) and no significant difference in CST before and after surgery (p > .05). Eyes without fluid pre-operatively saw an improvement in visual acuity, but with an initial significant increase in CST (p = .03) that normalized over time (p = .33) without an increase in frequency of anti-VEGF injections. CONCLUSION: Patients with cataracts who are actively managed for macular edema due to RVO with anti-VEGF agents may undergo cataract surgery, knowing they will have a transient increase in macular thickness that resolves without adjusting the frequency of intravitreal injections and is not visually significant.

Performance improvement system and postoperative corneal injuries: incidence and risk factors.

BACKGROUND: The authors' department conducted a performance improvement initiative aimed to reduce the rate of perioperative corneal injuries. This study reports the effects of the initiative and examines the risk factors for corneal injury. METHOD: The rate of corneal injuries during nonophthalmologic procedures under anesthesia was compared between the two time periods: preinitiative baseline (August 1, 2005-December 31, 2005) and initiative period (January 1, 2006-April 30, 2007). To examine the risk factors for corneal injury, a nested case-control study with a 2:1 matched-set design was separately performed and included cases between January 1, 2006 and July 31, 2008. RESULTS: During the baseline period, the corneal injury rate was 1.51 per 1,000, and it decreased to 0.79 per 1,000 during the performance initiative (P = 0.008). Independent risk factors were longer anesthetics (odds ratio = 1.2, 95% confidence interval (CI) 1.1-1.3 per 30 min), lower American Society of Anesthesiologists physical status (odds ratio 0.5, 95% CI 0.3-0.8 for American Society of Anesthesiologists physical status 3-4 vs. 1-2), and student nurse anesthetist as a primary anesthesia provider (odds ratio 2.6, 95% CI 1.3-5.0). CONCLUSION: Corneal injury rate in our institution was significantly reduced and remains at low levels long after initiation of perioperative eye care improvement initiative. The higher rate of corneal injuries among student nurse anesthetists highlights the importance of standardizing education and supervision among all anesthesia providers. We believe that our model of performance improvement initiative can be used to improve other perioperative outcomes.

Construct validity of anterior segment anti-tremor and forceps surgical simulator training modules: attending versus resident surgeon performance.

PURPOSE: To compare the performance of the anterior segment forceps and anti-tremor training modules of the EYESi surgical simulator (VRmagic) by residents and experienced attending surgeons using the simulator for the first time. SETTING: Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota, USA. METHODS: Twelve residents (4 per year) in the Mayo Clinic ophthalmology residency program and 3 experienced anterior segment surgeons participated. Each participant completed a total of 20 task trials on the EYESi forceps and anti-tremor level 4 training modules. Thus, the 15 participants completed a total of 300 task trials. RESULTS: For the forceps module, experienced surgeons achieved significantly better total scores (P = .03), with lower total task time (P = .007) and instrument-in-eye time (P = .006) measurements. For the anti-tremor module, experienced surgeons achieved significantly better total scores (P = .02), with lower task time (P = .04) and instrument-in-eye time (P = .02) measurements. In addition, experienced surgeons performing the anti-tremor task had 76% more precise surgical outcomes as measured by the out-of-tolerance percentage (P = .03). All forceps and anti-tremor-measured parameters indicated significantly lower performance (P< .05) for the first 1 or 2 trials, with the exception of anti-tremor module incision stress, out-of-tolerance percentage, and average tremor values. Experienced surgeons had more consistent (lower variance) total scores on the forceps (P = .05) and anti-tremor (P = .03) training modules. CONCLUSION: The EYESi surgical simulator anterior segment forceps and anti-tremor modules showed significant (P< .05) construct validity.

Racial/ethnic differences in rates of complex cataract surgery among United States Medicare beneficiaries.

