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Cole Eye Institute
2012
Outcomes
Measuring Outcomes Promotes Quality Improvement
Measuring and understanding outcomes of medical treatments promotes
quality improvement. Cleveland Clinic has created a series of Outcomes
books similar to this one for its disease-based institutes. Designed for a
physician audience, the Outcomes books contain a summary of many of
our surgical and medical treatments, with data on patient volumes and
outcomes and a review of new technologies and innovations.
The Outcomes books are not a comprehensive analysis of all treatments
provided at Cleveland Clinic, and omission of a particular treatment does
not necessarily mean we do not offer that treatment. When there are no
recognized clinical outcome measures for a specific treatment, we may
report process measures associated with improved outcomes. When process
measures are unavailable, we may report volume measures; a relationship
has been demonstrated between volume and improved outcomes for many
treatments, particularly those involving surgical techniques.
In addition to these institute-based books of clinical outcomes, Cleveland
Clinic supports transparent public reporting of healthcare quality data and
participates in the following public reporting initiatives:
• Joint Commission Performance Measurement Initiative (qualitycheck.org)
• Centers for Medicare & Medicaid Services (CMS) Hospital Compare (hospitalcompare.hhs.gov)
• Ohio Department of Health (ohiohospitalcompare.ohio.gov)
• Cleveland Clinic Quality Performance Report (clevelandclinic.org/QPR)
Our commitment to transparent reporting of accurate, timely information
about patient care reflects Cleveland Clinic’s culture of continuous
improvement and may help referring physicians make informed decisions.
We hope you find these data valuable, and we invite
your feedback. Please send your comments and
questions via email to:
[email protected] or scan here.
To view all our Outcomes books, please visit Cleveland Clinic’s Quality and
Patient Safety website at clevelandclinic.org/outcomes.
Dear Colleague:
Welcome to this 2012 Cleveland Clinic Outcomes
book. We distribute Outcomes books for more than
14 specialties. These publications are unique in
healthcare. Each one provides a summary overview
of medical or surgical trends, innovations, and
clinical data for a Cleveland Clinic specialty over
the past year.
Cleveland Clinic uses data to manage outcomes
across the full continuum of care. Clinical services
are delivered through patient-centered institutes,
each based around a single disease or organ
system. Institutes combine medical and surgical
services, along with research and education, under
unified leadership. The individual institute defines
quality benchmarks for its specialty services and
reports longitudinal progress.
All Cleveland Clinic Outcomes books are available
in print and online. Additional data are available
through our online Quality Performance Report
(clevelandclinic.org/QPR). The site offers process
measure, outcome measure, and patient experience
data in advance of national and state public
reporting sites.
Our practice of releasing annual outcomes reports
has received favorable notice from colleagues,
media, and healthcare observers. We appreciate
your interest and hope you find this information
useful and informative.
Sincerely,
Delos M. Cosgrove, MD
CEO and President
what’s inside
Chairman’s Letter
04
Institute Overview
05
Quality and Outcomes Measures
Cataract Surgery 08
Cornea Surgery
12
Glaucoma Surgery
15
Oculoplastic Surgery
18
Ocular Oncology Surgery
20
Refractive Surgery
22
Vitreoretinal Surgery
26
Strabismus Surgery
30
Institute Patient Experience
33
Cleveland Clinic — Improving Quality, Safety, and the Patient Experience
34
Innovations40
Selected Publications
42
Staff Listing
48
Contact Information
50
Institute Locations
51
About Cleveland Clinic
52
Resources 54
Prefer an e-version?
Visit clevelandclinic.org/OutcomesOnline, and
we’ll remove you from the hard copy mailing list
and email you when next year’s books are online.
Chairman’sLetter
Letter
Chairman
Dear Colleagues,
I am pleased to share the 2012 Outcomes from Cleveland Clinic
Cole Eye Institute with referring physicians, alumni, and potential
patients across the country.
The future of electronic health records (EHR) is now. Cole Eye
Institute continues to be a national leader in EMR implementation,
and current versions offer physicians and patients robust access to
ophthalmic imaging and clinical data. In 2012, we began to use
our EMR to report integrated outcomes data. Our goals for the
EMR are to optimize clinical efficiency and to use it as a tool to
implement quality measures and best practices systemwide. Our
world-class EMR system is further proof of our commitment to
innovation, discovery, and the best in patient care.
Our staff and services continued to grow last year. We welcomed a new retina specialist and a pediatric
ophthalmologist to our practice, and 2012 saw an increased migration of our retina and other subspecialists in
to our community locations. This geographic expansion of our ophthalmology practice increases patient access
to our services — another example of Cleveland Clinic’s dedication to putting patients first.
In 2012, we had our most productive year ever. Across Cleveland Clinic in Northeast Ohio, we conducted
241,264 physician visits and performed 12,742 surgeries. In reporting our outcomes data, we relied on two key
assessment measures: visual acuity, using Early Treatment of Diabetic Retinopathy Study protocol refraction, and
surgical complication rates.
On behalf of my colleagues, I hope that you find this edition of the Cole Eye Institute Outcomes book informative
and useful.
Daniel F. Martin, MD
Chairman, Cole Eye Institute
4
Outcomes 2012
Institute Overview
Cleveland Clinic Cole Eye Institute is a center of excellence
for highly specialized ophthalmologic care and research,
with a reputation for innovation and superior outcomes. Its
patient volume is among the highest of any eye program
in the United States. Cleveland Clinic’s ophthalmology
program is rated No. 9 in the U.S. News & World Report
“America’s Best Hospitals” survey.
Spearheading Research, Innovation
Cole Eye Institute staff members aggressively pursue
research to bridge the gap between laboratory and patient
care. The institute’s ophthalmologists are national leaders in
clinical trials for age-related macular degeneration and have
pioneered comparative effectiveness research in heading
the Comparison of Age-Related Macular Degeneration
Treatments Trials (CATT).
Vitreoretinal Conditions
Surgical procedures developed by the institute’s vitreoretinal
faculty are used worldwide for the treatment of retinal
detachments, diabetic macular edema, diabetic traction
detachments, macular holes, and pediatric retinal surgery.
Cole Eye Institute experts are also helping develop the next
generation of vitreoretinal surgical devices. They utilize
advanced retinal imaging devices such as next-generation
spectral domain optical coherence tomography. Cole Eye
Institute retina specialists provide access to the latest
clinical trials for patients who are in the early stages of
age-related macular degeneration, those who have failed
standard medical therapy, and those with macular edema
from diabetes or vein occlusion.
Glaucoma
Cole Eye Institute is among the first academic centers to
customize an electronic medical record for ophthalmic use.
The two-year project allowed Cole Eye Institute staff across
the system to share this type of record by the end of 2012.
The electronic medical record integrates ophthalmic imaging
and provides full access to patient histories for maximal
clinical efficiency. It also streamlines data collection and
allows quality measures to be adopted systemwide.
Cole Eye Institute glaucoma specialists employ automated
visual field testing, retinal nerve fiber layer photography,
stereoscopic disc photography, and computerized optic
disc analysis in the diagnosis of primary, secondary, or
complicated glaucoma. They offer patients of all ages access
to the latest treatments: topical medications, glaucoma
implants, mitomycin C, glaucoma filtration surgery, cataract
surgery, combined glaucoma/cataract surgery, and laser
surgery (argon, Nd:YAG, and pulsed-dye).
Cornea and External Diseases
Keratorefractive Surgery
The Cornea and External Diseases staff performs more
than 1,800 cataract surgeries each year. They also offer
advanced procedures such as Descemet’s stripping
automated endothelial keratoplasty, deep anterior lamellar
keratoplasty, and highly specialized transplant procedures.
Cole Eye Institute surgeons use a leading-edge excimer laser
system for customized treatment of myopia, hyperopia, and
astigmatism. The institute’s keratorefractive surgeons rely on
advanced laser technologies that offer increased accuracy
and faster healing, including all-laser or “bladeless” LASIK
and photorefractive keratectomy.
Cole Eye Institute
5
Institute Overview
Neuro-Ophthalmology
Ophthalmic Oncology
The institute’s neuro-ophthalmologists are experts in optic
nerve disorders, visual field loss, unexplained or transient
vision loss, diplopia, nystagmus, thyroid eye disease,
ocular myasthenia gravis, unequal pupil size, and eyelid
abnormalities. They collaborate with Cleveland Clinic
Neurological Institute specialists on patient care
when needed.
Cole Eye Institute oncologists treat uveal melanoma and
other ocular tumors using advanced techniques such as
radioactive plaque therapy to preserve vision. A technique
they have developed for resecting circumscribed iris
tumors utilizes gentle aspiration through a small corneal
incision to reduce morbidity. Ophthalmic oncologists
collaborate with Taussig Cancer Institute and other
Cleveland Clinic specialists on research projects to
improve the outlook for these diseases.
Pediatric Ophthalmology/Strabismus
Cole Eye Institute pediatric specialists offer expert
treatment for strabismus, retinopathy of prematurity, and
congenital cataracts. They perform about 200 surgical
procedures annually for esotropia, exotropia, thyroid eye
disease, cranial nerve palsies, dissociated deviations,
hypertropia and hypotropia, Duane and Brown syndromes,
nystagmus, and related conditions.
Oculoplastics
Cole Eye Institute oculoplastic specialists perform more
than 900 eyelid, lacrimal (tear duct), and orbital surgery
procedures annually. Complex procedures performed
include repairs of orbital fractures, ptosis, and
lacrimal obstruction.
6
Uveitis
Cole Eye Institute specialists are international leaders
in the diagnosis and management of uveitis. They
collaborate with rheumatologists and other Cleveland
Clinic specialists when uveitis signals a systemic immune
disorder, offering topical therapy, antibiotics, or other
medications along with careful follow-up to prevent/
manage relapses and to minimize vision damage.
Genetic Eye Diseases
Cole Eye Institute’s Center for Genetic Eye Diseases
is an international referral center for multidisciplinary
diagnosis, treatment, and research. Specialists care for
patients with inherited corneal and retinal dystrophies
and microphthalmia, as well as patients with inherited
systemic disorders that involve the eye such as
neurofibromatosis, albinism, neurodegenerative disorders,
and Marfan syndrome.
Outcomes 2012
Serving the Northeast Ohio Community
Cole Eye Institute offers comprehensive specialty ophthalmic
care in a modern building equipped with advanced
technology and designed for patient comfort. High-quality
ophthalmic care is also offered at five Cleveland Clinic
community locations. Comprehensive general ophthalmology
and retina services are provided at Hillcrest Hospital in
Mayfield Heights and at Twinsburg Family Health and
Surgery Center. Ophthalmologists are on call 24/7 for
emergency care across the system. Cole Eye Institute
specialists also provide all retina services for MetroHealth
Medical Center in Cleveland.
Research
Cole Eye Institute is heavily engaged in research, with
an aggregate annual grant level of $10,617,150 for
2011–2012, including $5,843,450 from federal sources
for basic research and $1,650,000 annually for clinical
research. This funding helps both basic and clinical
researchers better understand ophthalmic conditions and
pioneer new treatments and techniques that will improve
visual outcomes. Major research initiatives underway
include those in the areas of age-related macular
degeneration, diabetic retinopathy, retinal degeneration,
and retinopathy of prematurity.
In 2012, Cole Eye Institute researcher Brian Perkins, PhD,
received the prestigious Jules and Doris Stein Professorship
for the study of the genetics of retinal ciliopathies. The
award, bestowed by Research to Prevent Blindness, helps
attract exceptionally talented basic scientists to careers
devoted to eye research.
