A comparison of self-reported utilization of ophthalmic care for diabetes in managed care versus fee-for-service

PURPOSE

To assess the association between structural factors in the health care delivery system and self-reported utilization of ophthalmic services by patients with diabetes in the Medical Outcomes Study (MOS).

METHODS

Self-reported utilization of ophthalmic services within the 6 months preceding enrollment into the MOS among 522 of 567 individuals with diabetes in the MOS longitudinal panel was measured. Use of eye care services was regressed (logistic model) on patient demographics, geographic location, physician specialty, type of practice, and finance plan (prepaid or fee-for-service).

RESULTS

None of the variables was significantly associated with a higher or lower likelihood of having used ophthalmic services in the preceding 6 months. Thus, no difference between prepaid or fee-for-service plans or among solo practice, large multispecialty groups, or HMOs were identified. Having seen an internist, family practitioner, or diabetes specialist for diabetes care was not related to use of ophthalmic services.

CONCLUSIONS

Despite a presumed greater interest in preventive health, prepaid health plans were no more or less likely than the fee-for-service sector to have patients with diabetes reporting an eye examination within the prior 6 months. Thus, steps to improve the rate of eye examinations of diabetics may need to focus beyond the structural elements of the health care delivery system.

Subspecialty distributions of ophthalmologists in the workforce

OBJECTIVE

To describe the distribution of the supply and requirements for subspecialty ophthalmologists.

METHODS

Estimates from the Eye Care Workforce Study were used to provide subspecialty-based assessments of the supply and public health need, as well as market demand, for care provided by subspecialists. Reconciliation with the boundary models (optometry first, ophthalmology first) of the Eye Care Workforce Study and current market status also were performed.

RESULTS

Whether subspecialists are in excess depends first on which boundary model most closely approximates the current market conditions. Under an optometry-first model, 70% of all ophthalmologists are in excess, although subspecialists (39%) are relatively less in excess than comprehensive ophthalmologists (91% excess). Under an ophthalmology-first model, no ophthalmologists would be in excess. Extrapolating from current market conditions, a slight excess of ophthalmologists exists, probably proportional across subspecialists and comprehensive ophthalmologists. Future growth in the ophthalmologist supply will be almost entirely among subspecialists.

CONCLUSION

Under current market conditions, substantial excesses in subspecialist ophthalmologists are likely to develop and grow worse over time, given current training levels.

Trabeculectomy with intraoperative 5-fluorouracil

BACKGROUND AND OBJECTIVE

To investigate the outcome and complication rates of trabeculectomy following the combined use of intraoperative, topical 5-fluorouracil (5-FU) and low-dose, postoperative subconjunctival 5-FU injections.

PATIENTS AND METHODS

Forty-one eyes of 41 patients with advanced, medically uncontrolled glaucoma underwent trabeculectomy with intraoperative episcleral application of 5-FU (50 mg/ml for 5 minutes). A variable number of subconjunctival 5-FU injections were administered postoperatively at the discretion of the operating surgeon.

RESULTS

Six-, 12-, and 15-month life-table success rates (5 mm Hg < or = intraocular pressure [IOP < or = 21 mm Hg) were 100%, 97%, and 83%, respectively. Mean postoperative IOP was 12.1 +/- 4.3 mm Hg. An average of 2.2 +/- 1.6 (range 0 to 7) supplemental subconjunctival 5-FU injections were administered postoperatively. Corneal epithelial erosions developed in 7 (17%) of the eyes. Five of 7 patients who underwent subsequent surgical procedures maintained successful control of IOP at an average of 11.0 +/- 4.8 (range 5 to 16) months after the secondary surgery.

CONCLUSION

Trabeculectomy with intraoperative 5-FU is effective in controlling IOP while possibly minimizing the need for frequent postoperative injections and the occurrence of corneal epitheliopathy.

Work time estimates for ophthalmic diagnoses and procedures. Results from the Eye Care Workforce Study

OBJECTIVE

To provide estimates of patient-level annual ophthalmologist work times for the care of common ophthalmic conditions and patient-level global surgical care time for common or important ophthalmic procedures.