PURPOSE: To determine racial/ethnic differences in rates of complex cataract surgery among United States Medicare beneficiaries. SETTING: Departments of Ophthalmology and Health Science Research, Mayo Clinic, Rochester, Minnesota, USA. DESIGN: Retrospective case series. METHODS: The U.S. Medicare 5% Limited Data Set, representing a 5% sample of over 28 million fee-for-service Medicare beneficiaries predominantly aged 65 years and older, were analyzed for rates of complex cataract surgery (Current Procedural Terminology [CPT] code 66982) among all beneficiaries who had cataract surgery (CPT codes 66982, 66984), stratified by race/ethnicity between January 1, 2014, and December 31, 2014. Associations were tested by using multivariate regression analysis. RESULTS: Data from approximately 1 087 680 Medicare beneficiaries were analyzed. After adjustment for age and sex, the likelihood of complex cataract surgery was significantly higher in African Americans (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.75-2.08), Asians (OR, 1.57; 95% CI, 1.34-1.85), and Hispanics (OR, 1.42; 95% CI, 1.18-1.71) than in whites among fee-for-service Medicare beneficiaries. Complex cataract surgery was more likely in men (OR, 1.83; 95% CI, 1.73-1.92) than in women, and the likelihood of complex cataract surgery increased in the elderly, with beneficiaries older than 84 years more likely to have complex surgery (OR, 2.68, 95% CI, 2.45-2.93) than beneficiaries aged 65 to 69 years. CONCLUSION: There were racial/ethnic differences in the likelihood of complex cataract surgery among fee-for-service Medicare beneficiaries; racial/ethnic minorities (Hispanics, Asians, and African Americans) were 42% to 90% more likely to have complex cataract surgery than whites.

Racial Differences in Age-Related Macular Degeneration and Associated Anti-Vascular Endothelial Growth Factor Intravitreal Injections among Medicare Beneficiaries.

PURPOSE: To determine racial and ethnic differences in age-related macular degeneration (AMD) and the use of anti-vascular endothelial growth factor (VEGF) injections for AMD among United States Medicare beneficiaries. DESIGN: Cross-sectional Medicare database study. PARTICIPANTS: 2014 United States fee-for-service Medicare beneficiaries. METHODS: The 2014 Medicare 5% Limited Data Set Standard Analytic Files, representing a 5% sample of approximately 28 238 660 fee-for-service Medicare beneficiaries 65 years of age and older, were used to identify all beneficiaries who received a diagnosis of AMD and who received intravitreal anti-VEGF injections for AMD, stratified by race, gender, and age. Logistic regression analysis determined racial differences in the likelihood of an AMD diagnosis and anti-VEGF treatment for AMD, adjusted for age and gender. MAIN OUTCOME MEASURES: Number of beneficiaries diagnosed with AMD in 2014 and number of beneficiaries who received anti-VEGF intravitreal injections for AMD in 2014. RESULTS: Among approximately 28 238 660 Medicare beneficiaries in 2014, 2 210 000 (7.8%) were diagnosed with AMD. Among beneficiaries with an AMD diagnosis, 360 640 (16.3%) received 1 or more anti-VEGF intravitreal injection for AMD. After adjustment for age and gender, an AMD diagnosis was 74% less likely in African Americans (odds ratio [OR] 0.26; 95% confidence interval [CI], 0.25-0.27), 44% less likely in Latinos (OR, 0.56; 95% CI, 0.53-0.60), and 19% less likely in Asian Americans (OR, 0.81; 95% CI, 0.77-0.85) than in white beneficiaries. Anti-VEGF injections for AMD were 86% less likely in African Americans (OR, 0.14; 95% CI, 0.12-0.16), 61% less likely in Latinos (OR, 0.39; 95% CI, 0.33-0.45), and 48% less likely in Asian Americans (OR, 0.52; 95% CI, 0.46-0.60) than in whites. Race- and gender-adjusted odds of both AMD and the use of anti-VEGF agents for AMD increased with age (P < 0.001). CONCLUSIONS: There are racial differences in the prevalence of an AMD diagnosis and in receiving anti-VEGF injections for AMD among fee-for-service Medicare beneficiaries 65 years of age or older. African Americans, Latinos, and Asian Americans were 19% to 74% less likely to have a diagnosis of AMD and were 48% to 86% less likely to receive an anti-VEGF intravitreal injection for AMD than in whites.

Outcomes of Cataract Surgery in Patients With Exudative Age-related Macular Degeneration and Macular Fluid.