2012 Cole Eye Institute Key Statistics
Total Clinic Visits | 182,663
Total Surgeries | 8,054
Total Surgical Procedures | 10,020
(surgeries in operating
rooms and all outpatient
procedures)
Total Laser Procedures | 1,807
Cole Eye Institute
7
Cataract Surgery
Cataract Surgery
Cataract Surgery
Cataract Surgery
8
Cataract surgery is the most commonly performed surgical
procedure in ophthalmology and thus represents a significant
proportion of the surgical caseload at Cleveland Clinic’s Cole
Eye Institute. From October 2011 through September 2012, a
total of 1,882 cataract extraction procedures were performed.
The goal of cataract surgery is improvement of visual acuity,
which is accomplished for the vast majority of patients at Cole
Eye Institute. There was a 94% improvement with ≥ 15 letter
improvement in ETDRS (Early Treatment Diabetic Retinopathy
Study) protocol refraction visual acuity in 42% of patients at
their one-month follow-up, and 52% of patients had a 1 to 14
letter improvement. The remaining 5.7% had no change or a
decrease from baseline status.
The overall improvement in vision was seen in patients with a
cataract condition; some also may have had other disorders of
the eye, such as glaucoma, retina disease, or anterior segment
disease. A significant number of the institute’s cataract
patients have multiple clinical morbidities. In patients without
other eye disease, the mean visual acuity score with best
glasses correction following surgery was 79 ETDRS letters,
corresponding to nearly 20/20 vision.
Outcomes 2012
Complications During Cataract Surgery (N = 1,882)
October 2011 – September 2012
1.87% Complications:
0.64% Posterior Capsule Tear
0.11% Zonular Dialysis
0.48% Vitreous Loss
0.21% Retained Lens
0.11% Choroidal Hemorrhage
98.13% None
0.32% Iris Trauma
Intraoperative complications during cataract surgery were uncommon, occurring in only 1.87%
of patients. The most common complication was a capsular tear, reported in 0.64% of patients,
most of whom ended up with excellent vision.
Postoperative Complications (N = 844)
October 2011 – September 2012
0.36% Complications:
0.24% Retina-Related
0.12% Pressure-Related
99.64% None
Postoperative complications also were rare, occurring in less than 1% of patients. The most
common complication was cystoid macular edema.
Cole Eye Institute
9
Cataract Surgery
Difference Between Actual and Target Refractive Error
October 2009 – September 2010
October 2010 – September 2011
October 2011 – September 2012
Patients (%)
80
Most patients achieved a refractive outcome
following cataract surgery that was near the
anticipated refractive error. Despite the large
number of patients with other conditions
that can influence refractive outcome, or the
accuracy in measuring the final refractive
error, 88% of patients achieved a final
spherical equivalent refractive error within
1 diopter of the expected result.
2009-10 (N = 696)
2010-11 (N = 763)
2011-12 (N = 595)
60
40
20
0
< -2
-2 to -1
-1 to 0
0 to +1
+1 to +2
> +2
Diopters
Visual Acuity by Ocular Comorbidity
October 2009 – September 2010
October 2010 – September 2011
October 2011 – September 2012
ETDRS* Visual Acuity Score
100
2009-10 Preop
2009-10 Postop
2010-11 Preop
2010-11 Postop
2011-12 Preop
2011-12 Postop
80
60
40
20
0
None
Cornea
Glaucoma
Retina
Other
Ocular Comorbidities
N=
857 623 600
47 29 26
51 55 24
125 69 37
31
15 14
*Early Treatment Diabetic Retinopathy Study
10
Outcomes 2012
ETDRS Vision Improvement
October 2009 – September 2010
October 2010 – September 2011
October 2011 – September 2012
Patients (%)
60
2009-10
2010-11
2011-12
50
40
30
20
10
0
N=
Cole Eye Institute
1–14 Letters
Improvement
Vision Improvement
No Change
or Worse
35
27
36
395
379
332
≥ 15 Letters
Improvement
342
301
265
11
Cornea Surgery
Corneal transplant surgeons at Cleveland Clinic’s Cole Eye Institute perform state-of-the-art procedures for numerous
conditions that distort or cloud the normally transparent cornea. Traditional full-thickness procedures, also known as
penetrating keratoplasties (PK), make up the majority of the grafts performed in recent years. From October 2011 to
September 2012, 65 PKs were performed, and 89% of these grafts remained clear at three to six months.
Cole Eye Institute surgeons also are contributing to the development of cutting-edge lamellar corneal transplant
procedures in which only the diseased portion of the cornea is replaced. Using a procedure called Descemet’s
stripping automated endothelial keratoplasty (DSAEK), surgeons selectively transplant the endothelium for conditions
such as pseudophakic bullous keratopathy and Fuchs endothelial dystrophy. These patients experience faster visual
recovery and more stable and predictable refractive outcomes than those who undergo traditional PK. During the
interval described above, 114 DSAEKs were performed at Cole Eye Institute, and 99% of these grafts remained clear
at three to six months. In deep anterior lamellar keratoplasty for corneal scars and keratoconus, the recipient’s anterior
cornea is replaced but the patient’s healthy endothelium is retained, eliminating the risk of endothelial rejection. In
2008 to 2009, equivalent numbers of PKs and DSAEKs were performed. In the past year, DSAEK cases outnumbered
PKs, reflecting an international trend toward less invasive corneal transplant procedures for endothelial disease.
Highly specialized transplants are performed in smaller numbers for uncommon sight-threatening corneal conditions.
For patients with end-stage corneal disease who are not candidates for other forms of transplantation, synthetic
corneas (Boston keratoprostheses) are implanted to allow them to regain their visual function.
A total of 190 corneal procedures were performed last year, and most patients had no complications. Of the 176 who
were tracked for outcomes, the intraoperative complication rate was 1.2% and included one case each of capsular
rupture and vitreous prolapse. After three to 12 months of follow-up, the postoperative complication rate was 5.7%
and included seven episodes of graft rejection and three patients with corneal ulcers.
Corneal transplant surgeons at Cole Eye Institute have integrated intraoperative optical coherence tomography into
their approach to lamellar transplant surgeries such as DSAEK and deep anterior lamellar keratoplasty to better
identify surgical endpoints in real time and to study the effect of enhanced intraoperative visualization on postoperative
outcomes. Eye surgeons across the institute are participating in a comprehensive prospective study of this technology
in a variety of applications.
12
Outcomes 2012
Intraoperative Complications (N = 176)
October 2011 – September 2012
1.2% Complications:
0.6% Capsular Rupture
0.6% Vitreous Prolapse
98.8% None
Postoperative Complications (N = 176)
October 2011 – September 2012
5.7% Complications:
4.0% Graft Rejection Episode
1.7% Corneal Ulcer
94.3% None
Cole Eye Institute
13
Cornea Surgery
Visual Acuity by Procedure
October 2011 – September 2012
ETDRS* Visual Acuity Score
80
Preop
Postop
60
40
20
0
DSAEK
Penetrating Keratoplasty
Changes in visual acuity by the type of corneal
transplant procedure are shown in the graph.
For patients who completed a three- to
12-month follow-up, the mean improvement in
ETDRS visual acuity score in DSAEK patients
was 28.49 letters, corresponding to an
improvement of about five lines of visual acuity.
PK patients had worse preoperative vision
than DSAEK patients and gained 38 letters,
equivalent to seven lines of vision.
Type of Procedure
N=
83
35
*Early Treatment Diabetic Retinopathy Study
Graft Clear at Three to 12 Months
October 2011 – September 2012
Surgeries (%)
100
Yes
No
80
60
40
20
0
DSAEK
Penetrating Keratoplasty
Type of Procedure
N=
14
114
65
Outcomes 2012
Glaucoma Surgery
Glaucoma is the second most common cause of irreversible blindness in the United States, after age-related macular
degeneration. While visual loss from glaucoma cannot be reversed, adequate control of eye pressure can halt the
progressive loss of vision. The keys to preserving vision in glaucoma are early detection and good intraocular pressure
(IOP) control. Glaucoma can be managed with eyedrops, laser treatment, or surgery. Medication can help patients
avoid the need for laser treatment or surgery to control glaucoma, but medication, usually in the form of eyedrops,
entails long-term cost and some potential for local and systemic side effects. Laser surgery for glaucoma is generally
quick, safe, and convenient but has only a relatively small effect in reducing eye pressure in many patients, and the
effect may wear off over time. For some patients, surgery to control glaucoma is the best option.
Trabeculectomy is the most frequently performed glaucoma surgical procedure in the United States. For some patients
with more difficult-to-control glaucoma or who have had previous other eye surgery or trauma, a glaucoma implant
(glaucoma drainage device) is used instead. From January 2006 through September 2012, 1,895 glaucoma surgeries
were performed at Cleveland Clinic’s Cole Eye Institute. These included 973 trabeculectomies, 694 glaucoma implants,
and 141 revisions of other glaucoma surgeries.
Volume of Glaucoma Surgeries
October 2009 – September 2010
October 2010 – September 2011
October 2011 – September 2012
Surgeries (%)
60
50
2009-10 (N = 313)
40
2011-12 (N = 276)
2010-11 (N = 313)
30
20
10
0
Trabeculectomy
Glaucoma
Implant
Revision of
Trabeculectomy
Revision of
Glaucoma Implant
Other
Type of Surgery
Cole Eye Institute
15
Glaucoma Surgery
Intraoperative trabeculectomy complications were low (0.4%). The total
postoperative complication rate was 3.6%, which included hypotony
(IOP < 5 mm Hg), bleb leak, choroidal effusion, and shallow flat anterior chamber.
Intraoperative Complications (N = 275)
October 2011 – September 2012
0.4% Scleral Perforation
99.6% None
Postoperative Complications at Three-Month Follow-up (N = 140)
October 2011 – September 2012
3.5% Complications:
0.7% Hypotony (IOP < 5 mm Hg)
1.4% Bleb Leak
0.7% Choroidal Hemorrhage
0.7% Shallow Flat Anterior Chamber
96.5% None
16
Outcomes 2012
Change in IOP at Three-Month Follow-up (N = 140)
October 2011 – September 2012
Intraocular Pressure (mm Hg)
30
Preop
Postop
20
10
0
Trabeculectomy
Glaucoma Implant
85
55
N=
In procedures performed at Cole Eye
Institute in the 12-month period from
Oct. 1, 2011, to Sept. 30, 2012,
trabeculectomies reduced IOP in patients
from a mean of 21.0 mm Hg to 15.5
mm Hg, and glaucoma implant surgery
reduced IOP from 25.8 mm Hg to 16.1
mm Hg. A normal range of eye pressure is
approximately 10 to 21 mm Hg.
Change in Visual Acuity at Three-Month Follow-up (N = 140)
October 2011 – September 2012
ETDRS Visual Acuity Score
80
Preop
Postop
60
40
20
0
Trabeculectomy
Glaucoma Implant
89
51
N=
Cole Eye Institute
The goal of glaucoma surgery is to preserve
the current level of vision. Glaucoma
surgery usually does not improve visual
acuity unless combined with cataract
surgery. In surgeries at Cole Eye Institute,
the mean level of visual acuity, as
measured on ETDRS (Early Treatment
Diabetic Retinopathy Study) protocol
visual acuity charts, improved slightly after
trabeculectomy surgery.
17
Oculoplastic Surgery
Oculoplastic surgery outcomes were divided into three
categories: eyelid surgery, lacrimal surgery, and orbital
surgery. There were 954 oculoplastic surgeries performed
at Cleveland Clinic Cole Eye Institute from October
2011 through September 2012. Eyelid surgery outcome
measures included intraoperative complications and
postoperative eyelid symmetry.
