Download ARVO 2016 Annual Meeting Abstracts 479 Clinical potpourri

ARVO 2016 Annual Meeting Abstracts
479 Clinical potpourri
Wednesday, May 04, 2016 3:45 PM–5:30 PM
Exhibit/Poster Hall Poster Session
Program #/Board # Range: 5536–5586/D0041–D0091
Organizing Section: Clinical/Epidemiologic Research
Program Number: 5536 Poster Board Number: D0041
Presentation Time: 3:45 PM–5:30 PM
Patient Utilization of Web-Based Health Data Management
Technology in an Outpatient Ophthalmology Practice Setting
Robert W. Wong1, 2, Mackenzie Franklin1, 3, Shelley Day1, 2,
Jose A. Martinez1, 2, Clio A. Harper1, 2, James W. Dooner1, 2,
Mark Levitan1, 2, Peter A. Nixon1, 2. 1Ophthalmology, Austin Retina
Associates, Austin, TX; 2Surgery, Texas A&M Health Science Center,
Bryan, TX; 3Molecular, Cellular and Developmental Biology |
Neuroscience, Yale University, New Haven, CT.
Purpose: In today’s evolving healthcare environment, technology has
improved patient access to medical services from remote locations
outside of the physician’s office. We performed a survey to assess our
patients’ preferences and utilization patterns of web-based technology
in managing their ocular disease.
Methods: A fourteen question survey was conducted at a single,
outpatient, private retina practice. The questions were designed to
assess demographics, patients’ utilization of a smartphone, tablet, or
personal computer (PC) to manage their personal health with regards
to scheduling an appointment, pay medical bills, browse online
physician reviews, or to research a medical condition within the past
six months, patients’ interest in participating in telemedicine, using
a wearable device, and using an at-home monitoring device for their
ocular condition. Groups were compared across age (<35, 35 to 49,
50 to 64, and >65 years) and diagnosis.
Results: 200 of 283 subjects completed the survey for a response
rate of 71%. Age groups reflected those of a typical retina practice:
Age <35 years (13.5%), age 35-49 (22.5%), age 50-64 (25.5%) and
age >65 (38.5%). Younger patients use a smartphone, tablet or PC to
manage or track their health (age <35, 74%; 35-49, 40%) more than
older patients (age 50-64, 14%; >65, 12%). 77% of patients have
either already used or were interested in using telemedicine in the
future in lieu of a doctor’s visit to manage their healthcare. Nearly all
younger patients (age <35, 93% and 35-49, 93%) and the majority
of older patients (age 50-64, 66%; and >65, 56%) were interested in
using a wearable device to monitor their health. Interest in using an
at-home monitor device was fairly even across age groups (age <35,
74%; 35-49, 68%; 50-64, 56%; and >65, 62%). Of these, 100% of
central serous retinopathy and 69% of macular degeneration patients
expressed interest.
Conclusions: The majority of younger patients, and some older
patients, are currently using web-based technology to manage
their health care and are interested in remote-based monitoring via
telemedicine or wearable devices in the future. Most patients across
all age groups expressed interest in using an at-home monitoring
device with special concern for macular pathology where central
vision is at risk. These findings may be helpful in guiding which
services to offer patients in the future.
Commercial Relationships: Robert W. Wong, None;
Mackenzie Franklin, None; Shelley Day, None; Jose A. Martinez,
None; Clio A. Harper, None; James W. Dooner, None;
Mark Levitan, None; Peter A. Nixon
Program Number: 5537 Poster Board Number: D0042
Presentation Time: 3:45 PM–5:30 PM
Implementation and assessment of visual acuity screening
of Ebola Virus Disease survivors utilizing the Peek Vision
smartphone platform
Sina Vahedi1, Allen O. Eghrari2, Rachel J. Bishop3,
Christopher J. Brady2, Cavan S. Reilly4, Frederick L. Ferris3,
Jemma Larbelee5, Mosoka Fallah6. 1Jefferson Medical College,
Philadelphia, PA; 2Wilmer Eye Institute, Baltimore, MD; 3National
Eye Institute, Bethesda, MD; 4University of Minnesota, Minneapolis,
MN; 5Redemption Hospital, Liberian Ministry of Health, Monrovia,
Liberia; 6PREVAIL III, Monrovia, Liberia.
Purpose: Vision loss is a leading complaint among survivors of
Ebola Virus Disease. Vision screening tools are needed that can be
implemented in cross-cultural settings by technicians with minimal
previous health care training. The PREVAIL III Ebola Survivor
Study is a 5-year longitudinal study of the medical effects of Ebola
Virus Disease (EVD) on survivors sponsored by the US National
Institute for Allergy and Infectious Disease and the Liberian Ministry
of Health and Social Welfare. We report the practical application
of the smartphone-based Peek visual acuity assessment tool in
Monteserrado County, Liberia among Ebola survivors and close
contacts participating in the study.
Methods: Non-ophthalmic health care workers were trained to use
the Peek Vision Beta application, which presents the tumbling E in
ETDRS character sizes. The Moto G smartphone, which contains
a 4.5-inch screen and 1280 x 720 pixel resolution, was calibrated
for use at 2.4 meters based on the visual angle of ETDRS
character size. Visual acuity of each eye was independently tested
using an occluder and results documented. 81.4% of survivors
and 84.2% of controls failed visual acuity threshold of 20/25
or reported eye complaints and received a second, uncorrected
distance visual acuity testing by an ophthalmic technician in a
standardized examination lane using a tumbling E chart. Results
were categorized as a binary outcome, either “good”(better than
20/40) or “not good” (20/40 or worse visual acuity).
Results: Of 1092 total eyes examined by both eye technicians and
health care workers, vision in was categorized as “not good” in 154
eyes (14.1%) by health care workers and in 103 eyes (9.4%) by eye
technicians. Sensitivity for identification of “not good” vision was
73.7% and specificity for “good” vision was 92.1%.
Conclusions: Health care workers without ophthalmic experience
can perform smartphone visual acuity screening. Additional analyses
will explore ideal screening cutoffs. These results are significant for
capacity building in regions with limited ophthalmic personnel or
facilities for both research and clinical care delivery.
Commercial Relationships: Sina Vahedi; Allen O. Eghrari,
None; Rachel J. Bishop, None; Christopher J. Brady,
None; Cavan S. Reilly, None; Frederick L. Ferris, None;
Jemma Larbelee, None; Mosoka Fallah, None
Program Number: 5538 Poster Board Number: D0043
Presentation Time: 3:45 PM–5:30 PM
Assessing the utility of phenylephrine 2.5% for diagnostic
pupillary dilation
James C. Liu1, 2, Wesley Green1, Susan M. Culican1, Gregory Van
Stavern1. 1Department of Ophthalmology and Visual Sciences,
Washington University School of Medicine, St. Louis, MO; 2Indiana
University School of Medicine Transitional Residency Program,
Indianapolis, IN.
Purpose: Phenylephrine eye drops are routinely used in dilated
eye examinations, but have increased drastically in price over the
past few years. We performed a prospective, unmasked, crossover
These abstracts are licensed under a Creative Commons Attribution-NonCommercial-No Derivatives 4.0 International License. Go to http://iovs.arvojournals.org/
to access the versions of record.
ARVO 2016 Annual Meeting Abstracts
pilot study to evaluate whether the addition of phenylephrine to
tropicamide produces any statistically and clinically significant
change in pupil size.
Methods: Twenty healthy students and faculty members affiliated
with the Washington University School of Medicine were enrolled.
Each had 3 distinct dilating eye drop regimens administered to the
left eye on separate days. The routine regimen used clinically at
Washington University for dilated eye examination is tropicamide
(T) + proparacaine (PP) + phenylephrine (PE) (T+PP+PE). This was
considered the standard therapy to which tropicamide + proparacaine
(T+PP) and tropicamide alone (T alone) were compared.
Measurements of pupil size were made before and 30 minutes after
eye drop administration using an automated pupillometer. Primary
outcome measures were post-dilation pupil size and proportion of
pupils able to achieve post-dilation pupil size >7mm. The latter
served as a measure of clinical significance. Comparisons between
the 3 regimens were made using paired t-tests and McNemar’s test,
with T+PP+PE serving as the standard therapy.
Results: Mean post-dilation pupil size was 7.94±0.78mm,
7.64±0.78mm, and 7.48±0.77mm for T+PP+PE, T+PP, and T alone,
respectively. T+PP+PE was statistically superior to T+PP (p=0.0043)
and T alone (p<0.0001) with respect to post-dilation pupil size.
The proportion of pupils able to achieve adequate pupil dilation of
>7mm was 90%, 80%, and 70% for T+PP+PE, T+PP, and T alone,
respectively. No statistical difference was observed in each regimen’s
ability to achieve adequate pupil dilation of >7mm (T+PP+PE and
T+PP: p=0.47; T+PP+PE and T alone: p=0.13).
Conclusions: The addition of phenylephrine eye drops to tropicamide
provides larger pupil dilation, but the magnitude of benefit is
marginal and clinically insignificant in this healthy cohort.
Commercial Relationships: James C. Liu, None; Wesley Green,
None; Susan M. Culican, None; Gregory Van Stavern
Support: This work was supported by awards to the Department
of Ophthalmology and Visual Sciences at Washington University
from a Research to Prevent Blindness, Inc. unrestricted grant, the
NIH Vision Core Grant P30 EY 0268, and awards from the Lacy
Glaucoma Research Fund to SMC.
steroids, which are contraindicated in acute infectious conjunctivitis.