PURPOSE: To investigate whether having macular fluid on optical coherence tomography (OCT) prior to cataract surgery adversely affected vision or anatomic outcomes after cataract surgery in patients with exudative age-related macular degeneration (AMD). DESIGN: Retrospective cohort study. METHODS: We examined all patients who underwent cataract surgery and were receiving intravitreal anti-vascular endothelial growth factor (anti-VEGF) injections from January 1, 2012 through December 31, 2016. There were 81 eyes that underwent cataract surgery and had received at least 1 intravitreal anti-VEGF injection for a diagnosis of exudative AMD within 6 months prior to surgery. Data collected included the development of subretinal or intraretinal macular fluid, or subretinal hemorrhage, in the 6 months following surgery; number of injections; best-corrected visual acuity (BCVA); and central subfield thickness (CST). RESULTS: There was a significant improvement between preopertive and postoperative BCVA when comparing all patients (P values < .0001) and no significant difference in CST before and after surgery (P > .05). There were 23 eyes with fluid on the preoperative OCT. There were no differences in final BCVA or CST and no difference in the development of fluid postoperatively when compared to patients without fluid preoperatively (all P values > .05). These patients also saw a significant improvement in BCVA (P = .006). CONCLUSION: In a real-world setting, patients with both cataracts and wet AMD may safely undergo cataract surgery. Patients with stable preoperative fluid on OCT should be considered for cataract surgery, as these patients did well postoperatively, with no worsening of their neovascular process.

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.

Late spontaneous haptic disinsertion from a three-piece intraocular lens.

PURPOSE: To report two cases of spontaneous, late-onset haptic disinsertion from a three-piece posterior chamber intraocular lens (IOL). DESIGN: Interventional case reports. METHODS: Two eyes of two patients had uncomplicated phacoemulsification and presented 16 and 20 years after surgery with spontaneous, nontraumatic haptic disinsertion from a three-piece IOL. RESULTS: In one case, the disinserted haptic dislocated into the anterior chamber while the IOL optic-single haptic complex remained centered and supported within the capsular bag. Cystoid macular edema was present, but resolved after removal of the disinserted haptic. In the second case, the disinserted haptic remained within the capsular bag while the IOL optic dislocated into the anterior chamber. Removal of the IOL and exchange with a sulcus-fixated single piece IOL was required. CONCLUSIONS: Nontraumatic haptic disinsertion from a three-piece IOL is a rare long-term complication after phacoemulsification.

Association between Industry Payments and Anti-vascular Endothelial Growth Factor Use in Medicare Beneficiaries.

PURPOSE: To test for associations between anti-vascular endothelial growth factor (VEGF) industry payments to ophthalmologists who provide intravitreal injections and specific anti-VEGF agent use. DESIGN: Cross-sectional Medicare database study. PARTICIPANTS: US fee-for-service Medicare beneficiaries and all ophthalmologists who submitted intravitreal injection claims for >10 Medicare beneficiaries between August 1, 2013, and December 31, 2013. METHODS: The Sunshine Act Open Payments database was searched for all industry financial relationships in ophthalmology. The Medicare Provider Utilization and Payment Database was searched for all intravitreal injection claims and anti-VEGF drug claims among fee-for-service Medicare beneficiaries. A novel algorithm was used to merge the 2 datasets to identify physician-specific associations between industry payments and specific anti-VEGF agent use. Odds ratios (ORs) and corresponding confidence intervals (CIs) were estimated by using logistic regression models. MAIN OUTCOME MEASURES: Ophthalmologists providing intravitreal injections (Current Procedural Terminology 67028); ophthalmologists with reported nonresearch payment from anti-VEGF industry; physician-specific anti-VEGF agent use (treatment specific J-codes J0178 and J2778). RESULTS: Of 3391 ophthalmologists who performed intravitreal injections, 1187 (35%) received nonresearch payments from anti-VEGF industry. Of these 1187 ophthalmologists, 422 (35%) received payments from Regeneron Pharmaceuticals, 363 (31%) received payments from Genentech, and 402 (34%) received payments from both industries. When compared with ophthalmologists who perform intravitreal injections and who do not receive anti-VEGF industry payments, ophthalmologists receiving Genentech payments (median, $90; interquartile range, $22-$149) were more likely to use ranibizumab (OR, 2.14; 95% CI, 2.12-2.16), those receiving Regeneron payments (median, $55; interquartile range, $22-$131) were more likely to use ranibizumab (OR, 1.55; 95% CI, 1.54-1.56) and aflibercept (OR, 1.23; 95% CI, 1.22-1.24), those with payments from both manufacturers were more likely to use ranibizumab (OR, 2.69; 95% CI, 2.67-2.71) and aflibercept (OR, 1.53; 95% CI, 1.52-1.54), and all were less likely to use bevacizumab (OR, 0.33-0.64; P < 0.001 for all comparisons). CONCLUSIONS: Industry payments to ophthalmologists who perform intravitreal injections were associated with higher odds of ranibizumab and aflibercept use, and lower odds of bevacizumab use. These findings reflect an association, not a cause-and-effect relationship.