There were 157 lacrimal and 66 orbital procedures
performed during this period, none of which resulted in
any intraoperative or postoperative complications.
Distribution of Oculoplastic Surgeries (N = 954)
October 2011 – September 2012
6.9% Orbital
16.5% Lacrimal
100%
76.6% Eyelid
18
Outcomes 2012
Postoperative Complications — Eyelid (N = 630)
October 2011 – September 2012
2.8% Complications:
1.4% Needed Reoperation
0.3% Failed Dacrocystorhinostomy
0.6% Worsened
0.8%
Revision Needed
Dry Eye
0.8%
0.3% Bleeding/Infection
97.2% None
A total of 731 eyelid surgeries were performed during this period. In the 630 patients who returned for
their follow-ups, postoperative complications included the need for reoperation in 1.4%, worsened dry eye
in 0.8%, a failed dacrocystorhinostomy in 0.3%, and bleeding/infection in 0.3% of cases.
Postoperative Eyelid Symmetry (N = 254)
October 2011 – September 2012
30.3% Good
100%
72.0% Excellent
69.7%
Cole Eye Institute
Postoperative eyelid symmetry was excellent in
70% of cases and good in the remaining 30%.
Excellent and good eyelid symmetry was defined by
a marginal reflex distance within 0.5 mm and
1.0 mm of the desired position, respectively.
19
Ocular Oncology Surgery
Uveal melanoma is the most common primary intraocular malignancy in adults and accounts for approximately 85% of all
ocular melanomas. With current clinical examination techniques, the accuracy of clinical diagnosis of uveal melanoma exceeds
99%. A variety of imaging techniques have been used for differentiating uveal melanoma from other tumors or simulating
conditions. The primary diagnostic modalities include slit-lamp examination, transillumination, digital photography, A-scan and
B-scan ultrasonography, ultrasound biomicroscopy, angiography, and optical coherence tomography.
Fine Needle Aspiration Biopsy
In certain situations, such as atypical presentation or dense media opacity, or for diagnostic confirmation prior to the initiation of
therapy, biopsy may be warranted. Fine needle aspiration biopsy may be performed for diagnostic or prognostic purposes.
For iris tumors, entry into the anterior chamber can be accomplished using a 26- to 30-gauge needle under direct visualization
with an operating room microscope. The needle is inserted bevel up and is swept gently over the surface of the tumor
while approximately 0.5 ml of aqueous fluid is aspirated. Posterior-segment tumors can be biopsied via a trans-scleral or a
transvitreal approach. The trans-scleral approach, by far the most common technique employed, is often preferred for tumors
located within the ciliary body or the anterior choroid. Posteriorly located tumors are often more easily accessible through a
transvitreal approach.
Fundus photograph depicting a completely
amelanotic tumor.
20
Fine needle aspiration biopsy revealed spindle cells
lacking melanin, consistent with the clinical impression
of amelanotic choroidal melanoma.
A localized preretinal hemorrhage is seen
overlying the needle biopsy site, which
generally clears in several weeks.
Outcomes 2012
Methods of Treatment for Uveal Melanoma (N = 87)
2012
27% Enucleation
100%
73.9%Plaque
73%
Eyelid
Uveal Melanoma Surgeries (N = 421)
2007 – 2012
Number of Surgeries
100
Enucleation
Plaque Brachytherapy
75
50
25
0
2007
2008
2009
2010
2011
2012
Year
Cole Eye Institute
21
Refractive Surgery
Although Cole Eye Institute has two laser platforms and
several surgeons, the outcomes of laser vision correction are
summarized here for a single surgeon and single combined
laser platform (WaveLight® Refractive Suite: Allegretto Wave®
Eye-Q Laser and FS200 Femtosecond Laser). This is the first
year the institute is reporting the combination of these two
lasers as a single platform for the whole cohort, and the results
are improved over last year. They are subdivided based on the
type of surgery (defined below) and the patient’s preoperative
refractive status (low/moderate myopia (0 to -7.00 diopters),
high myopia (> -7.00 diopters), and hyperopia (0 to +4.00
diopters)). Both the type and magnitude of refractive error can
affect the likelihood that uncorrected visual acuity (UCVA) of
20/20 or better will be achieved. Another important metric in
assessing laser vision correction outcomes is the proportion of
patients whose final refractive error falls within ± 0.5 diopter of
the intended result.
This section documents the outcomes for laser-assisted in situ
keratomileusis (LASIK) with a femtosecond laser (FS200)
flap (FemtoLASIK) and photorefractive keratectomy (PRK)
(i.e., surface ablation) using the wavefront optimized ablation
profile of the WaveLight Allegretto Wave Eye-Q excimer laser.
The outcomes are reported as percentages of eyes with UCVA
of 20/20 or 20/25, eyes with an exceptional outcome (UCVA of
20/16 or better), and eyes with UCVA meeting the requirements
for driving without glasses (20/40 or better). This analysis
includes the outcomes of 331 eyes treated in 2012.
22
Outcomes 2012
Distance Only LASIK for Low to Moderate Myopia (0 to -7 Diopters Sphere With
Cylinder < 3 Diopters) (N = 221 at ≥ Three Months)
2012
Percentage
100
94%
97%
100%
100%
20/25
20/40
75%
80
60
40
20
0
± 0.5D
Refractive
Predictability
20/16
20/20
Following FemtoLASIK to treat mild/
moderate myopia, 94% of eyes achieved
UCVA of 20/20 or better and 100%
achieved 20/25 or better. The refractive
accuracy in achieving these excellent
visual outcomes is 97% within ± 0.5
diopter of the desired target. Overall, 75%
of eyes had an exceptional visual outcome
of 20/16 or better.
Visual Acuity
Distance Only LASIK for High Myopia (> -7 Diopters Sphere With Cylinder
< 3 Diopters) (N = 35 at ≥ Three Months)
2012
Percentage
100
80
95%
100%
86%
82%
63%
60
40
20
0
± 0.5D
Refractive
Predictability
Cole Eye Institute
20/16
20/20
20/25
20/40
Following FemtoLASIK to treat high
myopia, 86% of eyes achieved UCVA
of 20/20 or better and 95% achieved
20/25 or better. The refractive accuracy in
achieving these excellent visual outcomes
is 82% within ± 0.5 diopter of the desired
target. All eyes achieved UCVA of 20/40 or
better (legal driving vision), and 63% had
an exceptional visual result of 20/16
or better.
Visual Acuity
23
Refractive Surgery
Refractive Surgery
Refractive Surgery
Refractive Surgery
24
Distance Only PRK Surface Ablation for Myopia (N = 61 at ≥ Three Months)
2012
Percentage
100
97%
80
97%
97%
100%
20/20
20/25
20/40
66%
60
40
20
0
± 0.5D
Refractive
Predictability
20/16
Visual Acuity
Following PRK to treat both low and high myopia, 97% of eyes achieved
UCVA of 20/20 or better and the same number achieved 20/25 or better.
The refractive accuracy in achieving these excellent visual outcomes is 97%
within ± 0.5 diopter of the desired target. All eyes achieved UCVA of 20/40
or better (legal driving vision), and 66% had an exceptional visual result of
20/16 or better.
Outcomes 2012
Distance Only LASIK for Hyperopia (N = 14 at ≥ Three Months)
2012
Percentage
100
86%
86%
93%
100%
80
60
43%
40
20
0
± 0.5D
Refractive
Predictability
20/16
20/20
20/25
20/40
Visual Acuity
For FemtoLASIK in hyperopic eyes, where a precise refractive outcome is
known to be more difficult to achieve, 86% of eyes still achieved UCVA of at
least 20/20 and 93% achieved 20/25. The refractive accuracy in achieving
these visual outcomes is 86% within ± 0.5 diopter of the target outcome.
Again, 100% had UCVA of 20/40 or better (legal driving vision), and 43%
of eyes achieved an exceptional result with an uncorrected visual acuity of
20/16 or better.
Cole Eye Institute
25
Vitreoretinal Surgery
The Vitreoretinal Department at Cleveland Clinic Cole
Eye Institute has assembled a dedicated surgical team of
surgeons, nurses, and skilled technicians to deliver worldclass care for its patients. This team has developed several
surgical procedures that are now used worldwide for
treatment of retinal detachment, diabetic macular edema,
diabetic traction retinal detachments, and myopic macular
holes, and for microincision surgery and pediatric retinal
surgery. Members of the team have also helped develop
the next generation of vitreoretinal surgical devices
including microincision surgical instruments and techniques.
Finally, the Ophthalmic Imaging Center at Cole Eye
Institute is a leader in the new field of intraoperative
optical coherence tomography, developing new uses for
this pioneering technology.
In 2012, the team performed 635 surgical procedures. As in
previous years, the following were excluded from the analysis:
(1) emergency cases, (2) situations in which ETDRS (Early
Treatment Diabetic Retinopathy Study) protocol visual acuity
measurement could not be performed at baseline, and
(3) cases in which patients received postoperative care at
another facility.
Detailed efficacy outcomes were available for 58 surgeries
performed by the vitreoretinal team to close a macular hole.
Anatomic closure of the macular hole was achieved in 100%
of cases. Vision improved ≥ 3 ETDRS lines in 53% of cases,
with an average improvement in vision of 17.4 ETDRS letters,
or ≥ 3 lines.
Another commonly performed macular procedure was
epiretinal membrane removal, with detailed efficacy outcomes
available in 111 cases. The mean visual acuity improvement
after membrane peeling surgery was +11.2 ETDRS letters,
with 22% of patients having a ≥ 3 line gain in vision.
Primary rhegmatogenous retinal detachments are common,
and primary retinal detachment repair was performed in
26
38 patients in 2012. In 89.4% of cases, the retina was
reattached with one surgery. The mean change in vision after
primary retinal detachment repair was an improvement of
+14.8 ETDRS letters, with an improvement in vision of ≥ 3
lines in 40% of cases.
Cole Eye Institute is a tertiary care facility, and the
vitreoretinal team is called on to assist in difficult cases such
as giant retinal tears and complicated retinal detachments
that have proliferative vitreoretinopathy. Many of these
patients are referred to this facility after having had
vitreoretinal surgeries at other hospitals. Detailed efficacy
outcomes for these types of surgery were available for 217
patients in 2012. Although most patients had a previous
retinal surgery, the reattachment rate in these complicated
cases was 97%. Seven patients had to return to the
operating room after complicated retinal repair. Of these,
five were referred from outside Cleveland Clinic and two
were clinic patients who had undergone multiple previous
surgeries. After the additional surgery, retinal reattachment
was successful in all seven patients. The average
improvement in vision after proliferative vitreoretinopathy
retinal detachment repair was +15.2 ETDRS letters. A ≥ 3
line improvement in vision occurred in 35% of cases, while a
≥ 3 line loss in vision occurred in 8.8% of cases.
Diabetic vitrectomy surgery is among the most complex
surgeries performed by a vitreoretinal surgeon. The
vitreoretinal team has developed new techniques for diabetic
surgery, including pioneering the use of small-gauge surgery.
In 2012, detailed efficacy outcomes analysis was available
in 90 cases. In patients with traction retinal detachment,
the mean improvement in visual acuity was +11.9 ETDRS
letters, with 36% having a ≥ 3 line gain in vision and none
having a ≥ 3 line loss in vision. In diabetic patients, with
just a vitreous hemorrhage, the mean change in vision was
+37.4 ETDRS letters or 7 lines, with 55% having a ≥ 3 line
gain in vision and one patient having a ≥ 3 line loss
in vision.