Prescription fills differed by age, race, income & diagnosing provider
(all p<0.001) but not contact lens wear (p=0.58) or HIV diagnosis
(p=0.36) (Table 1). Whites, those with higher incomes, and more
educated patients had higher odds of receiving antibiotics for acute
conjunctivitis compared with non-whites, less affluent and educated
patients (all p<0.0001) (Table 2). Compared to patients diagnosed
by ophthalmologists (37% fill), patients had higher percentages &
odds of antibiotic fill if diagnosed by urgent care MDs (68% fill; OR
3.02, CI 2.91-3.13), internists (58%; OR 2.64, CI 2.55-2.74), family
practice MDs (55%; OR 2.31, CI 2.23-2.40), pediatricians (59%; OR
2.17, CI 2.03-2.32), and optometrists (45%; OR 1.19, CI 1.15-1.24).
Patients with HIV were no more likely to receive antibiotics (p=0.81)
and those with end-organ damage from diabetes were 18% less likely
to get antibiotics (p<0.0001) compared to patients without these
conditions.
Conclusions: We identify rampant over-prescription of antibiotics for
conjunctivitis in the US among insured patients, including potentially
harmful practices that may increase costs, prolong infection duration,
& lead to antibiotic resistance. Antibiotic use appears to be driven
more by sociodemographic factors & provider type than medical
indication.
Program Number: 5539 Poster Board Number: D0044
Presentation Time: 3:45 PM–5:30 PM
Substantial Over-Prescription of Antibiotics for Acute
Conjunctivitis in the United States
Nakul Shekhawat1, Roni M. Shtein1, Taylor Blachley1,
Joshua D. Stein1, 2. 1W.K. Kellogg Eye Center, Department of
Ophthalmology and Visual Sciences, University of Michigan,
Ann Arbor, MI; 2Institute for Health Care Policy and Innovation,
University of Michigan, Ann Arbor, MI.
Purpose: Acute conjunctivitis is often caused by a virus, thus
antibiotic therapy is usually unnecessary. We examined the extent that
patients diagnosed with acute conjunctivitis are treated with topical
antibiotics & factors associated with antibiotic use.
Methods: We analyzed health claims data from a large US managed
care plan from 2001-2014. Eligible patients were diagnosed with
acute conjunctivitis & continuously enrolled for >90 days after initial
diagnosis. We excluded hospitalized patients, those undergoing
eye surgery, or those with chronic conjunctivitis. Topical antibiotic
use was defined as a prescription fill within 14 days of initial
conjunctivitis diagnosis. Patient demographics, diagnosing provider,
time to prescription fill, & antibiotic class were studied. Multivariable
logistic regression determined factors associated with antibiotic use.
Results: Of 340,630 patients diagnosed with acute conjunctivitis,
198,511 (58%) filled prescriptions for topical antibiotics. 20% of
patients (N=38,774) filled prescriptions for combined antibioticThese abstracts are licensed under a Creative Commons Attribution-NonCommercial-No Derivatives 4.0 International License. Go to http://iovs.arvojournals.org/
to access the versions of record.
ARVO 2016 Annual Meeting Abstracts
These abstracts are licensed under a Creative Commons Attribution-NonCommercial-No Derivatives 4.0 International License. Go to http://iovs.arvojournals.org/
to access the versions of record.
ARVO 2016 Annual Meeting Abstracts
Commercial Relationships: Nakul Shekhawat, None;
Roni M. Shtein, None; Taylor Blachley, None; Joshua D. Stein,
None
Support: Research to Prevent Blindness; Kellogg Foundation
Program Number: 5540 Poster Board Number: D0045
Presentation Time: 3:45 PM–5:30 PM
Sharp injuries in ophthalmology residency: results of a resident
quality improvement project
Aliya Z. Jiwani, Jo Anne Ricca, Carolyn Kloek. Ophthalmology,
Mass. Eye and Ear Infirmary, Harvard Medical School, Boston, MA.
Purpose: While sharp injuries may occur more frequently in
residents1-3 than other health care workers, few studies in the
US examine sharp injuries in residents1-5 and none specifically
examine ophthalmology residents. The purpose of this research is to
characterize sharp injuries among ophthalmology residents at a high
volume academic center with a high number of resident procedures.
Methods: A retrospective chart review was conducted of the 27
ophthalmology resident sharp incident reports filed at Massachusetts
Eye and Ear Infirmary’s (MEEI) occupational health from 2009-2014.
An anonymous survey was administered to the 24 current MEEI
ophthalmology residents in June 2015.
Results: The 27 sharp injuries reported to occupational health by
ophthalmology residents occurred more frequently to PGY-2s,
during oculoplastics procedures and with suture needles. The source
patient’s blood was drawn 89% (24/27) of the time, and 12.5% (3/24)
of the source patient’s blood was positive. For the anonymous survey,
83% (20/24) responded. Of the respondents, 45% (9/20) self-reported
at least one sharp stick during ophthalmology residency, but 2 of
these residents failed to report the injuries. The majority (71%, 5/7)
of those who reported the stick felt the reporting process was very
easy to reasonable, with 29% (2/7) reporting that it was cumbersome.
70% of respondents knew how to report a sharp injury at the primary
teaching site, but only 10-20% knew how to do so at the other 7 sites.
Qualitative comments were collected about factors contributing to the
injury and reasons for non-reporting.
Conclusions: Education in sharp safety to decrease injuries and
improve reporting rates may be helpful.
Commercial Relationships: Aliya Z. Jiwani, None; Jo Anne Ricca,
None; Carolyn Kloek, None
Program Number: 5541 Poster Board Number: D0046
Presentation Time: 3:45 PM–5:30 PM
Triaging Ophthalmic Emergencies: A 4-Parameter Tool
embedded in an Emergency Department’s Electronic Health
Record System
Farhan Merali1, Oliver Schein1, Stephanie Figueroa2,
Peter Pronovost3, Mustapha Saheed2, Rose Johnson2, Tina Tolson2,
Peter Hill2, Michael P. Grant4, Shameema Sikder1. 1Cornea and
External Disease, Wilmer Eye Institute, Baltimore, MD; 2Department
of Emergency Medicine, Johns Hopkins Hospital, Baltimore, MD;
3
Armstrong Institute for Patient Safety and Quality, Johns Hopkins
Hospital, Baltimore, MD; 4Ophthalmic Plastic and Reconstructive
Surgery, Wilmer Eye Institute, Baltimore, MD.
Purpose: To assess the reliability of a 4-parameter triaging
system embedded in the electronic health record (EHR) system
in predicting ophthalmic urgency when conducted by emergency
department (ED) nurses.
Methods: A 4-parameter triaging system previously found to be
highly reliable in detecting urgent ophthalmic pathology at an
ophthalmic ED was adapted for use by non-ophthalmic providers:
(1) Descriptive and visual guidelines for use were developed, and (2)
The triaging system and developed guidelines were embedded into
the ED’s EHR. All patients presenting to the ED with an ophthalmic
complaint were assigned a score between 0 and 12 by an ED triaging
nurse that assessed the patient’s presentation in four categories: eye
redness, eye pain, risk of open globe, and vision loss. Color coding
was assigned based on the cumulative triaging score: 0–3 was
classified as green, 4–7 as yellow, and 8–12 as red. The triaging score
was compared against the ophthalmic consultant’s assessment in the
same categories and assigned diagnosis.
Results: During the study period, 250 patients were assessed. Of
these, 72 (28.8%) patient presentations were classified as urgent (a
code of yellow or red), with the remainder classified as non-urgent.
Patients were triaged using the tool within 9.1 ± 5.3 minutes of
arriving at the ED. The sensitivity of the system was 0.958(95% CI
0.88-0.99) and specificity 0.781(95% CI 0.71-0.84). The correlation
between urgency level as coded by triage nurses and eye care
providers was significant with a Spearman’s rank coefficient 0.67
(P<0.0001): 82.0% patients were coded at the identical level of
urgency by both providers; 6.0% were undercoded by one category
level, 11.6% were overcoded by one category level, and 0.4% were
overcoded by two category levels.
Conclusions: The triaging tool as administered by ED nurses using
the guidelines developed is a simple, rapid and highly sensitive
method of detecting urgent ocular pathology. Such a system holds
the potential to decrease the cost of eye care to patients and the
health care system more broadly. By reliably referring patients
with non-urgent ocular conditions to outpatient appointments in
collaboration with ophthalmic providers, wait times and length of
stay may be considerably reduced for all-comers, while valuable and
costly ED resources would be conserved for patients with truly urgent
conditions.
Commercial Relationships: Farhan Merali, None; Oliver Schein,
None; Stephanie Figueroa, None; Peter Pronovost, None;
Mustapha Saheed, None; Rose Johnson, None; Tina Tolson, None;
Peter Hill, None; Michael P. Grant, None; Shameema Sikder,
None
Program Number: 5542 Poster Board Number: D0047
Presentation Time: 3:45 PM–5:30 PM
Emergency Department Patient Experience of Eye Care:
Implications for First Year Ophthalmology Residents
Jenna Kim, Syed A. Hussnain, Ninani Kombo. Ophthalmology and
Visual Sciences, Yale University, New Haven, CT.
Purpose: Little is known about the level of patient satisfaction from
those who receive care from first year ophthalmology residents,
particularly in the Emergency Department (ED) setting. We
hypothesize that despite acuity of problems and the time constraints
placed by the nature of care in the ED, first year ophthalmology
residents provide satisfactory patient care with high level of empathy,
professionalism, and clinical competency.