METHODS

A random sample of the domestic membership (excluding members-in-training) of the American Academy of Ophthalmology, stratified by self-designated practice concentration, was surveyed in 1994 to provide estimates of work times for common ophthalmic services.

RESULTS

Comprehensive and subspecialty-specific results were obtained for ophthalmic diagnoses, services, and surgical procedures. For ophthalmic diagnoses and services, initial and follow-up visit work times are reported for comprehensive and subspecialty ophthalmologists separately. For common surgical procedures, aggregate results based on comprehensive and subspecialist survey responses are reported.

CONCLUSIONS

These ophthalmology-specific survey results can be used for a variety of purposes, including practice management, "benchmarking," health plan administration and national workforce planning. Such surveys should be repeated as techniques and practice patterns change over time.

Neuroendocrinology of melatonin in reproduction: recent developments

The circadian melatonin rhythm with high levels in the dark period is important for the synchronization of reproductive response to appropriate environmental conditions in animals. The target sites of melatonin action on reproductive functions remain to be clarified. Using autoradiography (ARG) and radioreceptor binding assays with 2[125I]iodomelatonin, a melatonin agonist, as the radioligand, studies on the sites of melatonin action have increased significantly in the last ten years. The recent cloning of melatonin receptor subtypes also allowed the characterization of receptor(s) to the molecular level. Earlier reports have documented that the hypothalamic-pituitary axis plays a vital role in the regulation of reproduction by melatonin. This is supported in part by the demonstration of melatonin receptors in the suprachiasmatic nuclei (SCN) in the brain and pars tuberalis (PT) in the pituitary. However, the nature of SCN and PT involvement in the reproductive action of melatonin remains unknown. In addition to the hypothalamus and pituitary, the two classical sites of melatonin action, other targets have been identified. The recent demonstration of 2[125I]iodomelatonin binding sites or melatonin receptors in the testis, epididymis, vas deferens, prostate, ovary and mammary gland suggest the concept of multiple sites of melatonin action on the reproductive system. The presence of melatonin receptors in the said tissues is consistent with earlier reports of direct melatonin actions on different levels of the reproductive system. This multiple levels of melatonin action, from the hypothalamus, pituitary, gonads to other reproductive tissues form a robust system of photoperiodic control in animal reproduction. This would guarantee successful gestation and delivery of the offspring at a time with optimum food availability and ultimately favourable for the survival of species. Molecular and cellular studies of melatonin signaling system(s), its regulation and effects on downstream functional events in the future may provide new insights and directions for the study of the physiology and pharmacology of fertility and contraception in animals and humans.

Melatonin: a chemical photoperiodic signal with clinical significance in humans

Secretion of pineal melatonin exhibits a diumal rhythm and a seasonal rhythm in humans. Night-time melatonin is high at 3-5 year-old and decreases with age. Many drugs and pathological conditions also change melatonin levels in the circulation. Melatonin has a mild sedative effect and has been used effectively in synchronizing the sleep-wake cycle of patients with sleep disorders. Immunoenhancing, anti-cancer, anti-aging and anti-oxidant effects of melatonin have been proposed. Recent studies suggest that melatonin receptors are present in central and peripheral tissues. The importance of melatonin receptors on the nervous, reproductive, immune and renal functions is implicated. Studies on the molecular biology, physiology and pathology of melatonin receptors in different tissues are progressing rapidly. The physiological and pathological changes in melatonin secretion, multifarious melatonin actions, and diverse melatonin receptors reported suggest that melatonin is a photoperiodic signal with clinical significance in humans.