Outcomes 2012
Category Definitions
Groupings for Graphs
DR 1 • Diabetic Macular Edema (DME)
– Macular edema due to posterior hyaloidal traction
Group 1: Diabetic Retinopathy (DR1 and Diabetic VH)
DR 2 •Complicated Diabetic Retinopathy
– Anterior hyaloidal fibrovascular proliferation
– Traction retinal detachment (TRD)
– Combined TRD and rhegmatogenous retinal
detachment (RRD)
RRD 1 •Rhegmatogenous Retinal Detachment (RRD)
RRD 2 •Complicated Rhegmatogenous Retinal
Detachment (RRD)
– Recurrent Retinal Detachment
– Proliferative Vitreoretinopathy
Vitreous Hemorrhage (VH)
Group 2: Complicated Diabetic Retinopathy
Group 3: Primary Rhegmatogenous Retinal Detachment
Group 4: Complicated Rhegmatogenous Retinal Detachment
and GRT
Group 5: Macular Hole
Group 6: Epiretinal Membrane
Note: For most emergency cases, especially RRD1, preoperative
baseline ETDRS visual acuity cannot be performed and therefore
the outcome results are not included in this analysis.
Giant Retinal Tear (GRT)
Macular Hole (MH)
Epiretinal Membrane (EM)
Vision Improvement by Indication for Surgery (N = 215)
October 2011 – September 2012
Percentage
60
Group
Group
Group
Group
Group
Group
50
40
1
2
3
4
5
6
(N
(N
(N
(N
(N
(N
=
=
=
=
=
=
14)
25)
72)
34)
38)
32)
30
20
10
0
≥-15 Letters
Cole Eye Institute
-14 to -5
Letters
-4 to +4
Letters
+5 to +14
Letters
≥ +15 Letters
27
Vitreoretinal Surgery
Intraoperative Complications (N = 463)
October 2011 – September 2012
Percentage
4
Iatrogenic Retinal Break
Choroidal Hemorrhage
Suture Microincision Sclerotomy
3
2
1
0
Group 1
Group 2
Group 3
Group 4
Group 5
Group 6
54
43
Indication for Surgery
N=
32
54
174
96
An analysis of intraoperative complications for all surgical procedures revealed no complications in 97.8% of
cases. Iatrogenic retinal breaks were the most common intraoperative complication, recorded in 1.3% of cases.
28
Outcomes 2012
Postoperative Complications
October 2011 – September 2012
Group 1
(N = 36)
IOP spike > 30 mm Hg
Group 2
Group 3
(N = 64) (N = 124)
2%
New retinal breaks
Group 4
(N = 85)
Group 5
(N = 30)
2%
1%
1%
1%
Hypotony
Visually significant cataract
Vitreous hemorrhage
3%
2%
Group 6
(N = 23)
4%
2%
An analysis of patients who had at least three months of follow-up revealed that 97% of cases did not have
any postoperative complications. The most prevalent postoperative complications were intraocular pressure
(IOP) spike > 30 mm Hg (1.1%), hypotony (0.3%), and new retinal breaks (0.6%).
Cole Eye Institute
29
Strabismus Surgery
Cole Eye Institute considers the outcome of surgery for strabismus in adults to be good if there is: (1) disappearance of diplopia
and/or anomalous head position in primary position of gaze or (2) in the absence of diplopia or anomalous head position, a
constant deviation of less than 10 prism diopters. In children, a good outcome is defined as: (1) a constant deviation of less than
10 prism diopters in primary position or (2) the disappearance of anomalous head position in those in whom the surgery was
done for that purpose, such as patients with a fourth nerve palsy, Brown syndrome, or Duane syndrome. The results here reflect
reviews of follow-up visits during the period between October 2011 and September 2012. Hence, the follow-up data for some
patients is not included here, nor are long-term outcomes.
For the above-mentioned period, 212 strabismus procedures were performed by three surgeons; 127 procedures were performed
on children and 85 on adults (defined as age 16 years or older).
30
Outcomes 2012
Adult Strabismus Cases (N = 85)
October 2011 – September 2012
Surgeries (%)
40
30
20
10
0
Esotropia
Exotropia
4th Nerve
Palsy
6th Nerve
Palsy
Hypertropia
Thyroid
Duane
Eye Disease Syndrome
Slipped
Muscle
Diagnosis
Adult Outcomes (N = 79)
October 2011 – September 2012
27% Poor − Over- or undercorrected
100%
73% Good − Ocular alignment within
10 prism diopters of orthotropia
if no diplopia, and/or diplopia
disappeared and/or anomalous
head position resolved
Note: This graph excludes six patients for whom follow-up was not available.
Cole Eye Institute
31
Strabismus Surgery
Pediatric Strabismus Cases (N = 127)
October 2011 – September 2012
Surgeries (%)
50
40
30
20
10
0
Esotropia
Exotropia
Dissociated
Vertical
Deviations
4th Nerve
Palsy
6th Nerve
Palsy
Nystagmus
Duane
Syndrome
3rd Nerve
Palsy
Diagnosis
Pediatric Outcomes (N = 110)
October 2011 – September 2012
10% Poor − Over- or undercorrected
100%
90% Good − Constant deviation
< 10 prism diopters in primary
position and/or anomalous head
position resolved
Note: This graph excludes 17 patients for whom follow-up was not available.
32
Outcomes 2012
Patient Experience — Cole Eye Institute
Cleveland Clinic is dedicated to delivering excellent clinical outcomes and the
best possible experience for our patients and their families. Patient feedback
is critical in driving priorities and assessing results. Based on this feedback,
Cleveland Clinic’s Office of Patient Experience implements training programs to
improve service and communication as well as educational initiatives to help
patients understand what to expect when they are in our care.
Outpatient Office Survey — Cole Eye Institute
2011 – 2012
Percent Best Response*
100
2011 (N = 4,414)
2012 (N = 4,141)
80
60
40
20
0
Appt Access/
Check-In
Clinic Wait Times
and Comfort
Nurse and
Assistant
Physician
Concern for
Needs and Privacy
Overall
Assessment
*Response options: Very Good, Good, Fair, Poor, Very Poor
Each bar represents a composite score based on responses to multiple survey questions.
Source: Press Ganey, a national hospital survey vendor
Cole Eye Institute
33
Cleveland Clinic — Improving Quality, Safety, and the Patient Experience
Overview
Cleveland Clinic health system uses a scorecard approach to measure and monitor quality, safety, and patient experience.
Real-time dashboard data are leveraged in each location to drive performance improvement. Although not an exact
match to publicly reported data, more timely internal data create transparency at all organizational levels and support
improved care in all clinical locations. The following measures are examples of health system 2012 quality and safety
focus areas. Throughout this section, “Cleveland Clinic” refers to the academic medical center or “main campus,” and
those results are shown.
Cleveland Clinic Core Measures
Appropriateness of Care
All-Cause 30-Day Readmission Rate
to Any Cleveland Clinic Hospital
2011 – 2012
2011 – 2012
Percent of Patients
100
Percent of Discharges
18
16
14
80
12
60
10
8
40
Cleveland Clinic Performance
Cleveland Clinic Target
20
0
Q1
Q2
Q3
2011
Q4
Q1
Q2
Q3
Q4
2012
Cleveland Clinic’s goal is for all patients to receive
all the recommended care for their condition. An
aggregated “all or nothing” measurement approach to
monitoring multiple publicly reported process-of-care
measures for heart failure, acute myocardial infarction,
pneumonia, and surgery patients yields results
consistently above 94%.
34
Cleveland Clinic Performance
6
4
2
0
Q1
Q2
Q3
2011
Q4
Q1
Q2
Q3
Q4
2012
Cleveland Clinic monitors 30-day readmission
rates for any reason to any of its system hospitals.
Unplanned readmissions are actively reviewed for
improvement opportunities. Strategies associated
with communication, education, and follow-up have
been implemented for several high-risk conditions,
including heart failure and pneumonia. These
practices are being expanded and enhanced to
reduce overall avoidable readmissions.
Outcomes 2012
Cleveland Clinic Deaths Among Surgical Patients
With Serious Treatable Complications (PSI 4)
Rate per 1,000 Eligible Patients
Cleveland Clinic Overall In-Hospital Mortality
Observed/Expected Ratio
2011 – 2012
2011 – 2012
O/E Ratio
1.2
Rate per 1,000 Patients
180
1.0
160
140
0.8
120
0.6
100
Cleveland Clinic Performance
UHC* 50th Percentile
(Academic Medical Center)
0.4
80
0.0
Cleveland Clinic Performance
UHC* 50th Percentile
(Academic Medical Center)
60
0.2
40
Q1
Q2
Q3
2011
Q4
Q1
Q2
Q3
Q4
2012
Cleveland Clinic’s observed/expected (O/E) mortality
ratio outperformed the University HealthSystem
Consortium (UHC) academic medical center 50th
percentile throughout 2012 based on the UHC
2012 risk model. Ratios less than 1.0 indicate
mortality performance “better than” expected in
UHC’s risk adjustment model.
20
0
Q1
Q2
Q3
2011
Q4
Q1
Q2
Q3
Q4
2012
The Agency for Healthcare Research and Quality’s
Patient Safety Indicator 4 (AHRQ PSI 4) reports
deaths among patients with serious treatable
complications. Cleveland Clinic performs in the
top third of UHC’s academic medical centers for
this measure.
*These data are prepared using the University HealthSystem
Consortium (UHC) Clinical Database. uhc.edu
Cole Eye Institute
35
Cleveland Clinic — Improving Quality, Safety, and the Patient Experience
Cleveland Clinic Postoperative Blood Clot Rate (PSI 12)
per 1,000 Eligible Patients
Cleveland Clinic Central Line-Associated Bloodstream
Infection—ICU Rate per 1,000 Line Days
2011 – 2012
2010 – 2012
Rate per 1,000 Patients
20
18
16
14
12
10
8
Cleveland Clinic Performance
6
UHC* 50th Percentile
4
(Academic Medical Center)
2
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Rate per 1,000 Line Days
3.5
2011
2012
Cleveland Clinic continues to improve its
performance with respect to postoperative
blood clots (AHRQ Patient Safety Indicator 12).
Improved screening and prevention strategies
have led to a 45% reduction in these events over
the past two years.
Cleveland Clinic Performance
Cleveland Clinic Target
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
2010
2011
2012
Cleveland Clinic has implemented several
strategies to reduce central line-associated
bloodstream infections (CLABSI), including a
central-line bundle of insertion, maintenance,
and removal best practices. In 2012, Cleveland
Clinic initiated focused reviews of every CLABSI
occurrence and is introducing equipment and
technology to support reductions in CLABSI rates
in its high-risk critical care population.
*These data are prepared using the University HealthSystem
Consortium (UHC) Clinical Database. uhc.edu
36
Outcomes 2012
Cleveland Clinic Hospital-Acquired Pressure
Ulcers Prevalence
Cleveland Clinic Falls Rate per 1,000 Patient Days
2011 – 2012
2011 – 2012
Percent
5
Rate per 1,000 Patient Days
4.0
3.5
4
3.0
2.5
3
2.0
2
Cleveland Clinic Performance
NDNQI®* 50th Percentile
(Academic Medical Center)
1
0
Q1
Q2
Q3
2011
Q4
Q1
Q2
Q3
Q4
2012
A pressure ulcer is an injury to the skin that can
be caused by pressure, moisture, or friction. These
sometimes occur when patients have difficulty
changing positions on their own. Cleveland Clinic
caregivers have been trained to provide appropriate
skin care and regular repositioning help while taking
advantage of special devices and mattresses to
reduce pressure for high-risk patients. In addition,
they actively look for hospital-acquired pressure ulcers
and treat them quickly if they occur.