Methods: Thirty-one consecutive patients presenting for follow-up
at our acute eye care clinic after initial ED encounter were requested
to fill out an anonymous survey on a voluntary basis. The inclusion
criteria was age greater than 18, competency in English language,
initial evaluation by a first year ophthalmology resident in ED and
subsequent discharge (i.e. no admission to the hospital), and absence
of altered mental status at the time of ED encounter. Providers were
blinded to patients’ participation and responses.
Results: Of the 31 survey responders, 20 were male (mean age
43 years, range 18-75 years). Over 50% presented to the ED with
an acute injury to the eye. Ninety percent of the patients rated the
importance of hand hygiene as “very” or “extremely important”, and
84% remembered the resident practicing hand hygiene, and 16%
did not remember whether hand hygiene was practiced. All survey
These abstracts are licensed under a Creative Commons Attribution-NonCommercial-No Derivatives 4.0 International License. Go to http://iovs.arvojournals.org/
to access the versions of record.
ARVO 2016 Annual Meeting Abstracts
participants reported that the provider spoke clearly, which was rated
“very” or “extremely important” by 93% of the participants. Level
of clinical knowledge was cited by 21 out of 31 responders as the
most important criteria when evaluating their provider. The overall
satisfaction score (possible score range between 0-10) was 9.4 ±1.02.
High education level was the greatest predictor for lower level of
satisfaction with the encounter (LR 5.75) compared to those with
fewer than 4 years of college education.
Conclusions: Our survey suggests that despite the obstacles in
providing optimal patient care due to the time constraints in the
ED and the relatively limited clinical experience of the first year
ophthalmology residents, high level of patient satisfaction can be
achieved by adhering to principles of patient-centered care such as
clear communication and hand hygiene. As level of knowledge was
perceived as the most important factor by patients in this survey,
beginning residents should not ignore the value of enhancing their
knowledge depth and breadth.
Commercial Relationships: Jenna Kim; Syed A. Hussnain, None;
Ninani Kombo, None
Program Number: 5543 Poster Board Number: D0048
Presentation Time: 3:45 PM–5:30 PM
Internal Medicine Residents and the Fundus: Improving skill
with direct ophthalmoscopes and increasing knowledge of basic
ocular pathology
Christine Martinez, Cheryl Bloomfield. Internal Medicine, Lehigh
Valley Health Network, Breinigsville, PA.
Purpose: Following graduation from medical school, internal
medicine physicians-in-training receive very little instruction on
use of the direct ophthalmoscope and basic eye pathology. We
surveyed residents to determine comfort level and skill with the direct
ophthalmic exam, implemented a structured didactic curriculum and
then re-surveyed the same residents. We hypothesize that appropriate
and focused education will result in resident-reported improvement in
comfort, skill, and knowledge.
Methods: Sixty-one internal medicine residents were administered
a 10-question survey to determine comfort and skill level with the
direct ophthalmoscope, frequency of attempted and successful fundus
exams, and knowledge of basic ocular pathology. Five structured
didactic sessions were then planned and implemented by a program
faculty member and optometrist. These teaching sessions included
material presented in a lecture format as well as hands-on exam
practice. Following the conclusion of the sessions residents were resurveyed to assess for improvement in comfort level, exam skills and
knowledge of eye pathology.
Results: The response rate of the initial survey was 51% (31/61).
77% (24/31) of residents reported that they are either “very”
uncomfortable or “somewhat” uncomfortable with the direct
ophthalmoscope. 90% (28/31) attempt a fundus exam on half
or less than half of patients in whom an eye exam with a direct
ophthalmoscope is clinically indicated. 26% (8/31) of residents are
“never” or “rarely” able to visualize blood vessels on retinal exam
and 74% (23/31) are “never” or “rarely” able to visualize the optic
nerve. 65% (20/31) of residents answered a basic knowledge question
regarding the visualization of the optic nerve incorrectly. The
results of the repeat survey are still pending at the time of abstract
submission.
Conclusions: Our study demonstrates that internal medicine
residents report significant discomfort and difficulty with the
direct ophthalmoscope exam. A deficiency in ocular knowledge
is also revealed. Residents will likely report improvement in
comfort, skill, and knowledge following the implementation of a
focused didactic program.
Commercial Relationships: Christine Martinez, None;
Cheryl Bloomfield, None
Program Number: 5544 Poster Board Number: D0049
Presentation Time: 3:45 PM–5:30 PM
The profile of respondents to a survey of ophthalmologists in the
English-speaking Caribbean: principal findings
Andrew F. Smith1, 2, Alex Klotz1, Juan Carlos Silva3, Nigel Barker4.
1
Medmetrics Inc., Ottawa, ON, Canada; 2Department of
Ophthalmology, King’s College London, London, United
Kingdom; 3Pan American Health Organization, Bogota, Colombia;
4
Ophthalmological Society of the West Indies, St. Michael, Barbados.
Purpose: There is no data on the profile of ophthalmologists
providing ophthalmological services and treatments across the
English-speaking Caribbean. We aimed to gather such data, as it is
potentially useful for planning the delivery of eye care services and
training initiatives across the region.
Methods: As no comprehensive database of ophthalmologists
working in the English-speaking Caribbean could be located,
both national and regional ophthalmological societies across the
English-speaking Caribbean were contacted to extract a listing
of ophthalmologists likely to be involved in the provision of
ophthalmological services and treatments. A total of 171 practicing
ophthalmologists and/or ophthalmology residents were identified
and contacted via email and telephone across 12 English-speaking
Caribbean nations in late 2014 and early 2015.
Results: A total of 49 completed questionnaires were returned,
yielding a response rate of 29%. Survey respondents, reported
working 42.71 hours per week, with 60%, 38% and 2% of these
hours spent in the private, public and NGO sectors, respectively.
Among those ophthalmologist’s returning completed questionnaires,
70% percent had completed their ophthalmology training outside of
the Caribbean, and 40% had obtained some form of sub-specialty
qualification. Overall, the average length of the residency training
for responding ophthalmologists was 48.5 months with a range
from between 36 and 60 months. The average length of tenure as a
practicing ophthalmologist among respondents was 15.27 years and
only 8% indicated that they would retire in the next 5 years. Most of
the small numbers of responding ophthalmologists reported they had
good access to key the pieces of ophthalmological equipment needed
for diagnosing, treating and conducting eye surgery.
Conclusions: Given the small number of respondents to the
survey, the findings from this survey do not represent the entire
ophthalmological community in the English speaking Caribbean.
Strategies to increase the coverage of data collection on the
ophthalmological workforce across the region warrant urgent
attention in assessing the human resources development needs in
ophthalmology.
Commercial Relationships: Andrew F. Smith, MedMetrics Inc (C),
MedMetrics Inc (F), MedMetrics Inc; Alex Klotz, MedMetrics Inc.
(C), MedMetrics Inc (F); Juan Carlos Silva, Pan American Health
Organization; Nigel Barker, None
Support: Pan-American Health Organization (PAHO)
Program Number: 5545 Poster Board Number: D0050
Presentation Time: 3:45 PM–5:30 PM
Influence of Post-interview Communication Between Residency
Applicants and Ophthalmology Residency Programs on
Programs’ Ranking of Applicants
Nicholas Behunin, Ingrid U. Scott, Mark Goerlitz-Jessen,
Darren Hill. Ophthalmology, Penn State Hershey, Hummelstown, PA.
Purpose: While San Francisco Match rules permit postinterview communication (PIC) between residency applicants
These abstracts are licensed under a Creative Commons Attribution-NonCommercial-No Derivatives 4.0 International License. Go to http://iovs.arvojournals.org/
to access the versions of record.
ARVO 2016 Annual Meeting Abstracts
and ophthalmology residency programs, it is unknown whether
PIC affects programs’ ranking of applicants. The current study
investigates the influence of PIC between residency applicants
and ophthalmology residency programs on programs’ ranking of
applicants.
Methods: An anonymous survey including multiple choice and
Likert-type questions was created using RedCAP electronic data
capture tools hosted at Penn State Hershey. An e-mail with a
description of the study and link to the survey was sent to the
program director (PD) of each ophthalmology residency training
program in the United States accredited by the Accreditation Council
for Graduate Medical Education (ACGME). Weekly reminders were
sent for two consecutive weeks.
Results: Thirty-three of 116 (28.4%) PDs completed the survey.
The type of PIC followed by the proportion of respondents who
reported that type of PIC would typically result in an applicant being
moved upward (more favorably) on the program’s rank list included:
applicant stating they will rank the program highly (3.0%), applicant
stating they will rank the program “number 1” (3.0%), applicant’s
faculty mentor (NOT personally known to PD) stating the candidate
will rank program “number 1” (0.0%), applicant’s faculty mentor
(personally known to PD) stating the candidate will rank program
“number 1” (21.2%), applicant’s faculty mentor (NOT personally
known to PD) endorsing candidate as outstanding (15.2%),
applicant’s faculty mentor (personally known to PD) endorsing
candidate as outstanding (42.4%). Among respondents, 39.4% agreed
they would not consider changing applicant rank order as a result
of any PIC from an applicant or their faculty mentor(s), and 6.0%
agreed that applicants who did NOT have a faculty mentor contact
the program on their behalf were disadvantaged compared to those
who contacted programs.
Conclusions: Post-interview endorsement by a faculty mentor who
is personally known to an ophthalmology residency PD is more
likely to improve the rank of an applicant than any other type of
PIC included in the study. This suggests that applicants who do not
engage in PIC or who do not have “well-connected” mentors may
be at a disadvantage. Further study is warranted to investigate these
findings further.