Demand-based assessment of workforce requirements for orthopaedic services

On the basis of an analysis of the supply of and demand for orthopaedic surgeons, we projected that there will be 21,134 full-time-equivalent orthopaedists in the year 2010 if training continues at current levels. We estimated a demand-based requirement of 17,012 full-time-equivalent orthopaedic surgeons, indicating a surplus of 4122 full-time equivalents. In terms of orthopaedist-to-population ratios, we estimated that there will be 7.5 full-time-equivalent orthopaedists per 100,000 population in 2010 compared with a demand-based requirement of 6.0 full-time equivalents. However, we did not include estimates of the demand for orthopaedic surgeons as assistants in the operating room in our model. If an assistant orthopaedic surgeon is required for all procedures, an additional 3906 full-time-equivalent orthopaedists would be demanded, thus eliminating the surplus. The demand for an assistant orthopaedic surgeon in only half of the procedures would still lead to a sizable reduction in the surplus.

Identifying the content area for the 51-item National Eye Institute Visual Function Questionnaire: results from focus groups with visually impaired persons

OBJECTIVE

To identify the content area for a questionnaire designed to measure vision-targeted health-related quality of life and to determine whether problems with vision-related functioning are qualitatively similar across different common eye diseases.

DESIGN

Twenty-six condition-specific focus groups were conducted with 246 patients from 5 geographic regions to identify the content area for a questionnaire for use among persons with diabetic retinopathy, glaucoma, macular degeneration, cytomegalovirus retinitis, and cataract. A standard protocol was used to structure each focus group discussion. Sessions were audiotaped, transcribed, and coded in preparation for a content analysis.

SETTINGS

Five university-based ophthalmology practices and 1 nonprofit eye care foundation.

PARTICIPANTS

Eligible participants had to have 1 of the following eye conditions: age-related cataracts, age-related macular degeneration, diabetic retinopathy, primary open angle glaucoma, cytomegalovirus retinitis, or low vision from any cause. All eligible persons were older than 21 years, spoke English, and had sufficient cognitive function to provide informed consent.

RESULTS

Among the 246 participants, 2623 problems with vision-related functioning were mentioned. The mean number of problems per person ranged from 13.5 for those with diabetic retinopathy to 7.9 for persons with glaucoma. For the sample overall, reading problems were mentioned most frequently, followed by driving, general problems with seeing clearly, and mental health complaints caused by vision. Although the proportion of persons who reported each problem varied by condition, at least some persons with each eye disease reported each problem. The 3 most common descriptors associated with each problem were difficulty or ease of performance (13%), psychological distress associated with performance of the activity (11%), and complete inability to participate in a visual activity (11%).

CONCLUSION

An item-generation strategy for a new questionnaire using a standardized focus group method identified content areas and aspects of visual disability that are not included in currently available vision-specific instruments that assess the impact of common eye diseases on visual functioning in every-day life. Although participants mentioned problems that were unique to their disease, across conditions the problems mentioned were similar. These findings provide empirical evidence of content validity for a vision-targeted, health-related quality-of-life survey designed for use across conditions.

Literacy levels of ophthalmic patient education materials

Health care providers have become increasingly aware of poor patient understanding of their illnesses and their treatments. A major, increasingly recognized factor in poor understanding and compliance is the low literacy skills of 90 million Americans. This article reviews the literature on the relationship between patients' literacy skills and the literacy levels required to read educational health care materials, and applies a similar analysis to commonly used ophthalmic patient-educational materials. Understanding the relationships between patient literacy skills and health care utilization will be critical in improving the efficiency of the health care system.

T helper 2-dominant antilymphoma immune response is associated with fatal outcome

The precise role of the endogenous immune system in modulating cancer development remains unclear. Tumor cells are generally thought to be nonimmunogenic because they are of 'self' origin. However, tumor-reactive lymphocytes can be isolated from patients with many types of cancer. It is unclear what role these lymphocytes play and why they fail to protect the host. Using a murine B-cell leukemia/lymphoma (BCL1) model, we showed the development of a vigorous antitumor T-cell response in the tumor-susceptible host. Specific T-cell responses against BCL1 developed as early as day 4. However, the nature of this nonprotective response is different from the protective response produced in a major histocompatibility complex-matched tumor-resistant host. Susceptible hosts developed a T helper 2 (Th2)-dominant response, whereas resistant hosts developed a Th1-dominant response to BCL1. Cytolytic activity against BCL1 developed in both resistant and susceptible hosts, but in the susceptible host, this response was weaker and delayed compared with that in the resistant host. Thus, tumor susceptibility does not necessarily mean the absence of an antitumor immune response. Rather, the nature of the antitumor immune response is critical in determining clinical outcome.