1.5
Cleveland Clinic Performance
NDNQI®* 50th Percentile
(Academic Medical Center)
1.0
0.5
0.0
Q1
Q2
Q3
Q4
2011
Q1
Q2
Q3
Q4
2012
Nationally, falls are a leading cause of hospital
patient injury. Cleveland Clinic fall prevention efforts
include identifying patients who are at risk for
falls, checking on them frequently, assisting them
to the bathroom, and providing nonskid footwear.
Caregivers make sure patients have all necessary
items, including a call light, within easy reach.
*The National Database of Nursing Quality Indicators® (NDNQI®) is owned
by the American Nurses Association. The database collects and evaluates
unit-specific nurse-sensitive data from hospitals domestically and globally,
with > 1900 hospitals participating. The comparison data represented
here are based on a third of all hospitals in the U.S. participating. © 2012,
American Nurses Association, All Rights Reserved. www.nursingquality.org
Cole Eye Institute
37
Cleveland Clinic — Improving Quality, Safety, and the Patient Experience
Patient Experience
The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is
a standardized national tool used to measure patients’ perspectives of hospital care. Results
collected for public reporting are available at medicare.gov/hospitalcompare.
Cleveland Clinic HCAHPS Overall Assessment
2011 – 2012
Percent Best Response*
100
84.9
84.0
80
80.0
80.8
60
2011 (N = 10,378)
2012 (N = 11,190)
40
National Average
July 1, 2011 – June 30, 2012
20
0
Recommend Hospital
(% Definitely Yes)*
Hospital Rating
(% 9 or 10)
0–10 Scale
*Response options: Definitely Yes, Probably Yes, Probably No, Definitely No
Source: Centers for Medicare & Medicaid Services and Press Ganey, a national hospital survey vendor
38
Outcomes 2012
Cleveland Clinic HCAHPS Domains of Care
2011 – 2012
Percent Best Response*
100
2011 (N = 10,378)
2012 (N = 11,190)
National Average
July 1, 2011 – June 30, 2012
80
60
40
20
0
Discharge
Information
% Yes
Doctor
Nurse
Communication Communication
Pain
Management
Room
New Medications Responsiveness
Clean
Communication
to Needs
% Always
(Options: Always, Usually, Sometimes, Never)
Quiet at
Night
*Except for “Room Clean” and “Quiet at Night,” each bar represents a composite score based on responses to multiple survey questions.
Source: Centers for Medicare & Medicaid Services and Press Ganey, a national hospital survey vendor
The guiding principle of Cleveland Clinic is “Patients First,” and improving the patient experience is a major strategic
organizational goal. The Office of Patient Experience collaborates with physician and nursing leadership to establish
best practices and implement standardized protocols that ensure delivery of patient-centered care.
Cole Eye Institute
39
Innovations
Creating Next-Generation Electronic Health Record Tools to Care for Patients
In 2012, Cleveland Clinic’s Cole Eye Institute completed a total migration to an electronic health
records (EHR) system. This project took more than three years and $3 million in support to complete.
Substantial modifications to clinic and billing workflows, hardware, image storage, and Epic content
were required to optimize the system and ensure successful deployment.
Now that the migration is complete, Cole Eye Institute has started reaping some of the rewards of
customization, data collection, and streamlined workflow. There was little economic change from
year-to-date values, whereas other ophthalmology peers showed significant declines. “EHR has
allowed us to examine every aspect of patient care,” explains Rishi Singh, MD, who has served as
physician leader for the project’s scope, design, development, and implementation. “We can track
improvements following procedures, display summary reports that help physicians follow trends,
and aggregate our collective experiences to assess our practice.”
With the EHR, cross-communication among doctors who manage complex patients can occur with
ease. For example, a patient who has both rheumatologic disease and eye disease and who requires
care from multiple specialists now has the opportunity to take advantage of joint clinics, which allow
him or her to see all providers in one day, at one location. Aside from being convenient for patients,
joint clinics allow ophthalmologists and other physicians to provide coordinated multidisciplinary care.
Cole Eye Institute has begun leveraging its experiences through an EHR Optimization Services
Program. As part of this program, the team from Cole Eye Institute has been traveling to leading
ophthalmic programs across the country and sharing best practices and advice on EHR system
implementation. This program has been extremely well received, and multiple institutions have
entered into agreements with Cole Eye Institute to provide EHR services from workflow optimization
through complete implementation of the EHR system.
The EHR system will be rolled out to Cole Eye Institute physicians throughout the year, and the
next phase of EHR will offer decision-support tools for physicians, create a data repository or data
mart for ongoing clinical research, and provide dashboards that will display the ongoing clinical,
administrative, quality, and safety metrics at the institute. “Our work on EHR is giving Cole Eye
Institute a monumental opportunity to contribute knowledge to and lead in the field
of ophthalmology.”
40
Outcomes 2012
Refractive Laser Assisted Cataract Surgery
Cataract surgery today has changed from what it used
to be. It essentially began as a therapeutic procedure for
older patients, but is now used on patients of all ages and
expectations. Patients today not only want their cataracts
removed but also want it to be done in a faster, better, and
more technologically refined manner.
Now that the laser is available at Cole Eye Institute and
ReLACS is offered by a number of the institute’s surgeons
performing cataract surgery, the results of ReLACS will be
published in a subsequent Cleveland Clinic outcomes report
once the procedure has been performed enough times to
warrant comparison with the results of standard cataract
surgery. So far, with the limited number of ReLACS cases
performed at Cleveland Clinic, the results have
been encouraging.
With the introduction of refractive laser assisted cataract
surgery (ReLACS), standard cataract procedure (which
focuses on the removal of a cloudy lens for replacement
with a synthetic lens implant) is now moving beyond
the best lens implant calculation and aspheric, toric, or
multifocal shape to refractive laser precision. ReLACS is
changing modern-day cataract surgery into a refractive
procedure, striving to achieve the same kind of refractive
precision with cataract surgery as is experienced
with LASIK.
A growing number of “baby boomers” are reaching the age
for cataract development and surgery, and this generation
has high expectations for vision correction derived from their
knowledge of LASIK. Thus, ReLACS represents the next
big wave of refractive cataract surgery within a population
wishing for not just cataract removal, but vision correction.
Ronald R. Krueger, MD, as an early innovator and
co-founder of one of the four commercial companies
offering ReLACS, serves as the lead editor of and contributor
to a textbook on the procedure.1 This first textbook
on ReLACS summarizes the historical, technological,
commercial, and early clinical aspects of laser assisted
cataract surgery and how it can be used to enhance the
visual outcomes and meet the expectations of patients
seeking cataract surgery and a glasses-free result.
Cole Eye Institute
Krueger RR, Talamo JH, Lindstrom RL, Eds.
Textbook of Refractive Laser Assisted Cataract
Surgery (ReLACS). Springer; 2012. 289 pp.
1
41
Selected Publications
For a complete list of
Ophthalmology
2012 publications go to
Ahmad BU, Barakat MR, Feldman M, Singh RP. Bilateral subcutaneous
emphysema from pressurized infusion during pars plana vitrectomy:
A case report. Retin Cases Brief Rep. 2012 Winter;6(1):22-24.
clevelandclinic.org/outcomes.
Alraiyes AH, Alraies MC, Almeida FA, Singh AD. Flashing lights, floaters,
and reduced vision. Cleve Clin J Med. 2012 Sep;79(9):616-618.
Ariss M, Natan K, Friedman N, Traboulsi EI. Ophthalmologic abnormalities
in Mowat-Wilson syndrome and a mutation in ZEB2. Ophthalmic Genet.
2012 Sep;33(3):159-160.
Aronow M, Sun Y, Saunthararajah Y, Biscotti C, Tubbs R, Triozzi P,
Singh AD. Monosomy 3 by FISH in uveal melanoma: Variability in
techniques and results. Surv Ophthalmol. 2012 Sep-Oct;57(5):463-473.
Aronow ME, Nakagawa JA, Gupta A, Traboulsi EI, Singh AD. Tuberous
sclerosis complex: genotype/phenotype correlation of retinal findings.
Ophthalmology. 2012 Sep;119(9):1917-1923.
Barbosa FL, Lin M, Santhiago MR, Singh V, Agrawal V, Wilson SE.
Interleukin-1 receptor role in the viability of corneal myofibroblasts.
Exp Eye Res. 2012 Mar;96(1):65-69.
Biscotti CV, Singh AD. Uveal melanoma: diagnostic features.
Monogr Clin Cytol. 2012;21:44-54.
Browning DJ, Kaiser PK, Rosenfeld PJ, Stewart MW. Aflibercept for
age-related macular degeneration: a game-changer or quiet addition?
Am J Ophthalmol. 2012 Aug;154(2):222-226.
Canton VM, Quiroz-Mercado H, Velez-Montoya R, Lopez-Miranda MJ,
Moshfeghi AA, Shusterman EM, Kaiser PK, Sanislo SR, Gertner M,
Moshfeghi DM. 24-Gy low-voltage x-ray irradiation with ranibizumab
therapy for neovascular AMD: 6-month safety and functional outcomes.
Ophthalmic Surg Lasers Imaging. 2012 Jan-Feb;43(1):20-24.
Chappelow AV, Tan K, Waheed NK, Kaiser PK. Panretinal photocoagulation
for proliferative diabetic retinopathy: pattern scan laser versus argon laser.
Am J Ophthalmol. 2012 Jan;153(1):137-142.
Chute DJ, Biscotti CV, Singh AD. Uveal lymphoma. Monogr Clin Cytol.
2012;21:31-43.
Coussa RG, Traboulsi EI. Choroideremia: A review of general findings and
pathogenesis. Ophthalmic Genet. 2012 Jun;33(2):57-65.
Coussa RG, Kim J, Traboulsi EI. Choroideremia: Effect of age on visual
acuity in patients and female carriers. Ophthalmic Genet. 2012
Jun;33(2):66-73.
42
Outcomes 2012
Dhoot DS, Kaiser PK. Ranibizumab for age-related macular
degeneration. Expert Opin Biol Ther. 2012 Mar;12(3):371-381.
Farag E, Sessler DI, Kovaci B, Wang L, Mascha EJ, Bell G,
Kalfas I, Rockwood E, Kurz A. Effects of crystalloid versus colloid
and the alpha-2 agonist brimonidine versus placebo on intraocular
pressure during prone spine surgery: a factorial randomized trial.
Anesthesiology. 2012 Apr;116(4):807-815.
Folgar FA, Chow JH, Farsiu S, Wong WT, Schuman SG,
O’Connell RV, Winter KP, Chew EY, Hwang TS, Srivastava SK,
Harrington MW, Clemons TE, Toth CA. Spatial correlation between
hyperpigmentary changes on color fundus photography and
hyperreflective foci on SDOCT in intermediate AMD. Invest
Ophthalmol Vis Sci. 2012;53(8):4626-4633.
Gabriel LAR, Wang LW, Bader H, Ho JC, Majors AK, Hollyfield JG,
Traboulsi EI, Apte SS. ADAMTSL4, a secreted glycoprotein widely
distributed in the eye, binds fibrillin-1 microfibrils and accelerates
microfibril biogenesis. Invest Ophthalmol Vis Sci. 2012;53(1):
461-469.
Ghanem RC, Netto MV, Ghanem VC, Santhiago MR, Wilson SE.
Peripheral sterile corneal ring infiltrate after riboflavin-UVA collagen
cross-linking in keratoconus. Cornea. 2012 Jun;31(6):702-705.