Commercial Relationships: Nicholas Behunin, None;
Ingrid U. Scott, None; Mark Goerlitz-Jessen, None; Darren Hill,
None
Program Number: 5546 Poster Board Number: D0051
Presentation Time: 3:45 PM–5:30 PM
The experiences and perceptions of paediatric ophthalmic
clinicians using electronic medical records in the United Kingdom
Maria S. Cross1, George W. Aylward3, Jugnoo S. Rahi1, 2. 1UCL
Institute Child Health, London, United Kingdom; 2National Institute
for Health Research (NIHR) Biomedical Research Centre at
Moorfields Eye Hospital NHS Foundation Trust, London, United
Kingdom; 3UCL Institute of Ophthalmology, London, United
Kingdom.
Purpose: Electronic medical records (EMRs) are at the core of a
recent movement towards information-driven healthcare. However,
paucity in the evidence base surrounding EMR adoption, use and
evaluation within paediatric ophthalmology hinders technological
development and meaningful application within the field.
We conducted a national survey to investigate paediatric ophthalmic
clinicians’ experiences and perceptions surrounding routine EMR use
in the United Kingdom (UK).
Methods: A survey was designed with four sections that considered
(1) routine documentation practices, (2) the perceived benefits
of routine EMR use, (3) the perceived barriers, and (4) optional
questions assessing experiences of routine EMR use.
The survey was administered online. Email invitations were sent
to potential participants via the national mailing list for paediatric
ophthalmologists, with two reminder emails sent three weeks apart.
Responses were collected between June and August 2015, and
analysed using univariate statistical tests.
Results: 90 individuals from 42 different UK hospitals completed
the survey. Only 16.9% of respondents routinely use electronic
documentation methods, although 64.4% reported some experience
using an EMR. Respondents’ perceptions varied according to these
experiences. Individuals with any prior experience (N=58) were
significantly more like to identify ‘difficult-to-navigate system
designs’ (p=0.013) and ‘poor user interface’ (p=0.015) as barriers or
challenges preventing routine EMR use. However in both groups,
‘software functionalities not meeting clinical needs’ was most
frequently identified as the biggest barrier preventing use (25.3% of
all individuals).
Conclusions: This survey suggests UK paediatric ophthalmic
clinicians do not believe EMRs meet clinical demands. The increased
likelihood of those with prior EMR experience to select certain
usability-related barriers indicates system usability is a bona fide
challenge faced when adopting these systems.
These findings highlight the need to fully understand the specific
clinical requirements and limitations of EMR users during system
design, procurement and implementation, to produce both a useful
and usable information system.
Commercial Relationships: Maria S. Cross, None;
George W. Aylward, None; Jugnoo S. Rahi, None
Support: Ulverscroft Vision Research Group (UVRG), National
Institute for Health Research (NIHR) Great Ormond Street
Biomedical Research Centre
Program Number: 5547 Poster Board Number: D0052
Presentation Time: 3:45 PM–5:30 PM
Accuracy of Internet Image Search of fundus pathology as a
learning tool in ophthalmology
David Xu, Shawn R. Lin, Pradeep S. Prasad. Jules Stein Eye
Institute, Los Angeles, CA.
Purpose: Image and pattern recognition is key to clinical competence
in ophthalmology. Internet Image Search, notably Google Image
Search (GIS) in the U.S., has become an important teaching tool for
ophthalmology trainees and allied health staff. Users utilize search
results to enhance their own foundry of reference images for each
disease. However, Google results are presented by a search-rank
algorithm which does not take into account the accuracy of the image
to what was searched. We quantify the accuracy of results and assess
the quality of the image source in several fundus pathologies.
Methods: Ten common and 10 uncommon fundus pathologies were
randomly selected from an ophthalmic text. GIS was performed and
the top 10 consecutive results were analyzed. Results were graded
as having adequate (> 300 pixel resolution) or poor image quality,
correct diagnosis, peer-reviewed source, brief, comprehensive or no
supporting text, and correct supporting text. Correctness of diagnosis
was evaluated by review of the image and context in the supporting
text. The image source was classified as originating from professional
ophthalmic education, professional medical education, general
health information, ophthalmic health information, private practice,
ophthalmic retail, medical association, peer-reviewed journal, book
or private websites.
Results: In total, 200 images and source websites were evaluated
in the study. The majority were of adequate quality (74%). Most
images were fundus photographs (80%) and a minority contained
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ARVO 2016 Annual Meeting Abstracts
multiple image modalities (30%). Overall, 7.5% were of the incorrect
diagnosis. Among common pathologies, 1% were of the incorrect
diagnosis while 14% of uncommon pathologies were incorrect. Half
(51%) of the top image results were from professional ophthalmic
education websites. 30% of images were from peer-reviewed sources.
About one third (30%) of websites had only brief descriptions of the
pathology while 20% had no supporting text. 10% of images were
published on private websites created by non-experts. Ten websites
contributed 46% of all resulted images. Images of the incorrect
diagnosis were presented most often due to mis-attribution to part of
the search phrase (e.g. drusen in “dominant drusen”).
Conclusions: Internet Image Search rapidly generates a collection
ophthalmic pathology for study. Attention should be paid to the
accuracy of images originating from a myriad of sources.
Commercial Relationships: David Xu, None; Shawn R. Lin, None;
Pradeep S. Prasad, None
Program Number: 5548 Poster Board Number: D0053
Presentation Time: 3:45 PM–5:30 PM
Ophthalmology in the Emergency Department: A survey of
Emergency Medicine Residents
Andrew Parlin1, Josh Oliver2, Walter Steigleman1, Michael D. April2.
1
Ophthalmology, Brooke Army Medical Center, San Antonio, TX;
2
Emergency Medicine Department, Brooke Army Medical Center,
San Antonio, TX.
Purpose: The purpose of the study is to assess San Antonio Military
Medical Center (SAMMC) Emergency Medicine (EM) residents’
understanding of ophthalmology/ophthalmic emergencies. After
graduating, most new Emergency Physicians will be practicing
without the benefit of ophthalmology residents or support
immediately available for consultation. This will be true in both small
community military and civilian hospitals, and even more relevant
while providing care in an austere deployed environment. This is
especially true when considering the military’s rules for taking care
of civilian patients in a deployed setting. These rules are referred
to as medical rules of engagement (MEDROE) and limit care to
civilians with threat to life, limb, or eyesight. This study could be
used to assess if more ophthalmologic education/training needs to
be instituted at SAMMC and other EM programs, as well as gauge
progress within the residency
Methods: EM residents will undergo a test approved by the
Ophthalmology department twice during the year—at both the
beginning and ending of the academic year, to gauge progress
of ophthalmic knowledge. Only second year residents have the
opportunity to rotate within the ophthalmology department and the
rotation is limited to two weeks. Testing biannually can provide
objective data regarding the efficacy of this rotation, as well as the
routine teaching that occurs within the emergency department. In
addition to the test, residents will also fill out a survey containing a
self-assessment of ophthalmic knowledge and exams skills/abilities,
to include individual comfort in managing ophthalmic emergencies
after graduation. During our first phase of data collection 31 residents
completed the test and survey. We are expecting similar numbers at
the end of the academic year.
Results: After the second round of testing, the data will be analyzed,
and a comparison made between the different residency years,
and between those who have and have not rotated through the
ophthalmology department at SAMMC.
Conclusions: To be determined
Commercial Relationships: Andrew Parlin, None; Josh Oliver,
None; Walter Steigleman, None; Michael D. April
Program Number: 5549 Poster Board Number: D0054
Presentation Time: 3:45 PM–5:30 PM
Patient Satisfaction in Emergency Eye Care: Yelp Reviews as a
first look
Benjamin Jastrzembski1, 2. 1Department of Ophthalmology,
Massachusetts Eye and Ear Infirmary, Boston, MA; 2Department of
Ophthalmology, Harvard Medial School, Boston, MA.
Purpose: Patient satisfaction is a growing priority in the context
of pay for performance reimbursement, but the determinants of
patient satisfaction in the setting of emergency eye care are poorly
characterized. In this retrospective study, public, online Yelp reviews
(www.yelp.com) of 4 dedicated eye emergency departments in the
U.S. were examined to identify factors affecting patient satisfaction.
Methods: All online Yelp reviews discussing eye emergency
departments at 4 U.S. hospitals were included in the study. Each
review rated overall experience on a scale from 1 (low) to 5 (high)
stars and included an unstructured, free-form comment. Freeform comments were categorized as discussing one or more of the
following themes: visit time, cost & insurance, medical knowledge &
competence, physician & staff interpersonal skills, and care provided
by residents / trainees.
Results: Thirty-three online Yelp reviews from 4 eye emergency
departments were included in the analysis. The average numerical
rating was 2.9 stars with a standard deviation of 1.7 stars. The most
common theme discussed in free-form comments was visit time (79%
of reviews). Twelve of the 13 one-star reviews discussed visit time in
the free-form comment. The least common theme discussed was cost
& insurance (12% of reviews) and care by residents / trainees (18%
of reviews). Only 1 of the 13 one-star reviews discussed care being
provided by a resident / trainee. There was no statistically significant
difference in star rating between reviews that discussed care being
provided by residents / trainees and those that did not (p=0.678).