Evidence for an ATP-dependent bile acid transport protein other than the canalicular liver ecto-ATPase in rats

BACKGROUND & AIMS

Canalicular secretion is rate limiting in overall blood-to-bile transport of bile acids. Studies using transfected cells have implicated the canalicular ecto-adenosine triphosphatase (ecto-ATPase) in adenosine triphosphate (ATP)-dependent bile acid transport. However, the structural features of this ecto-ATPase are not those anticipated for an in-to-out ATP-dependent transporter. The aim of this study was to explore the possible existence of an ATP-dependent bile acid transport mechanism distinct from ecto-ATPase.

METHODS

Bile acid transport activity and ecto-ATPase expression were analyzed in primary rat hepatocytes, rat hepatoma HTC cells, and specially adapted HTC (HTC-R) cells using plasma membrane vesicles and Northern blot, slot blot, ribonuclease protection assay, and Western blot analyses.

RESULTS

Plasma membranes isolated from HTC-R cells exhibited ATP-dependent taurocholate transport, which was many-fold greater than that in HTC cells. Hepatocytes showed the highest transport rates. Protein and RNA analyses showed very low expression of ecto-ATPase in HTC and HTC-R cells compared with hepatocytes. There was no difference between the two cell types at both the RNA and protein level.

CONCLUSIONS

These findings show the presence in HTC-R cells and, apparently in hepatocytes, of one or more proteins other than the ecto-ATPase that mediate ATP-dependent transport of bile acids.

Glaucoma associated with uveitis

Raised intraocular pressure is a common and frequently serious complication of anterior uveitis. The milieu of inflammatory cells, the mediators they release, and the corticosteroid therapy used to treat the uveitis can participate in the pathogenesis of uveitic glaucoma. These factors alter the normal anatomic structure of the anterior chamber and angle, influencing aqueous production and outflow. These changes act to disrupt the homeostatic mechanisms of intraocular pressure control. Structural changes in the angle can be acute, such as in secondary angle closure with pupillary block glaucoma, or chronic, such as combined steroid-induced and secondary open angle glaucoma. Management of uveitic glaucoma may be difficult because of the numerous mechanisms involved in its pathogenesis. Diagnostic and therapeutic decisions are guided by careful delineation of the pathophysiology of each individual case. The goal of treatment is to minimize permanent structural alteration of aqueous outflow and to prevent damage to the optic nerve head. This article reviews the pathogenesis of uveitic glaucoma, with specific attention to etiology. Medical and surgical therapies are also discussed, with emphasis on the more recent developments in each category.

The impact of blurred vision on functioning and well-being

OBJECTIVE

To determine the impact of blurred vision on functional status and well-being, the authors used a cross-sectional analysis of Medical Outcomes Study (MOS) 2-year follow-up data.

METHODS

One thousand six hundred forty-two respondents were asked to report how often they experienced blurred vision not correctable by glasses or contact lenses, as well as other various symptoms, at the 2-year follow-up. Participants completed the SF-36, a general functioning and well-being instrument. Demographic, medical, and other data also were collected. The association of these symptoms, including blurred vision, and tracer medical conditions with SF-36 scores were evaluated.

RESULTS

The unique impact of blurred vision on role limitations due to physical health problems was significantly greater than the impact of hypertension, history of myocardial infarction, type II diabetes mellitus, indigestion, trouble urinating, and headache. Blurred vision also had a significantly greater negative impact on energy than Type I diabetes mellitus, on social function than indigestion, and on physical functioning than trouble urinating.