Ginat DT, Singh AD, Moonis G. Multimodality imaging of hydrogel
scleral buckles. Retina. 2012 Sep;32(8):1449-1452.
Gomes BAF, Smadja D, Espana EM, Ahn ES, Netto MV, Santhiago MR.
Very late-onset corneal scar triggered by trauma after photorefractive
keratectomy. J Cataract Refract Surg. 2012 Sep;38(9):1694-1697.
Gomes BDAF, Santhiago MR, de Azevedo MNL, Moraes HV, Jr.
Evaluation of dry eye signs and symptoms in patients with systemic
sclerosis. Graefes Arch Clin Exp Ophthalmol. 2012 Jul;250(7):
1051-1056.
Goshe JM, Lewis CD, Meine JG, Schoenfield L, Perry JD. Primary
dermatofibrosarcoma protuberans invading the orbit. Ophthal Plast
Reconstr Surg. 2012 May-Jun;28(3):e65-e67.
Grunwald JE, Daniel E, Ying GS, Pistilli M, Maguire MG,
Alexander J, Whittock-Martin R, Parker CR, Sepielli K, Blodi BA,
Martin DF. Photographic assessment of baseline fundus morphologic
features in the comparison of age-related macular degeneration
treatments trials. Ophthalmology. 2012 Aug;119(8):1634-1641.
Cole Eye Institute
Gupta N, Singh RP. Resolution of a choroidal abscess in the setting
of endophthalmitis in an immunocompetent host with noninvasive
treatment. Retin Cases Brief Rep. 2012 Spring;6(2):184-186.
Gupta PK, Ehlers JP, Kim T. Evaluation of clear corneal wound
dynamics with contrast-enhanced spectral-domain optical
coherence tomography. Ophthalmic Surg Lasers Imaging. 2012
May-Jun;43(3):222-228.
Hall EF, Ahmad B, Schachat AP. Spectral-domain optical coherence
tomography findings in acute retinal pigment epitheliitis. Retin Cases
Brief Rep. 2012 Summer;6(3):309-312.
Hallahan KM, Sood A, Singh AD. Acute episode of eyelid oedema.
Br J Ophthalmol. 2012 Jun;96(6):909, 913.
Heier JS, Brown DM, Chong V, Korobelnik JF, Kaiser PK, Nguyen QD,
Kirchhof B, Ho A, Ogura Y, Yancopoulos GD, Stahl N, Vitti R,
Berliner AJ, Soo Y, Anderesi M, Groetzbach G, Sommerauer B,
Sandbrink R, Simader C, Schmidt-Erfurth U. Intravitreal aflibercept
(VEGF trap-eye) in wet age-related macular degeneration.
Ophthalmology. 2012 Dec;119(12):2537-2548.
Ho AC, Prenner JL, Kaiser RS, Kaiser PK. Maximizing patient
outcomes in AMD: A review of evolving, evidence-based therapeutic
options for clinical practice. Retina Today. 2012 Sep;1-20.
Hong CW, Sinha-Roy A, Schoenfield L, McMahon JT, Dupps WJ, Jr.
Collagenase-mediated tissue modeling of corneal ectasia and
collagen cross-linking treatments. Invest Ophthalmol Vis Sci.
2012;53(4):2321-2327.
Kaiser PK. Choroidal imaging offers a new window on disease
management: The technology is already in use for diagnosis and
management of some conditions. Retina Today. 2012 Apr;60-63.
Kaiser PK, Cruess AF, Bogaert P, Khunti K, Kelly SP. Balancing risk in
ophthalmic prescribing: assessing the safety of anti-VEGF therapies
and the risks associated with unlicensed medicines. Graefes Arch Clin
Exp Ophthalmol. 2012 Nov;250(11):1563-1571.
Kaiser PK, Boyer DS, Cruess AF, Slakter JS, Pilz S, Weisberger A.
Verteporfin plus ranibizumab for choroidal neovascularization in
age-related macular degeneration: Twelve-month results of the DENALI
study. Ophthalmology. 2012 May;119(5):1001-1010.
Khan N, Khan MK, Bena J, Macklis R, Singh AD. Plaque
brachytherapy for uveal melanoma: a vision prognostication model.
Int J Radiat Oncol Biol Phys. 2012 Nov 1;84(3):e285-e290.
43
Selected Publications
Koenekoop RK, Wang H, Majewski J, Wang X, Lopez I, Ren H, Chen Y,
Li Y, Fishman GA, Genead M, Schwartzentruber J, Solanki N,
Traboulsi EI, Cheng J, Logan CV, McKibbin M, Hayward BE, Parry DA,
Johnson CA, Nageeb M, Poulter JA, Mohamed MD, Jafri H, Rashid Y,
Taylor GR, Keser V, Mardon G, Xu H, Inglehearn CF, Fu Q, Toomes C,
Chen R. Mutations in NMNAT1 cause Leber congenital amaurosis and
identify a new disease pathway for retinal degeneration. Nat Genet.
2012 Jul 29;44(9):1035-1039.
Lee BJ, Nelson CC, Lewis CD, Perry JD. External
dacryocystorhinostomy outcomes in sarcoidosis patients. Ophthal
Plast Reconstr Surg. 2012 Jan-Feb;28(1):47-49.
Lee BJ, Nelson CC, Lewis CD, Perry JD. External
dacryocystorhinostomy surgery in patients with Wegener
granulomatosis. Ophthal Plast Reconstr Surg. 2012
Nov-Dec;28(6):389-392.
Lima BR, Singh AD. Bevacizumab therapy for choroidal melanoma.
Eur Oncol Haematol. 2012 May;8(2):101-104.
Martin DF, Maguire MG, Fine SL, Ying GS, Jaffe GJ, Grunwald JE,
Toth C, Redford M, Ferris FL, III. Ranibizumab and bevacizumab for
treatment of neovascular age-related macular degeneration: Two-year
results. Ophthalmology. 2012 Jul;119(7):1388-1398.
Marwaha G, Wilkinson A, Bena J, Macklis R, Singh AD. Dosimetric
benefit of a new ophthalmic radiation plaque. Int J Radiat Oncol Biol
Phys. 2012 Dec 1;84(5):1226-1230.
Nicholson BP, Singh RP, Sears JE, Lowder CY, Kaiser PK. Evaluation of
fluocinolone acetonide sustained release implant (Retisert) dissociation
during implant removal and exchange surgery. Am J Ophthalmol.
2012 Dec;154(6):969-973.
Ohr M, Kaiser PK. Intravitreal aflibercept injection for neovascular
(wet) age-related macular degeneration. Expert Opin Pharmacother.
2012 Mar;13(4):585-591.
Pasquali T, Krueger R. Topography-guided laser refractive surgery.
Curr Opin Ophthalmol. 2012 Jul;23(4):264-268.
Pasquali TA, Mehta MP, Perry JD. Conjunctival bleeding after ectropion
repair due to paraneoplastic primary fibrinolysis. Ophthal Plast
Reconstr Surg. 2012 Mar-Apr;28(2):e44-e45.
Payne JF, Ray R, Watson DG, Delille C, Rimler E, Cleveland J,
Lynn MJ, Tangpricha V, Srivastava SK. Vitamin D insufficiency in
diabetic retinopathy. Endocr Pract. 2012 Mar-Apr;18(2):185-193.
Pelayes DE, Zarate JO, Biscotti CV, Singh AD. Calibrated needle for
ophthalmic fine needle aspiration biopsy. Br J Ophthalmol. 2012
Aug;96(8):1147-1148.
Mello GR, Rocha KM, Santhiago MR, Smadja D, Krueger RR.
Applications of wavefront technology. J Cataract Refract Surg. 2012
Sep;38(9):1671-1683.
Perry JD. Dysfunctional epiphora: a critique of our current construct of
“functional epiphora.” Am J Ophthalmol. 2012 Jul;154(1):3-5.
Moshfeghi AA, Morales-Canton V, Quiroz-Mercado H,
Velez-Montoya R, Zavala-Ayala A, Shusterman EM, Kaiser PK,
Sanislo SR, Gertner M, Moshfeghi DM. 16 Gy low-voltage x-ray
irradiation followed by as needed ranibizumab therapy for age-related
macular degeneration: 12 month outcomes of a ‘radiation-first’
strategy. Br J Ophthalmol. 2012 Oct;96(10):1320-1324.
Santhiago MR, Smadja D, Zaleski K, Espana EM, Armstrong BK,
Wilson SE. Flap relift for retreatment after femtosecond laser-assisted
LASIK. J Refract Surg. 2012 Jul;28(7):482-487.
Natan K, Traboulsi EI. Unilateral rectus muscle recession in the
treatment of Duane syndrome. J AAPOS. 2012 Apr;16(2):145-149.
44
Nguyen QD, Campochiaro PA, Shah SM, Browning DJ, Hudson HL,
Sonkin PL, Hariprasad SM, Kaiser PK, Slakter J, Haller JA, Do DV,
Mieler W, Chu K, Ingerman A, Vitti R, Berliner AJ, Cedarbaum J.
Evaluation of very high- and very low-dose intravitreal aflibercept in
patients with neovascular age-related macular degeneration.
J Ocul Pharmacol Ther. 2012 Dec;28(6):581-588.
Santhiago MR, Netto MV, Wilson SE. Mitomycin C: biological effects
and use in refractive surgery. Cornea. 2012 Mar;31(3):311-321.
Santhiago MR, Wilson SE, Netto MV, Ghanen RC, Monteiro MLR,
Bechara SJ, Espana EM, Mello GR, Kara-Junior N. Modulation transfer
function and optical quality after bilateral implantation of a +3.00 D
versus a +4.00 D multifocal intraocular lens. J Cataract Refract Surg.
2012 Feb;38(2):215-220.
Outcomes 2012
Saunthararajah Y, Triozzi P, Rini B, Singh A, Radivoyevitch T,
Sekeres M, Advani A, Tiu R, Reu F, Kalaycio M, Copelan E, Hsi E,
Lichtin A, Bolwell B. p53-independent, normal stem cell sparing
epigenetic differentiation therapy for myeloid and other malignancies.
Semin Oncol. 2012 Feb;39(1):97-108.
Schein OD, Banta JT, Chen TC, Pritzker S, Schachat AP.
Lessons learned: Wrong intraocular lens. Ophthalmology. 2012
Oct;119(10):2059-2064.
Seregard S, Singh AD. Retinoblastoma: direct chemotherapeutic
drug delivery into the vitreous cavity. Br J Ophthalmol. 2012
Apr;96(4):473-474.
Singh AD, Dolan B, Biscotti CV. Future of ophthalmic fine needle
aspiration biopsy. Monogr Clin Cytol. 2012;21:90-96.
Singh AD, Pelayes DE, Brainard JA, Biscotti CV. History, indications,
techniques and limitations. Monogr Clin Cytol. 2012;21:1-9.
Singh AD, Pabon S, Aronow ME. Management of radiation
maculopathy. Ophthalmic Res. 2012;48 Suppl 1:26-31.
Singh AD, Biscotti CV. Fine needle aspiration biopsy of ophthalmic
tumors. Saudi J Ophthalmol. 2012 Apr;26(2):117-123.
Singh AD, Aronow ME, Sun Y, Bebek G, Saunthararajah Y,
Schoenfield LR, Biscotti CV, Tubbs RR, Triozzi PL, Eng C. Chromosome
3 status in uveal melanoma: a comparison of fluorescence in situ
hybridization and single-nucleotide polymorphism array. Invest
Ophthalmol Vis Sci. 2012;53(7):3331-3339.