Conclusions: Online reviews of 4 dedicated eye emergency
departments suggest mixed patient satisfaction overall. The high
number of reviews discussing visit times indicates this is a key
determinant of patient satisfaction. There was no evidence to suggest
that care by residents / trainees, who typically provide the majority of
care in emergency eye settings, had a positive or negative effect on
patient satisfaction. The Center for Medicare and Medicaid Services
(CMS) is currently developing the Emergency Department Patient
Experiences with Care (EDPEC) survey, which will further elucidate
factors affecting patient satisfaction in EDs. The EDPEC survey
will also facilitate comparison between multiple EDs and pay for
performance reimbursement.
Commercial Relationships: Benjamin Jastrzembski, None
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ARVO 2016 Annual Meeting Abstracts
Program Number: 5550 Poster Board Number: D0055
Presentation Time: 3:45 PM–5:30 PM
Evaluation of the efficacy of the nurse triage at the ophthalmic
emergencies of the Jules Gonin Ophthalmic Hospital (HOJG),
Lausanne, Switzerland
Aurelie Pison1, Ciara Bergin2, Christina Gianniou2, Aurélie Martin2,
Alejandra Daruich1, 3, Yan Guex-Crosier2, Jean-Louis Bourges1, 3,
Francine Behar-Cohen2, 4. 1Ophthalmology, Groupe Hospitalier
Cochin-Hôtel-Dieu, Paris, France; 2Jules Gonin Ophthalmic Hospital,
Lausanne, Switzerland; 3Université Paris Descartes, Paris, France;
4
Centre de recherche des Cordeliers, Université Paris Descartes,
Paris, France.
Purpose: The urgency of an ophthalmic condition determines the
delay and the means undertaken to its management. Very few nurse
triage systems have been developed in the field of ophthalmology.
A local nurse triage system has been developed at the ophthalmic
emergency room of the Jules Gonin Ophthalmic Hospital (HOJG).
The purpose of the study was to determine the efficacy of this triage
system.
Methods: This retrospective study included 1133 consecutive
patients that showed up at the emergency room of the HOJG,
Lausanne, Switzerland from the 17th november 2014 to the 19th
december 2014.
The patients were evaluated by the nurse using a questionnaire to
classify patients into four degrees of emergency (white, yellow,
violet, and red : increasing degree of urgency) according to the
symptomatology described by the patient.
The patients were then examined by the doctor, who evaluated also
the degree of emergency (according to a scale).
The arrival time of the patient, the time of the nurse triage, and the
time of examination by the doctor were also recorded.
Results: 1269 patients were recruted in one month, and 1133 finally
included in the analysis. 64% of the patients were evaluated as «
violet » according to the nurses (725/1133). 43% of the patients were
evaluated as « white » according to the doctors (485/1133).
There had been an agreement between the nurse and the doctor for
23% of the patients (261/1133). 76% of the patients (857/1133) had
been overvalued during the nurse triage.1% of the patients (15/1133)
had been undervalued by the nurse triage. Among those 15 patients,
ten were evaluated as « red » by the doctor.
The mean waiting time for the patients evaluated as « red » by the
nurse was 60 minutes; for the « violet » patients it was 93 minutes;
for the « yellow » patients 102 minutes; and for the « white »
patients, 291 minutes. The distribution of the waiting time during the
day showed an increase in the waiting times for patients who arrived
at lunch hours (between noon and 2pm).
Conclusions: This nurse triage system showed overvaluation for 76%
of the patients, underevaluation for 1% but 67% of those undervalued
patients were evaluated as « red » by the doctor. A new optimized
system is presented and discussed.
Commercial Relationships: Aurelie Pison, None;
Ciara Bergin, None; Christina Gianniou; Aurélie Martin,
None; Alejandra Daruich, None; Yan Guex-Crosier,
None; Jean-Louis Bourges, None; Francine Behar-Cohen, None
Program Number: 5551 Poster Board Number: D0056
Presentation Time: 3:45 PM–5:30 PM
Community emergency department referral patterns, diagnostic
accuracy, and initial management of patients referred to a
tertiary emergency eye care department
Alia Durrani, Murtaza K. Adam, Charles M. Calvo,
Ann P. Murchison. Ophthalmology, Wills Eye Hospital, Philadelphia,
PA.
Purpose: Dedicated eye emergency departments remain a rare
resource in the United States. Availability of ophthalmologic consults
for emergency eye care remains a commodity in most community
emergency departments. Our dedicated eye emergency department
(EED) is located in an urban location, allowing for a large catchment
area and referral variety. We performed a prospective, cross-sectional
study to examine the referral patterns, initial management, and
diagnostic accuracy of referrals to a dedicated eye care emergency
department from community providers.
Methods: A telephone survey via a transcribed referral line
was conducted of referring providers between November 2014
and January 2015. Collected clinical and demographic data was
compared to EED documentation. Referrals were excluded from
analysis if an attending EED ophthalmologist did not complete a
clinical examination. Statistical analysis was performed with SPSS
V22.0. Diagnostic agreement between EED physicians and referring
providers (MD, RN, NP, PA) was calculated collectively and
separately.
Results: Sixty-five referrals were included in our study; 39 of these
were from emergency departments and urgent care providers with the
remainder from office-based eye care personnel. Overall diagnostic
agreement between EED ophthalmologists (OMDs) and referring
emergency providers was 27.5%, whereas diagnostic agreement
between EED OMDs and eye care personnel was 58.3%. There
was a significant difference in visual acuity obtained by referring
emergency providers and the EED. Forty-nine percent of referring
emergency providers noted availability of on-call OMDs available
for consultation, with no patient evaluated by an on-call OMD prior
to transfer. Thirty-nine percent of referrals from emergency providers
required urgent ophthalmic care.
Conclusions: The proportion of urgent referrals from referring
emergency providers highlights the need for access to ophthalmic
providers in community settings. Methods to improve on-site
ophthalmic care in the community could include increased
availability of eye care providers and tele-ophthalmology. The role of
mid-level providers in addition to ongoing ophthalmic education for
emergency providers should be explored.
Commercial Relationships: Alia Durrani, None;
Murtaza K. Adam, None; Charles M. Calvo, None;
Ann P. Murchison, None
Program Number: 5552 Poster Board Number: D0057
Presentation Time: 3:45 PM–5:30 PM
Enhancement of Clinical and Research Activity with a Novel
Electronic Medical Record System
Lorenzo Iuliano1, Rosangela Lattanzio1, Giuseppe Querques1,
Maurizio Battaglia Parodi1, Saretta Patrih2, Mauro Campigotto2,
Nicola Baratella2, Alessandro Meo2, Cesare Tanassi2,
Francesco Bandello1. 1Ophthalmology, Vita-Salute University, San
Raffaele Scientific Institute, Milan, Italy; 2NIDEK Technologies Srl,
Albignasego, Italy.
Purpose: Electronic Medical Records (EMRs) are known to be
useful tools in the daily clinical practice, but integration with
the research activity is critical. We performed a retrospective
observational study to evaluate the advantages of employment of a
novel ophthalmological EMR platform (NIDEK nLIFE), customized
for research purposes.
Methods: nLIFE system is designed to manage any subtype of
ophthalmological visit, tailored to the qualification of logging-in
user. The software entirely runs on a web-based interface and is
customized depending on the ophthalmologist subspecialty. nLIFE
is equipped with a built-in alert system that warns for the potential
patient eligibility in a specific trial. It also includes a structured-
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ARVO 2016 Annual Meeting Abstracts
language field for diagnosis and treatment history classification,
designed to ease the retrospective research of patients and/or diseases
with specific characteristics of interest.
We analyzed the time to fulfill the target patient number of a sample
of 10 research protocols that started 1 year before (June 2013-May
2014) and 10 protocols (matched for similar eligibility criteria) that
started 1 year after nLIFE employment (June 2014-May 2015).
Furthermore we calculated the proportion of studies that achieved the
target number in the first 60 days. We also made a research simulation
of candidate patients for all new protocols that are about to start in
our clinic.
Results: Average time for completing the target patient number
significantly reduced from 84±21 days to 49±12 days after nLIFE
employment (p<0.0001). The proportion of studies that reached the
target patient number in the first 60 days was superior in the postnLIFE period (7 out of 10) compared to the pre-nLIFE period (2 out
of 10) (p<0.0349). The research simulation of candidate patients
with protocol-specific enrolment criteria exceeded the required target
number for any tested protocol. Exceeding patient rate ranged from a
minimum of 31% to a maximum of 119% (average 52%).
Conclusions: Despite general ophthalmological EMRs are
commercially available since different years, the interconnection
between clinical and research activity is critical. nLIFE system is a
novel EMR platform customized on the ophthalmologist subspecialty
that, beyond showing an effortless capacity to share data with other
interfaces, demonstrated to be a useful and manageable tool for an
integrated clinical and research workflow.
Commercial Relationships: Lorenzo Iuliano, None;
Rosangela Lattanzio, None; Giuseppe Querques, Novartis (C),
Heidelberg (C), Allergan (C), Alimera sciences (C), Bayer schering
pharma (C), Bausch and Lomb (C), Zeiss (C); Maurizio Battaglia
Parodi, None; Saretta Patrih, NIDEK Technologies Srl (C), NIDEK
Technologies Srl; Mauro Campigotto, NIDEK Technologies
Srl, NIDEK Technologies Srl (C); Nicola Baratella, NIDEK
Technologies Srl (C), NIDEK Technologies Srl; Alessandro Meo,
NIDEK Technologies Srl (C), NIDEK Technologies Srl;
Cesare Tanassi, NIDEK Technologies Srl, NIDEK Technologies
Srl (C); Francesco Bandello, Farmila Thea (C), Sanofi-Aventis (C),
Bayer (C), Hoffmann-La Roche (C), Thrombogenics (C), Alcon
(C), Novartis (C), Bausch and Lomb (C), Pfizer (C), Allergan (C),
Genentech (C), Novagali Pharma (C), Alimera (C)
Program Number: 5553 Poster Board Number: D0058
Presentation Time: 3:45 PM–5:30 PM
Review of Malpractice Litigation in Glaucoma over the Decades
Christopher Shah1, Stephanie B. Engelhard1, Austin Sim1,
Ashvini Reddy2. 1University of Virginia, Charlottesville, VA;
2
Ophthalmology, Wilmer Eye Institute, Baltimore, MD.