CONCLUSIONS

Having blurred vision more than once or twice a month has a detectable and significant impact on functional status and well-being, especially in role limitations due to physical health problems. This demonstrates the impact of a common visual symptom on health status and well-being, as measured by the SF-36. In addition, comparison of the impact of various symptoms and conditions provides important and potentially clinically relevant information.

Annular peripheral choroidal detachment simulating aqueous misdirection after glaucoma surgery

PURPOSE

The purpose of the study was to define a newly recognized complication after glaucoma surgery and to recommend a therapeutic regimen.

METHODS

Eighteen patients diagnosed initially as having aqueous misdirection after glaucoma surgery, but who subsequently were found by ultrasonography to have an annular peripheral choroidal detachment that resulted in secondary angle closure glaucoma, were studied. Ten of these patients were treated with topical cycloplegics and corticosteroids, and 8 were treated with drainage of suprachoroidal fluid. Outcomes of these two treatment methods were compared.

RESULTS

Annular peripheral choroidal detachment reliably was diagnosed with ultrasonography. Of the variables studied, time elapsed before resolution of the annular peripheral choroidal detachment was noted to be statistically significant (P < 0.00005). Immediate resolution followed drainage of suprachoroidal fluid, whereas a mean of 19.6 days was required for resolution after medical therapy.

CONCLUSIONS

Annular peripheral choroidal detachment should be considered in the differential diagnosis of a flat or shallow anterior chamber with normal or high intraocular pressure after glaucoma surgery. The diagnosis of annular peripheral choroidal detachment can be confirmed most reliably by ultrasonography. Medical therapy is as effective as is surgery, although a significantly longer time to resolution is required.

Functional associations of "trouble seeing"

The purpose of this study was to determine how vision problems affect health status. The information was collected in 1990 from 2,249 household heads and spouses over 50 years of age during an annual survey of a nationally representative sample that was adjusted for attrition and nonresponse. Vision problems were defined as "trouble seeing (even with glasses or contact lenses)." Health status was measured principally with the Medical Outcomes Study Short-Form 36. Regression analyses found a significant relationship between "trouble seeing" and each of five health-status domains. We conclude that it may not be appropriate to require specific functional limitations as a precondition for cataract surgery and that instruments for measuring functional disabilities related to vision should include more general questions.

An oligonucleotide blocks interferon-gamma signal transduction

Interferon (IFN)-gamma is an important mediator of transplant graft rejection. It induces endothelial cell expression of HLA-DR and intercellular adhesion molecule-1, which render transplant grafts more susceptible to rejection by the host. Oligonucleotide 5'-GGG GTT GGT TGT GTT GGG TGT TGT GT-RNH2 (oligo I) blocks multiple IFN-gamma effects in human K562 cell cultures. A systematic approach revealed that oligo I has a novel, and potentially important, mode of action--it blocks the binding of IFN-gamma to its receptor, thus preventing activation of the IFN-gamma signal transduction pathway. The results are consistent with an aptamer mechanism of action, because oligo I exerts its inhibitory effects by interacting with protein, not intracellular nucleic acid targets, such as mRNA or genomic DNA.

Use of eye care services among the 1991 Medicare population

PURPOSE

To determine the use of eye care services by type of provider (ophthalmologist, optometrist, and non-ophthalmologist physician) in the Medicare population.

METHODS

As a basis for characterizing eye conditions and ophthalmic services among a population 65 years of age and older, 1991 claims from a representative 5% sample of Medicare beneficiaries were analyzed using a previously described classification scheme. Analysis was specifically conducted by type of provider as well as by the service provided.

RESULTS

Almost one half of the approximately 30 million Medicare beneficiaries 65 years of age or older received eye care services in 1991, resulting in more than 35,000,000 visits (claims). Ophthalmologists provided services to 71% of this eye care population, and optometrists to 22%; 36% of this population received ophthalmic-related services from other providers, and 14% from only other providers (commonly for eye lid dermatitis and tumors). Cataract was the most common condition, accounting for 41% of visits to ophthalmologists (and 1.2 million cases of surgery), glaucoma accounted for 19% of visits, and retinal diseases for 14%. The visit percentages for optometrists are 58%, 8%, and 11%, respectively. Ophthalmic examination and evaluation accounted for 63% of the 28,000,000 paid ophthalmologists' procedures, and 58% of the 5,500,000 optometrists' procedures.