Singh R, Alpern L, Jaffe GJ, Lehmann RP, Lim J, Reiser HJ, Sall K,
Walters T, Sager D. Evaluation of nepafenac in prevention of macular
edema following cataract surgery in patients with diabetic retinopathy.
Clin Ophthalmol. 2012;6:1259-1269.
Singh RP, Shusterman EM, Moshfeghi D, Danis R, Gertner M.
Pilot study of the delivery of microcollimated pars plana external
beam radiation in porcine eyes: 270-day analysis. J Ophthalmol.
2012;2012:615214.
Cole Eye Institute
Singh V, Agrawal V, Santhiago MR, Wilson SE. Stromal fibroblast-bone
marrow-derived cell interactions: Implications for myofibroblast
development in the cornea. Exp Eye Res. 2012 May;98(1):1-8.
Smadja D, Santhiago MR, Mello GR, Roberts CJ, Dupps WJ, Jr.,
Krueger RR. Response of the posterior corneal surface to myopic
laser in situ keratomileusis with different ablation depths. J Cataract
Refract Surg. 2012 Jul;38(7):1222-1231.
Smadja D, Colin J, Krueger RR, Mello GR, Gallois A,
Mortemousque B, Touboul D. Outcomes of deep anterior lamellar
keratoplasty for keratoconus: learning curve and advantages of the
big bubble technique. Cornea. 2012 Aug;31(8):859-863.
Smadja D, Santhiago MR, Mello GR, Espana EM, Krueger RR.
Suction loss during thin-flap femto-LASIK: Management and beneficial
refractive effect of the epithelium. J Cataract Refract Surg. 2012
May;38(5):902-905.
Smadja D, Reggiani-Mello G, Santhiago MR, Krueger RR. Wavefront
ablation profiles in refractive surgery: description, results, and
limitations. J Refract Surg. 2012 Mar;28(3):224-232.
Stacy RC, Jakobiec FA, Herwig MC, Schoenfield L, Singh A,
Grossniklaus HE. Diffuse large B-cell lymphoma of the orbit:
clinicopathologic, immunohistochemical, and prognostic features of
20 cases. Am J Ophthalmol. 2012 Jul;154(1):87-98.
Steinle NC, Gupta N, Yuan A, Singh RP. Oral rifampin utilisation for
the treatment of chronic multifocal central serous retinopathy.
Br J Ophthalmol. 2012 Jan;96(1):10-13.
Tarabishy AB, Hise AG, Traboulsi EI. Ocular manifestations of
the autoinflammatory syndromes. Ophthalmic Genet. 2012
Dec;33(4):179-186.
Teng K, Eng C, Hess CA, Holt MA, Moran RT, Sharp RR, Traboulsi EI.
Building an innovative model for personalized healthcare. Cleve Clin J
Med. 2012 Apr;79 Suppl 1:S1-S9.
Traboulsi EI. Pigmented and depigmented lesions of the ocular fundus.
Curr Opin Ophthalmol. 2012 Sep;23(5):337-343.
45
Triozzi PL, Singh AD. Blood biomarkers for uveal melanoma. Future
Oncol. 2012 Feb;8(2):205-215.
Triozzi PL, Achberger S, Aldrich W, Singh AD, Grane R, Borden EC.
The association of blood angioregulatory microRNA levels with
circulating endothelial cells and angiogenic proteins in patients
receiving dacarbazine and interferon. J Transl Med. 2012 Dec 5;10
(1):241.
Turell ME, Tubbs RR, Biscotti CV, Singh AD. Uveal melanoma:
prognostication. Monogr Clin Cytol. 2012;21:55-60.
Ventura BV, Moraes HV, Jr., Kara-Junior N, Santhiago MR. Role of
optical coherence tomography on corneal surface laser ablation.
J Ophthalmol. 2012;2012:676740.
Ventura BV, Ventura M, Lira W, Ventura CV, Santhiago MR,
Werner L. Microscopic analysis of opacification in Loflex®
hydrophilic acrylic intraocular lenses. Rev Bras Oftalmol. 2012
May-Jun;71(3):149-154.
Wang Y, Abu-Asab MS, Li W, Aronow ME, Singh AD, Chan CC.
Autoantibody against transient receptor potential M1 cation channels
of retinal ON bipolar cells in paraneoplastic vitelliform retinopathy.
BMC Ophthalmol. 2012 Nov 13;12:56.
Wilson SE, Santhiago MR. Flaporhexis: Rapid and effective technique
to limit epithelial ingrowth after LASIK enhancement. J Cataract
Refract Surg. 2012 Jan;38(1):2-4.
Wilson SE. Corneal myofibroblast biology and pathobiology: Generation,
persistence, and transparency. Exp Eye Res. 2012 Jun;99(1):78-88.
Yoder JS, Verani J, Heidman N, Hoppe-Bauer J, Alfonso EC, Miller D,
Jones DB, Bruckner D, Langston R, Jeng BH, Joslin CE, Tu E, Colby K,
Vetter E, Ritterband D, Mathers W, Kowalski RP, Acharya NR,
Limaye AP, Leiter C, Roy S, Lorick S, Roberts J, Beach MJ.
Acanthamoeba keratitis: The persistence of cases following a
multistate outbreak. Ophthalmic Epidemiol. 2012 Aug;19(4):
221-225.
Yuan A, Ehlers JP. Crystalline retinopathy from primary hyperoxaluria.
Retina. 2012 Oct;32(9):1994-1995.
46
Publications
Selected Publications
Outcomes 2012
Ophthalmology Research
Bagheri N, Bell BA, Bonilha VL, Hollyfield JG. Imaging human
postmortem eyes with SLO and OCT. Adv Exp Med Biol.
2012;723:479-488.
Bell BA, Kaul C, Rayborn ME, Hollyfield JG. Baseline imaging
reveals preexisting retinal abnormalities in mice. Adv Exp Med Biol.
2012;723:459-469.
Bollinger KE, Crabb JS, Yuan X, Putliwala T, Clark AF,
Crabb JW. Proteomic similarities in steroid responsiveness in
normal and glaucomatous trabecular meshwork cells. Mol Vis.
2012;18:2001-2011.
Grossman GH, Pauer GJ, Hoppe G, Hagstrom SA. Isolating
photoreceptor compartment-specific protein complexes for subsequent
proteomic analysis. Adv Exp Med Biol. 2012;723:701-707.
Gu X, Neric NJ, Crabb JS, Crabb JW, Bhattacharya SK, Rayborn ME,
Hollyfield JG, Bonilha VL. Age-related changes in the retinal pigment
epithelium (RPE). PLoS One. 2012;7(6):e38673.
Hagstrom SA, Watson RF, Pauer GJT, Grossman GH. Tulp1 is involved
in specific photoreceptor protein transport pathways. Adv Exp Med
Biol. 2012;723:783-789.
Peachey NS, Pearring JN, Bojang P, Jr., Hirschtritt ME,
Sturgill-Short G, Ray TA, Furukawa T, Koike C, Goldberg AFX, Shen Y,
McCall MA, Nawy S, Nishina PM, Gregg RG. Depolarizing bipolar
cell dysfunction due to a Trpm1 point mutation. J Neurophysiol. 2012
Nov;108(9):2442-2451.
Samuels IS, Lee CA, Petrash JM, Peachey NS, Kern TS. Exclusion of
aldose reductase as a mediator of ERG deficits in a mouse model of
diabetic eye disease. Vis Neurosci. 2012 Nov;29(6):267-274.
Stohr H, Anand-Apte B. A review and update on the molecular basis
of pathogenesis of Sorsby fundus dystrophy. Adv Exp Med Biol.
2012;723:261-267.
Sugimoto M, Cutler A, Grossman G, Anand-Apte B. Regulation of
retinal vascular permeability by betacellulin. Adv Exp Med Biol.
2012;723:293-298.
Yu M, Sturgill-Short G, Ganapathy P, Tawfik A, Peachey NS, Smith SB.
Age-related changes in visual function in cystathionine-beta-synthase
mutant mice, a model of hyperhomocysteinemia. Exp Eye Res. 2012
Mar;96(1):124-131.
Yu M, Zou W, Peachey NS, McIntyre TM, Liu J. A novel role of
complement in retinal degeneration. Invest Ophthalmol Vis Sci. 2012
Dec;53(12):7684-7692.
Hollyfield JG. Manuscript fabrication, image manipulation and
plagiarism. Exp Eye Res. 2012 Jan;94(1):1-2.
Matsuoka RL, Jiang Z, Samuels IS, Nguyen-Ba-Charvet KT,
Sun LO, Peachey NS, Chedotal A, Yau KW, Kolodkin AL.
Guidance-cue control of horizontal cell morphology, lamination, and
synapse formation in the mammalian outer retina. J Neurosci. 2012
May 16;32(20):6859-6868.
Peachey NS, Sturgill-Short GM. Response properties of slow PIII in
the Large (vls) mutant. Doc Ophthalmol. 2012 Dec;125(3):203-209.
Peachey NS, Ray TA, Florijn R, Rowe LB, Sjoerdsma T,
Contreras-Alcantara S, Baba K, Tosini G, Pozdeyev N, Iuvone PM,
Bojang P, Jr., Pearring JN, Simonsz HJ, Van Genderen M,
Birch DG, Traboulsi EI, Dorfman A, Lopez I, Ren H, Goldberg AFX,
Nishina PM, Lachapelle P, McCall MA, Koenekoop RK, Bergen AAB,
Kamermans M, Gregg RG. GPR179 is required for depolarizing
bipolar cell function and is mutated in autosomal-recessive complete
congenital stationary night blindness. Am J Hum Genet. 2012 Feb
10;90(2):331-339.
Cole Eye Institute
47
Staff Listing
Some physicians may practice in multiple
locations. For a detailed list including staff
photos, please visit clevelandclinic.org/staff.