Purpose: To report the allegations, outcomes, and monetary awards
of medical malpractice lawsuits in glaucoma to inform clinical
decision-making and guide risk management.
Methods: Retrospective review of malpractice verdicts, rulings, and
settlements related to ophthalmology in the United States WestLaw
database from 1930-2014. Data including subspecialty focus of
glaucoma, year filed, state, patient gender, legal allegation, nature of
injury, verdicts, indemnities, and (when applicable) financial award
were collected and analyzed. To enable meaningful comparison,
monetary awards were adjusted to 2015 United States dollars.
Results: A total of 1083 malpractice cases against ophthalmologists
were identified, and 68 (6.3%) of these had subspecialty focus in
glaucoma. These were subdivided into non-interventional (n = 49)
and surgical/procedural (n = 19). Overall, 67.6% of outcomes favored
the physician, defendants. Of the 24 outcomes favoring the plaintiff,
monetary awards were reported for 19 cases with a mean award of
$256,556.60 (range: $150,000 to $3,000,000) at time of filing. This
was adjusted to $342,297.20 (range: $589,891.09 to $3,020,022.30)
for value in 2015. The most common reason for litigation of those
with payout was failure to diagnose/treat (n= 12), followed by
surgical complication (n = 4) and adverse effect of medication (n
= 3). See Figure 1 for number of cases by decade and Figure 2 for
number of cases by State.
Conclusions: Glaucoma represents a small percentage of malpractice
litigation within ophthalmology and, historically, most outcomes
favor the defendant. Outcomes favoring the plaintiff were associated
with failure to diagnose/treat rather than from surgical or procedural
interventions.
Figure 2: Number of Malpractice Cases in Glaucoma by State. No
cases found for states not represented in the figure.
Commercial Relationships: Christopher Shah;
Stephanie B. Engelhard, None; Austin Sim, None; Ashvini Reddy,
None
Program Number: 5554 Poster Board Number: D0059
Presentation Time: 3:45 PM–5:30 PM
Ophthalmology malpractice litigation in pediatric patients
Stephanie B. Engelhard1, Christopher Shah1, Austin Sim1, 2,
Ashvini Reddy3. 1Ophthalmology and Visual Sciences, University of
Virginia, Charlottesville, VA; 2School of Law, University of Virginia,
Charlottesville, VA; 3Wilmer Eye Institute Johns Hopkins University,
Baltimore, MD.
Purpose: To report and analyze the causes and outcomes of
ophthalmology medical malpractice litigation involving patients
under age 18.
Methods: The WestLaw® database was reviewed for all lawsuits
including settlements and trial verdicts related to ophthalmology in
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ARVO 2016 Annual Meeting Abstracts
the United States from 1930-2014. All cases in which plaintiffs
were under 18 years of age at time of inciting event were
included in the analysis. Pediatric cases were compared to adult
cases in the database.
Results: Sixty-eight ophthalmology malpractice cases involving
plaintiffs under the age of 18 were included in the study. Thirty-six
cases (52.9%) resolved via jury trial. Defense verdicts were issued
in 19 (52.8%) pediatric cases compared to 418 (71.0%) adult cases
(P=0.021). Seventeen cases (47.2%) resulted in plaintiff verdicts,
with a mean jury award of $4,815,692.67 (median, $883,280.97;
range, $147,765.38-$42,061,689.81). Nine cases (13.2%) resulted
in settlement, with mean adjusted indemnities of $1,912,737.79
(median, $1,377,688.84; range, $92,070.38-$8,493,086.24). The
remaining 23 cases (33.8%) involved appellate rulings, post-trail
relief rulings, and one bench verdict. Jury awards (P=0.002) and
indemnity payments (P=0.003) were significantly higher in pediatric
cases than in adult cases. Legal blindness cases were more likely to
result in plaintiff verdicts (P=0.210). Common clinical scenarios in
cases of litigation were traumatic ocular injury (22.1%), retinopathy
of prematurity (ROP) (17.6%), and endophthalmitis (8.8%).
Conclusions: Cases involving pediatric patients were significantly
more likely to be resolved in favor of the plaintiff and to have
higher monetary value than adult cases. ROP cases resulted in the
highest payments to plaintiffs, and cases involving legal blindness
and/or endophthalmitis were more likely to be resolved in favor of
the plaintiff.
Commercial Relationships: Stephanie B. Engelhard, None;
Christopher Shah, None; Austin Sim, None; Ashvini Reddy, None
Program Number: 5555 Poster Board Number: D0060
Presentation Time: 3:45 PM–5:30 PM
Comparing the Psychometric Properties of the Original
and Short Versions of the Glaucoma Treatment Compliance
Assessment Tool
Gordon T. Barker, Steven L. Mansberger. Devers Eye Institute,
Portland, OR.
Purpose: To compare the psychometric properties of a reduced
(22 statements) to a long version (47 statements) of the Glaucoma
Treatment Compliance Assessment Tool (GTCAT), which is based on
the organizational structure of the Health Belief Model.
Methods: We created a reduced GTCAT by removing statements
that: 1) did not appear in either the final Principal Components
Analysis (PCA) model and 2) did not have a univariate association
with adherence; or 3) were highly correlated with a correlation
coefficient of .60 or higher with one another. To verify we did
not remove key statements, we used PCA on the 25 removed or
remaining statements to verify a stable organizational structure and
used univariate analysis to determine if we removed a potentially
predictive statement. Last, we assessed the construct validity of
the remaining statements using PCA and assessed their predictive
validity using univariate and multivariate analysis.
Results: Of the original 47 GTCAT statements, we removed
22 because they did not appear in either the PCA analysis or
the univariate regression analysis. We removed an additional 3
statements due to high intercorrelation (r = .76-.80). PCA of the
25 excluded statements resulted in no components extracted, and
univariate regression indicated no predictive statements. As a whole
the removed statements were not predictive (R2=.035, p = .26) of
adherence. Clinical acumen suggested re-inclusion of 4 statements
with alternate wording. PCA of the remaining 22 items resulted in the
extraction of 5 components (knowledge, susceptibility, cues to action,
self-efficacy, barriers). Multiple regression showed 6 statements
associated with higher adherence (adjusted R2 = 0.27, p<.001), and as
a whole the GTCAT-S predicted adherence (R2= .167, p = .01).
Conclusions: A reduced GTCAT maintained an organizational
structure consistent with the Health Belief Model and high predictive
ability. Future glaucoma medication adherence studies can use the
reduced model to determine whether a change in health behavior as
measured by the GTCAT is associated with a change in adherence.
Commercial Relationships: Gordon T. Barker, None;
Steven L. Mansberger, None
Program Number: 5556 Poster Board Number: D0061
Presentation Time: 3:45 PM–5:30 PM
Identification and Recognition of Limitations of Retrospective
Studies in Select Peer-reviewed Journal
Pooja Mehta, Neil M. Bressler. Retina, Wilmer Eye Institute, Johns
Hopkins Hospital, Baltimore, MD.
Purpose: Since retrospective designs can introduce bias or
confounding on results, and as such, should be noted by authors. This
study aimed to determine how often clinical research publications
in select ophthalmology journals that are retrospective in design
state “retrospective” design in the title or methods, and how often
limitations of that design are mentioned or commented upon in the
discussion section.
Methods: Original investigations from three ophthalmology journals
with relatively high impact factors as well as a similar specialty
journal in otolaryngology and a subspecialty journal in retina
were reviewed in 2004 to 2005 and in 2014 to 2015. All original
investigations, excluding brief reports; case series; case reports;
or observations, were reviewed to determine if the study design
was retrospective. Retrospective designs were defined as studies
performed after the outcomes of interest had already occurred; most
commonly case control studies, but also retrospective cohort or case
series.
Results: Journals reviewed included the American Journal of
Ophthalmology, JAMA Ophthalmology, JAMA Otolaryngology,
Ophthalmology, and RETINA. Preliminary results suggest that fewer
than one-third of all of the articles mentioned in the Discussion
section that the retrospective design was a limitation to the
interpretation of the results in 2004 to 2005; this increased relatively
by 50% to 100% by 2014 to 2015. However, in fewer than 5% of
the discussions did the authors mention how the retrospective design
might affect the interpretation of the results both last decade and this
decade.
Conclusions: Over the past decade, authors in the journals evaluated
are more likely to indicate that a retrospective study has limitations
that can affect the interpretation of the results, but few authors
indicate exactly how those limitations might affect the interpretation
of the results.