CONCLUSION

Optometrists and physicians other than ophthalmologists were the sole providers of ophthalmic-related services to a large percentage of beneficiaries who received eye care in 1991. Within the universe of service provided by ophthalmologists, the majority of all care consisted of evaluation and management services as opposed to surgical procedure-based care.

Sensitivity, specificity, and predictive values of screening tests for eye conditions in a clinic-based population

PURPOSE

To assess four commonly available visual function tests to detect visually disabling or vision-threatening eye conditions among new patients of a large, urban, public, general ophthalmology clinic.

METHODS

Three hundred seventeen patients were tested for contrast sensitivity, Amsler grid abnormalities, and visual acuity at near and at distance. A complete eye evaluation found the prevalence of serious eye diseases, allowing determination of the sensitivity (Sn), specificity (Sp), likelihood ratio (LR), and other characteristics of each test.

RESULTS

Of 317 patients, most were Hispanic (77%), women (60%), and middle-aged (44 +/- 17 years). Normal findings were reported in 18%; refractive error in 43%; cataracts in 16%; glaucoma in 7.3%; and macular degeneration in 4.1%. Near visual acuity of 20/40 or worse (Sn = 0.75; Sp = 0.74; LR = 2.8); and distance visual acuity testing of 20/30 or worse (Sn = 0.74; Sp = 0.73; LR = 2.7) correlated significantly with ocular disease, whereas contrast sensitivity testing (Sn = 0.62; Sp = 0.41; LR = 1.1) and Amsler grid test (Sn = 0.19; Sp = 0.92; LR = 2.4) did not. Test performance decreased when refractive errors were excluded and among those younger than 40 years of age relative to those 40 years of age or older.

CONCLUSION

Of the four screening tests studied, distance and near threshold visual acuities as defined above were judged to have the best correlations of an abnormal result with ocular disease, both including or excluding refractive error. Different combinations of tests did not result in more accurate detection of ocular disease. More efficient screening tools for detecting ocular disease need to be developed.

Documentation patterns before cataract surgery at ten academic centers

PURPOSE

To determine the adequacy of documenting the preoperative evaluation for cataract surgery using criteria derived from published practice guidelines.

METHODS

In 1990, 1139 surgeries that were performed on 1139 patients at ten institutions of the Academic Medical Center Consortium were reviewed for completeness of documentation of the preoperative evaluation. Criteria for completeness were derived from the American Academy of Ophthalmology Preferred Practice Pattern on cataract evaluation and the Agency for Health Care Policy and Research-sponsored guidelines.

RESULTS

Twenty-six percent of charts lacked documentation of at least one of four basic elements of the preoperative evaluation. These four elements are (1) vision in the surgical eye; (2) vision in the fellow eye; (3) evaluation of the fundus, macula, or visual potential in the surgical eye: and (4) presence of some form (general or specific) of functional visual impairment. If, as stated in the guideline, a specific deficit in visual functioning should be identified, then 40% of charts fail to meet criteria.

CONCLUSION

Documentation of the ocular preoperative assessment for cataract surgery is inadequate in more than one quarter of cases. The relation between lack of documentation and incompleteness of the examination is unknown. Improved documentation is needed to better measure and enhance the quality of care.

Glaucoma care and conformance with preferred practice patterns. Examination of the private, community-based ophthalmologist

BACKGROUND

Practice guidelines are becoming more prominent in the provision of medical care. A previous study demonstrated a high rate of conformance with recommended patterns of care for patients with open-angle glaucoma in an academic, public clinic setting. This study seeks to examine conformance within the private, community-based setting in which the vast majority of healthcare is delivered.