Institute Chairman
Daniel F. Martin, MD
Vice Chairman
Quality Review Officer
Andrew P. Schachat, MD
Vice Chairman, Education
Elias I. Traboulsi, MD
Surgical Outcomes Team
Peter K. Kaiser, MD
Cornea and External Disease
William J. Dupps Jr., MD, PhD
Jeffrey M. Goshe, MD
Roger H.S. Langston, MD
Martin A. Markowitz, MD
David M. Meisler, MD
Sheldon M. Oberfeld, MD
Allen S. Roth, MD
Scott A. Wagenberg, MD
Monica Jain, MBBS, MHA
Steven E. Wilson, MD
Comprehensive
Ophthalmology
Richard E. Gans, MD
Glaucoma
Jonathan A. Eisengart, MD
Philip N. Goldberg, MD
Shalini Sood-Mendiratta, MD
Martin A. Markowitz, MD
Edward J. Rockwood, MD
Shari Martyn, MD
Keratorefractive Surgery
William J. Dupps Jr., MD, PhD
Michael E. Millstein, MD
Ronald R. Krueger, MD
Sheldon M. Oberfeld, MD
Michael E. Millstein, MD
Allen S. Roth, MD
Allen S. Roth, MD
David B. Sholiton, MD
Steven E. Wilson, MD
Scott A. Wagenberg, MD
Neuro-Ophthalmology
Gregory S. Kosmorsky, DO
Lisa D. Lystad, MD
Oculoplastics and Orbital
Surgery
Julian D. Perry, MD
48
Outcomes 2012
Institute Overview
Ophthalmic Oncology
Arun D. Singh, MD
Pediatric Ophthalmology and
Adult Strabismus
Fatema Ghasia, MD
Optometry
David Barnhart, OD
Brian Perkins, PhD
Anita Chitluri, OD
Jonathan Sears, MD
Heather L. Cimino, OD
Priyadarshini Senanayake, PhD
Jian Hua Qi, PhD
Robert Engel, OD
Andreas Marcotty, MD
Vivek Singh, PhD
Reecha Kampani, OD
Paul Rychwalski, MD
Abhijit Roy Sinha, PhD
Rosemary Perl, OD
Elias I. Traboulsi, MD
Steven E. Wilson, MD
William E. Sax, OD
Jing Xie, PhD
Mary Jo Stiegemeier, OD
Minzhong Yu, PhD
Vitreoretinal
Justis P. Ehlers, MD
Peter K. Kaiser, MD
Daniel F. Martin, MD
Andrew P. Schachat, MD
Jonathan E. Sears, MD
Rishi P. Singh, MD
Sunil K. Srivastava, MD
Alex Yuan, MD
Diane Tucker, OD
Ophthalmic Research
Joe G. Hollyfield, PhD
Chairman
Ophthalmic Anesthesia
Marc A. Feldman, MD, MHS
Section Head
Bela Anand-Apte, MBBS, PhD
J. Victor Ryckman, MD
Vera Bonilha, PhD
Sara Spagnuolo, MD
John W. Crabb, PhD
William J. Dupps Jr., MD, PhD
Uveitis
Careen Y. Lowder, MD, PhD
Lindsey Ebke, PhD
Sunil K. Srivastava, MD
Stephanie A. Hagstrom, PhD
Gregory Grossman, PhD
George Hoppe, PhD
Geeng-Fu Jang, PhD
Lisa Kuttner-Kondo, PhD
Michelle Lin, PhD
Neema Mayhugh, PhD
Neal S. Peachey, PhD
Cole Eye Institute
49
Contact Information
General Patient Referral
24/7 hospital transfers or
physician consults
800.553.5056
Cole Eye Institute
Appointments
216.444.2020 or
800.223.2273, ext. 42020
Cole Eye Institute Referrals
216.444.2030 or
800.223.2273, ext. 42030
On the Web at
clevelandclinic.org/eye
Additional Contact
Information
General Information
216.444.2200
Hospital Patient Information
216.444.2000
General Patient
Appointments
216.444.2273 or
800.223.2273
50
Referring Physician Center
and Hotline
24/7 hotline to streamline
access to our array
of medical services
and schedule patient
appointments
855.REFER.123
(855.733.3712)
Medical Concierge
Complimentary assistance
for out-of-state patients
and families
800.223.2273, ext.
55580, or email
[email protected]
Cleveland Clinic Abu Dhabi
clevelandclinicabudhabi.ae
Or email [email protected] or
visit clevelandclinic.org/
refer123
Cleveland Clinic Canada
Request for Medical
Records
Cleveland Clinic Florida
216.444.2640 or
800.223.2273, ext. 42640
Same-Day Appointments
216.444.CARE (2273)
Global Patient Services/
International Center
888.507.6885
866.293.7866
Cleveland Clinic Nevada
702.483.6000
For address corrections or
changes, please call
800.890.2467
Complimentary assistance
for international patients
and families
001.216.444.8184 or visit
clevelandclinic.org/gps
Outcomes 2012
Institute Locations
Cleveland Clinic
Main Campus
Independence Family
Health Center
9500 Euclid Ave.
Cleveland, OH 44195
Crown Centre II
5001 Rockside Road
Independence, OH 44131
216.444.2020
216.986.4000
Cole Eye Institute,
Beachwood
25101 Chagrin Blvd.
Beachwood, OH 44122
216.831.0120
Strongsville Family Health
and Surgery Center
16761 SouthPark Center
Strongsville, OH 44136
440.878.2500
Cole Eye Institute,
Hillcrest Hospital
Atrium Medical Building
6770 Mayfield Road,
Suite 326
Mayfield Heights, OH
44124
Twinsburg Family Health
and Surgery Center
8701 Darrow Road
Twinsburg, OH 44087
330.888.4000
440.461.4733
Cole Eye Institute
51
About Cleveland Clinic
Overview
Cleveland Clinic is an academic medical center offering patient care services supported by
research and education in a nonprofit group practice setting. More than 3,000 Cleveland
Clinic staff physicians and scientists in 120 medical specialties care for more than 5 million
patients across the system, performing more than 200,000 surgeries and conducting
450,000 Emergency Department visits. Patients come to Cleveland Clinic from all 50 states
and more than 132 nations around the world.
Cleveland Clinic is an integrated healthcare delivery system with local, national, and
international reach. The main campus in midtown Cleveland, Ohio, has a 1,450-bed
hospital, outpatient clinic, specialty institutes, labs, classrooms, and research facilities in
46 buildings on 167 acres. Cleveland Clinic patients represent the highest CMS case-mix
index in the nation. Cleveland Clinic encompasses 75 northern Ohio outpatient locations,
including 16 full-service family health centers, eight community hospitals, an affiliate
hospital, and a rehabilitation hospital for children. Cleveland Clinic also includes Cleveland
Clinic Florida, Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas, Cleveland
Clinic Canada, and Sheikh Khalifa Medical City (management contract). Cleveland Clinic Abu
Dhabi is a full-service hospital and outpatient center in the United Arab Emirates scheduled
to begin offering services in 2014. Cleveland Clinic is the second-largest employer in Ohio
with nearly 44,000 employees. It generates $10.5 billion of economic activity a year.
The Cleveland Clinic Model
Cleveland Clinic was founded in 1921 by four physicians who had served in World War I and
hoped to replicate the organizational efficiency of military medicine. The organization has
grown through the years by adhering to the model set forth by the founders. All Cleveland
Clinic staff physicians receive a straight salary with no bonuses or other financial incentives.
The hospital and physicians share a financial interest in controlling costs, and profits are
reinvested in research and education.
The Cleveland Clinic system began to grow in 1987 with the founding of Cleveland Clinic
Florida and expanded in the 1990s with the development of 16 family health centers across
Northeast Ohio. Fairview Hospital, Hillcrest Hospital, and six other community hospitals
joined Cleveland Clinic over the past decade and a half, offering Cleveland Clinic institute
services in heart and neurological care, physical rehabilitation, and more. Clinical and
support services were reorganized into 27 patient-centered institutes beginning in 2007.
Institutes combine medical and surgical specialists around specific diseases or body systems
under single leadership and in a shared location to provide optimal team care for every
patient. Institutes work with the Office of Patient Experience to give every patient the best
outcome and experience.
52
Outcomes 2012
Cleveland Clinic Lerner Research Institute
At the Lerner Research Institute, hundreds of principal
investigators, project scientists, research associates,
and postdoctoral fellows are involved in laboratorybased translational and clinical research. Total research
expenditures from external and internal sources exceeded
$265 million in 2012. Research programs include
cardiovascular, oncology, neurology, musculoskeletal,
allergy and immunology, ophthalmology, metabolism, and
infectious diseases.
Cleveland Clinic Lerner College of Medicine
Lerner College of Medicine of Case Western Reserve
University, which celebrated its 10th anniversary in 2012,
is known for its small class size, unique curriculum, and
full-tuition scholarships for all students. The program is
open to 32 students who are preparing to be physician
investigators.
Graduate Medical Education
In 2012, nearly 1,800 residents and fellows trained at
Cleveland Clinic and Cleveland Clinic Florida, which is part
of a continuing upward trend.
U.S. News & World Report Ranking
Cleveland Clinic is consistently ranked among the top
hospitals in America by U.S. News & World Report, and
our heart and heart surgery program has been ranked
No. 1 in the nation since 1995. In 2012, Cleveland Clinic’s
urology and nephrology programs were both ranked No. 1
in the nation.
For more information about Cleveland Clinic, please visit
clevelandclinic.org.
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Resources
Referring Physician Center and Hotline
24/7 hotline to streamline access to our array of
medical services and schedule patient appointments,
call 855.REFER.123 (855.733.3712),
email [email protected], or visit clevelandclinic.org/refer123
Remote Consults
Online medical second opinions from Cleveland Clinic’s
MyConsult® are particularly valuable for patients who
wish to avoid the time and expense of travel. Cleveland
Clinic offers online medical second opinions for more
than 1,200 life-threatening and life-altering diagnoses.
For more information, visit clevelandclinic.org/myconsult,
email [email protected], or call 800.223.2273,
ext. 43223.
Request Medical Records
216.444.2640 or 800.223.2273, ext. 42640
Track Your Patients’ Care Online
DrConnect® offers referring physicians secure access to
their patients’ treatment progress while at Cleveland
Clinic. To establish a DrConnect account, visit
clevelandclinic.org/drconnect or email [email protected].
Medical Records Online
Cleveland Clinic continues to expand and improve
electronic medical records (EMRs) to provide faster,
more efficient, and more accurate care by sharing patient
data through a highly secure network. Patients using
MyChart® can renew prescriptions and review test results
and medications from their personal computers. MyChart
provides a link to Microsoft HealthVault, a free online
54
service that helps patients securely gather and
store health information. It connects to Cleveland
Clinic’s social media and Internet site, currently the
most visited hospital website in America. For more
information, visit clevelandclinic.org/mychart.
Critical Care Transport Worldwide
Cleveland Clinic’s critical care transport team and
fleet of mobile ICU vehicles, helicopters, and fixedwing aircraft serve critically ill and highly complex
patients across the globe.
To arrange a transfer for STEMI (ST elevated
myocardial infarction), acute stroke, ICH
(intracerebral hemorrhage), SAH (subarachnoid
hemorrhage), or aortic syndrome, call
877.379.CODE (2633).
For all other critical care transfers, call
216.444.8302 or 800.553.5056.
CME Opportunities: Live and Online
Cleveland Clinic’s Center for Continuing Education
operates one of the largest and most successful
CME programs in the country. The center’s
website (ccfcme.org) is an educational resource for
healthcare providers and the public. Available 24/7,
it houses programs that cover topics in 30 areas.
Among other resources, the website contains a
virtual textbook of medicine (Disease Management
Project) and myCME, a system for physicians
to manage their CME portfolios. Live courses,
however, remain the backbone of the center’s CME
operation. Most live courses are held in Cleveland,
but outreach plans are underway.
Outcomes 2012
Clinical Trials
Since its establishment in 1921, Cleveland
Clinic has been an innovator in medical
breakthroughs, with a mission of unlocking
basic science and pursuing clinical research.
Today, Cleveland Clinic is running more
than 2,000 clinical trials of various types.
Our researchers are focusing on an array
of conditions, including breast and liver
cancer, coronary artery disease, heart
failure, epilepsy, Parkinson disease, chronic
obstructive pulmonary disease, asthma,
high blood pressure, diabetes, depression,
and eating disorders. To learn more, go to
clevelandclinic.org/research.
Healthcare Executive Education
Cleveland Clinic’s dynamic executive
education program provides real-world
insights into the highly competitive
business of healthcare. The Executive
Visitors’ Program is an intensive threeday program that provides a behind-thescenes view of our organization for the busy
executive. The Samson Global Leadership
Academy is a two-week immersion into
the challenges of leadership, management,
and innovation. The curriculum includes
coaching and a personalized three-year
leadership development plan. Learn more at
clevelandclinic.org/execed.
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This project would not have been possible without
the commitment and expertise of a team led by
Peter K. Kaiser, MD, and Monica Jain, MBBS, MHA.
Graphic design and photography were provided by
Cleveland Clinic’s Center for Medical Art and Photography.
© The Cleveland Clinic Foundation 2013
9500 Euclid Avenue, Cleveland, OH 44195
clevelandclinic.org
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