Commercial Relationships: Pooja Mehta, None; Neil M. Bressler,
None
Support: Unrestricted grants to Retina Division - Johns Hopkins
University School of Medicine
Program Number: 5557 Poster Board Number: D0062
Presentation Time: 3:45 PM–5:30 PM
The fate of research abstracts presented at the ARVO Annual
Meeting
Edoardo Villani1, Filippo Tresca Carducci2, Stela Vujosevic3,
Paolo Nucci1. 1Department of Clinical Sciences and Community
Health, University of Milan. San Giuseppe Hospital., Milan, Italy;
2
Istituto Clinico San Siro, Milan, Italy; 3University of Padova,
Padova, Italy.
These abstracts are licensed under a Creative Commons Attribution-NonCommercial-No Derivatives 4.0 International License. Go to http://iovs.arvojournals.org/
to access the versions of record.
ARVO 2016 Annual Meeting Abstracts
Purpose: To evaluate the publication rate of research abstracts
presented at the ARVO Annual Meeting and to assess influencing
factors.
Methods: We randomly selected and reviewed 20% of all accepted
abstracts, presented as either oral or poster presentations, at the 2010
ARVO Annual Meeting. A Pubmed-Medline search was performed
to identify a matching journal article. Two- and 5-year publication,
impact factor of publication (Journal Citation Reports® published by
Thomson Reuters), sub-specialty (Scientific Sections), area of origin,
and presentation type were tabulated.
Results: We selected 1238 abstracts, 1097 (88.5%) presented
as poster and 142 (11.5%) presented as oral papers. The most
represented Scientific Sections were Retina-RE (n=212; 17.1%),
Cornea-CO (n=176; 14.2%), and Glaucoma-GL (n=149; 12%). The
less represented was Anatomy and Pathology/Oncology-AP (n=43;
3.5%). The most represented areas of origin were North America
(n=702; 56.7%), Europe (n=284; 22.9%), and Asia (n=158; 12.8%).
The overall 5-year publication rate was 51.7% (n=641), significantly
higher for papers than for posters (66.2% vs 50%; P<0.001, Fisher’s
exact test).
The overall 2-year publication rate was 36% (n=446), significantly
higher for papers than for posters (47.2% vs 34.5%; P<0.01).
Chi-Square test showed significant different publication rates
among the Scientific Sections (P<0.001): >60% for Physiology/
Pharmacology-PH, Retinal Cell Biology-RC and Visual
Neuroscience-VN; <50% for Eye Movements/Strabismus/
Amblyopia/Neuro-ophthalmology-EY, RE, and Visual
Psychophysics/Physiological Optics-VI; 50-60% for all the other
Sections.
No significant different publication rates were found among the areas
of origin (51%-58%), except South America (37%) and Africa (25%).
The mean impact factor of journals where the abstracts were
published was 3.4±2.7 (range 0-33.6), significantly higher for
oral papers than for posters (4.6±4.1 vs 3.2±2.3; P<0.001, T-test),
significantly higher for VN (5.9±7.8) compared to the other Sections
(P<0.001, ANOVA and Tukey post hoc test), and significantly lower
for South America compared to North America and Europe (P<0.05).
Conclusions: The ARVO Annual Meeting is a largely
interdisciplinary platform for exchanges of ideas and information
for a large number of researchers all over the world. The differences
in publication rate between posters and papers and among Sections
should be kept in mind when interpreting the presented results.
Commercial Relationships: Edoardo Villani, None; Filippo Tresca
Carducci, None; Stela Vujosevic, None; Paolo Nucci, None
Program Number: 5558 Poster Board Number: D0063
Presentation Time: 3:45 PM–5:30 PM
Female Authorship in Major Academic Ophthalmology Journals:
trends in recent years
Michael Mimouni1, Ori Segal2, Shiri Zayit-Soudry1, Arie Y. Nemet2,
Yoreh Barak1, Noa Geffen2. 1Ophthalmology, Rambam Health Care
Campus, Atlit, Israel; 2Ophthalmology, Meir Medical Center, Kfar
Sava, Israel.
Purpose: Despite an improvement in the disparities between men
and women, a significant gap between genders exists in many fields
of scientific research. The purpose of this study was to evaluate
trends in the prevalence of female authorship in Ophthalmology over
recent years.
Methods: Using the PubMed Search engine, we conducted an
observational study of trends in gender distribution of all authors in 6
Ophthalmology journals between January 2002 and December 2014.
Journals were chosen based on published impact factors. The full
names and the positions (first, middle or last) of all authors in every
article were collected. A Google based name identifier was used to
determine the gender of authors based on their first names. Names
identified with a probability of 3 to 1 and greater were included in
final analyses.
Results: A total of 102,254 authors from 23,026 published articles
were included. There was a significant rise in the percentage of
female authors over time with a steeper slope for first authors than
for last (p<0.001) though in 2014 female authors were still below the
50% mark in all categories of authorship. The rise in the percentage
of female authorship was similar in basic and clinical research but
was steeper for first authorship than for last authorship (p<0.001). In
all three authorship positions, female contribution was consistently
higher in basic research publications. The rise in the percentage of
female authorship was significantly steeper for general journals than
for subspecialty journals (p<0.001). There was no significant rise
over the years for last authorship in subspecialty journals. In all three
authorship positions female contribution was consistently higher in
general ophthalmology journals than for subspecialty journals. In
multivariate analysis, subspecialty journals and last author position
were significantly predictive of male gender while advancing
publication year and first author position were significantly predictive
of female gender (p<0.001).
Conclusions: Despite an overall increase in the contribution of
women to the field of Ophthalmology, a gap still exists between
the frequency of women in roles of clinical-practice and that in
roles of scientific leadership. In particular, female contribution to
papers published in subspecialty Ophthalmology journals, and the
proportion of women listed as last authors on overall Ophthalmology
publications, are still low.
Commercial Relationships: Michael Mimouni, None; Ori Segal,
None; Shiri Zayit-Soudry, None; Arie Y. Nemet, None;
Yoreh Barak, None; Noa Geffen, None
Program Number: 5559 Poster Board Number: D0064
Presentation Time: 3:45 PM–5:30 PM
Tele-ophthalmology for age related macular degeneration and
diabetic retinopathy: A systematic review and meta analysis
Karim F. Damji, Atsushi Kawaguchi, Noha Sharafeldin,
Aishwarya Sundaram, Sandra Campbell, Christopher Rudnisky,
Ezekiel Weis, Matthew Tennant. University of Alberta, Edmonton,
AB, Canada.
Purpose: Recent technological advances combined with the
projected rise in chronic eye disease and shortage of ophthalmologists
have led to an increased interest in tele-ophthalmology. We conducted
an up-to-date systematic review to evaluate the clinical effectiveness
of tele-ophthalmology as an alternative to face-to-face patient
screening and management for three major chronic eye diseases: agerelated macular degeneration (AMD), diabetic retinopathy (DR), and
glaucoma.
Methods: A search was executed by an expert librarian of the
following databases: MEDLINE, EMBASE, EBM Reviews
including Cochrane Databases using controlled vocabulary and key
words representing “telehealth” and “ophthalmology”. We included
English language, randomized controlled trials (RCTs) published
after 2000 for the analysis. Two reviewers independently assessed
quality and extracted data. We used the standard methods of The
Cochrane Collaboration to assess methodological quality and risk of
bias. For all included trials, bias due to participant knowledge of the
allocated intervention was categorized as high risk; however, given
the characteristics of the tele-ophthalmology intervention, we assume
participant blinding was not feasible.
Results: The search results identified 2,239 unique records and after
screening 6 reports of 4 RCTs met the inclusion criteria: 2 trials on
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ARVO 2016 Annual Meeting Abstracts
AMD and 2 trials on DR. No RCTs were found on glaucoma. Four
different outcomes were analyzed: visual outcome, participation
in the screening program, referral accuracy, and waiting time
to receive referral. Three trials compared detection of choroidal
neovascularization (CNV) (n=2146, Odds Ratio (OR): 1.55, 95%
Confidence Interval (CI): 1.11 to 2.17). One trial compared teleophthalmology using a home monitoring device to standard selfreporting of changes in visual acuity (n=1520, OR: 1.74, 95%CI:
1.09 to 2.76). Two trials on diabetic retinopathy screening reported
on participation in the screening program (n=626, OR: 12.99, 95%CI:
7.90 to 21.33).
Conclusions: The review provides evidence of clinical benefits
for detection of neovascular AMD and DR screening using teleophthalmology. It also demonstrates feasibility of carrying out
randomized trials of tele-ophthalmology, albeit with differing
modalities for tele-screening. Further research is needed specifically
to study clinical effectiveness for glaucoma.
Commercial Relationships: Karim F. Damji; Atsushi Kawaguchi,
None; Noha Sharafeldin, None; Aishwarya Sundaram, None;
Sandra Campbell, None; Christopher Rudnisky, None;
Ezekiel Weis, None; Matthew Tennant, None
Program Number: 5560 Poster Board Number: D0065
Presentation Time: 3:45 PM–5:30 PM
Risk Indicators and Prevalence of Undetected Eye Disease in
Chinese Americans: The Chinese American Eye Study (CHES)
Roberta McKean-Cowdin1, Rohit Varma2, Mina Torres2,
Charlotte E. Joslin3, Chunyi Hsu2, Xuejuan Jiang2. 1Preventive
Medicine, Univ of Southern California, Los Angeles, CA;
2
Ophthalmology, USC Eye Institute, Los Angeles, CA;
3
Ophthalmology and Visual Science, Illinois Eye and Ear Infirmary,
Chicago, IL.
Purpose: To characterize the level of undetected eye disease (UED)
in Chinese Americans 50 years of age and older, and the proportion
of UED attributable to uncorrected refractive error (URE) and
specific types of eye disease.