METHODS

One-hundred ninety-three charts (average, 24 charts each from 8 different practices) of patients who received diagnoses for at least 2 years of open-angle glaucoma were evaluated retrospectively for conformance with recommendations from the American Academy of Ophthalmology's Preferred Practice Pattern (PPP) for primary open-angle glaucoma. The criteria were evaluated in three areas: (1) the performance of specified examination steps at the initial visit; (2) the performance of specified examination steps at follow-up; and (3) the time interval between follow-up visits.

RESULTS

In 56.4% of patients who had stable moderate to severe glaucomatous damage, documentation of examination findings on the initial visit ranged from 39.4% for a pupil examination to 100% for intraocular pressure. At the initial visit, visual fields were obtained or scheduled in 90.2% of eyes, gonioscopy was performed in 51.3%, and the disc/nerve fiber layer status was noted in 97.9%. On follow-up, 44% of patients had documentation concerning the status of their glaucoma, but only 23.3% of patients had an optic nerve head drawing or photograph within 15 months of the most recent visit. In addition, the authors found that 37.8% of patient charts had neither an optic nerve head drawing nor a photograph documented after the initial visit. Finally, although 92.2% of patients with glaucoma were scheduled for follow-up within the time intervals recommended by the PPP, patients with uncontrolled or unstable glaucoma were the least likely to be followed up within PPP-recommended time intervals.

CONCLUSIONS

Chart reviews from private, community-based ophthalmologists show that some initial examination steps such as gonioscopy and pupil examination are performed to widely varying degrees. While patients are generally likely to be scheduled for follow-up within PPP-recommended intervals, patients with unstable glaucoma are the least likely to be so scheduled. In addition, the visual appearance of the optic nerve is recorded for a relatively low percentage of patients. Additional data are needed from other geographic areas and other practice settings and for other patterns of care to more fully assess provider behavior relative to PPPs.

Cataract surgery after trabeculectomy

BACKGROUND AND OBJECTIVE

To determine the effect of cataract surgery on glaucomatous eyes with good intraocular pressure (IOP) control after trabeculectomy.

PATIENTS AND METHODS

Twenty-two eyes with functional blebs that underwent cataract extraction were retrospectively analyzed.

RESULTS

The mean (+/- SD) preoperative IOP was 11.0 +/- 4.3 mm Hg. The mean (+/- SD) postoperative IOPs at 1, 2, 6, and 9 months were 15.5 +/- 4.9, 12.6 +/- 4.7, 14.6 +/- 5.6, and 19.0 +/- 7.9 mm Hg, respectively. At each interval except for the second month, the mean IOP was statistically significantly higher than the preoperative value (P = .0003, .24, .02, and .0009, respectively). The total number of medications was also higher (3 preoperatively versus 27 postoperatively). The interval between the two surgeries had no influence on IOP control. Intraoperative complications during cataract surgery, particularly vitreous loss, were associated with poor IOP control. Phacoemulsification had less of an effect on the postoperative IOP control than did extracapsular cataract extraction.

CONCLUSIONS

Eyes with previous successful trabeculectomies had higher IOPs and required more medications after subsequent cataract surgeries.

Suprachoroidal hemorrhage after Molteno implantation

PURPOSE

The objective of this study is to identify the rate and the associated risk factors for suprachoroidal hemorrhage (SCH) after Molteno drain implantation.

METHODS

Data from the Molteno pilot study and single versus double-plate Molteno study were reviewed retrospectively for the occurrence of SCH. Follow-up intervals, demographic variables, ocular data, and medical history were collected.

RESULTS

SCH occurred in 6% of the patients enrolled in the Molteno studies; all cases were delayed and none were intraoperative. Significantly associated factors in a multiple logistic regression for SCH were the extent of intraocular pressure (IOP) drop after surgery, the post-operative IOP, a diagnosis of angleclosure glaucoma, and possibly the number of prior surgeries as well. Eyes with SCH did significantly less well in terms of visual acuity outcomes and were more likely to have inadequately controlled IOP.

CONCLUSIONS

This study suggests that SCH occurs at the same frequency after Molteno implantation as after filtering surgery with antimetabolite use and that eyes with SCH do less well.