Methods: A population-based study of adults participating in the
Chinese American Eye Study was completed. Data were obtained
by clinical examination and participants were defined as having
eye disease if diagnosed at the clinic with macular degeneration,
glaucoma, diabetic retinopathy, cataract, or refractive error.
Participants diagnosed with incident eye disease at the clinic visit and
not reporting a past history were considered undetected. URE was
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to access the versions of record.
ARVO 2016 Annual Meeting Abstracts
defined as an improvement of 2+ lines in visual acuity in the better
seeing eye after refraction. Odds ratios and 95% confidence intervals
(95%CI) were calculated to evaluate potential associations between
demographics, clinical characteristics, or lifestyle factors and UDE.
Results: Of the 2,284 cases of eye disease in CHES, 1,077 (47.2%)
were undetected prior to completing the CHES clinical examination.
Of these, 668 (29.3% of 2,284) had URE, and 331 (14.5% of 2,284)
had URE alone (without any known ocular diseases). Of the 1,077
with UDE, 197 (18.3% of 1077) were visually impaired based on
presenting visual acuity (VA), while only 57 (5.3% of 1077) were
visually impaired based on best corrected VA. The major types of
undetected eye disease included 281 (12.3% of 2,284) of macular
degeneration, 255 (11.2%) glaucoma/ocular hypertension, 193 (8.5%)
diabetic retinopathy, and 67 (2.9%) cataract. The major predictors of
UDE included male sex, older age, a history of diabetes, not speaking
English, never having a regular physical exams, not having a regular
place of medical care, low income, not having other comorbidities,
and never having a complete eye exam.
Conclusions: While Chinese Americans are typically not recognized
as a racial group in the United States negatively impacted by health
disparities or experiencing limited access to health care, we found
that a high proportion of Chinese Americans in our population-based
sample had UED. Outreach and education to the Chinese American
community on the value of regular eye exams is needed. Proper
refraction and early detection of disease and treatment can improve
vision of older, Chinese Americans.
Commercial Relationships: Roberta McKean-Cowdin;
Rohit Varma, None; Mina Torres, None; Charlotte E. Joslin,
None; Chunyi Hsu, None; Xuejuan Jiang, None
Support: grants EY-017337 from the National Eye Institute,
National Institute of Health, Bethesda, Maryland and an unrestricted
Departmental grant from Research to Prevent Blindness, New York,
NY 10022
Program Number: 5561 Poster Board Number: D0066
Presentation Time: 3:45 PM–5:30 PM
Ophthalmic Screening Patterns Among Youth with Type 1 and
Type 2 Diabetes Enrolled in a Large U.S. Managed Care Network
Sophia Wang1, Chris A. Andrews1, Thomas W. Gardner1,
Michael Wood2, Kanakadurga Singer2, Joshua D. Stein1, 3.
1
Ophthalmology, University of Michigan, Ann Arbor, MI; 2Pediatric
Endocrinology, University of Michigan, Ann Arbor, MI; 3Institute
for Healthcare Policy and Innovation, University of Michigan, Ann
Arbor, MI.
Purpose: The American Academy of Ophthalmology recommends
that ophthalmic screening for diabetic retinopathy (DR) occur by
5 years after initial diabetes mellitus (DM) diagnosis among youth
with Type 1 DM (T1DM); the American Diabetes Association
recommends that youth with Type 2 DM (T2DM) be screened at the
time of initial DM diagnosis. It is unknown to what extent youth with
DM obtain eye examinations in accordance with these guidelines. We
investigated the rate of screening for DR and its associated factors in
a large cohort of youth with T1DM and T2DM in a nationwide U.S.
managed care network.
Methods: We reviewed health care claims database records to
identify all youth age ≤21 years who were newly diagnosed with DM
from 2001 to 2014. A previously validated algorithm characterized
each youth with T1DM or T2DM. We identified the proportion of
youth who underwent ≥1 eye examinations by an ophthalmologist
or optometrist based on healthcare encounter records. Kaplan-Meier
survival curves estimated the time from first DM diagnosis to initial
eye exam. Multivariate Cox proportional hazard regression models
identified sociodemographic factors associated with undergoing an
eye exam following DM diagnosis.
Results: Among the 5515 eligible youth with T1DM and 7304 youth
with T2DM, Kaplan-Meier survival analysis estimated that 60% and
38% had undergone an eye exam by 5 years after DM diagnosis,
respectively. Children and adolescents with T1DM had 116%
increased hazard of undergoing an eye exam by 5 years compared to
youth with T2DM (HR 2.16, 95% CI 1.98-2.35). Blacks and Latinos
had 11% and 18% decreased hazard of undergoing an eye exam by
5 years compared to Whites, respectively (Blacks HR 0.89, 95% CI
0.79-0.92; Latinos HR 0.82, 95% CI 0.73-0.92). As household net
worth increased, youth were increasingly more likely to undergo
an eye exam by 5 years (HR 1.46, 95% CI 1.30-1.62 for net worth
≥$500,000 vs <$25,000).
Conclusions: Youth with T2DM are significantly less likely to
undergo ophthalmic screening than youth with T1DM. Blacks,
Latinos, and youth from less affluent families are significantly less
likely to undergo a timely eye exam to check for DR than whites and
youth from more affluent families. These groups are an underserved
population that should be targeted in efforts to increase adherence
to ophthalmic screening guidelines to prevent sight-threatening
complications from DR.
Commercial Relationships: Sophia Wang, None;
Chris A. Andrews, None; Thomas W. Gardner, None;
Michael Wood, None; Kanakadurga Singer, None;
Joshua D. Stein, None
Support: Research to Prevent Blindness; the Kellogg Foundation
Program Number: 5562 Poster Board Number: D0067
Presentation Time: 3:45 PM–5:30 PM
Modeling Clinical Workflow In Pediatric Ophthalmology
Michelle Hribar1, Sarah Read-Brown2, Leah G. Reznick2,
Thomas Yackel1, Michael F. Chiang2, 1. 1Department of Medical
Informatics and Clinical Epidemiology, OHSU, Portland, OR;
2
Ophthalmology, OHSU, Portland, OR.
Purpose: Pediatric ophthalmologists have raised concerns that
EHRs negatively impact clinical productivity, but lack guidance
about how to improve efficiency. This study demonstrates proof-ofconcept simulation models using EHR timestamp data may be used to
improve clinic workflow.
Methods: Clinical workflow was mapped for a single pediatric
ophthalmologist (LGR). EHR databases were used to identify
timestamps that best correlated with clinical activities during one year
(2258 patient visits, 496,301 timestamps). EHR timestamps were
validated against manual timings of activities for 89 patient visits by
trained observers. Data were used to develop computer simulation
models (Arena; Rockwell, Wexford, PA) to evaluate different
scheduling policies and clinic configurations for minimizing patient
wait time.
Results: EHR timestamp data were within 3 minutes of manual
observed times in 95/146 (65%) of clinical activities. EHR timestamp
data shows mean wait time was 36 ± 26 minutes/patient per visit.
Simulation models were used to evaluate new scheduling strategies
and clinic configurations. We determined that scheduling patients
requiring shortest times earlier, and those requiring longer times
later, should reduce wait time from 37 to 15 minutes/patient. This
optimized schedule was implemented in the clinic setting (3 sessions,
30 patients), and decreased mean wait time to 31± 22 minutes/patient
(p=0.04). Further, we determined that using 2 staff members and 3
exam rooms provides the best marginal returns for reducing wait time
as shown in Figure 1.
Conclusions: These study findings indicate that EHRs can be
extended toward a holistic tool for managing clinical workflow. EHR
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to access the versions of record.
ARVO 2016 Annual Meeting Abstracts
timestamp data may be used to develop computer simulation models
for testing alternative clinic configuration and scheduling policies,
which have potential to decrease patient wait time.
Figure 1: Effects of varying the number of staff and the number of
exam rooms on patient wait time. We conclude that 2 ancillary staff
members and 3 exam rooms is a good configuration for reducing
patient wait time.
Commercial Relationships: Michelle Hribar, None;
Sarah Read-Brown; Leah G. Reznick, None; Thomas Yackel,
None; Michael F. Chiang, None
Support: NLM grant K99LM012238; NIH Core Grant P30
EY010572; unrestricted grant from Research to Prevent Blindness
Program Number: 5563 Poster Board Number: D0068
Presentation Time: 3:45 PM–5:30 PM
Noncompliance with Vision Care Guidelines in Chinese
Americans with Type 2 Diabetes Mellitus
Chunyi Hsu, Xuejuan Jiang, Mina Torres, Rohit Varma.
Ophthalmology, University of Southern California, Los Angeles, CA.
Purpose: The American Diabetes Association (ADA) guidelines
recommend yearly dilated eye exams for type 2 diabetes mellitus
(T2DM) patients. Compliance with ADA guidelines among Asian
Americans may be more difficult because of additional barriers of
language, differences in cultures, and the shortage of resources due to
the minority status of the population. We aim to assess the prevalence
of noncompliance with ADA vision guidelines among 50+ years old
Chinese Americans with T2DM and identify personal risk factors
associated with noncompliance.
Methods: Data were from the population-based Chinese American
Eye Study. All participants with a self-reported history and treatment
of diabetes were asked about health and vision care utilization
and diabetes self-care. Noncompliance was defined as having had
no dilated eye examination in the previous 12 months. Logistic
regression analyses were used to identify personal factors associated
with noncompliance.
Results: Among the 540 Chinese Americans who self-reported
having physician-diagnosed diabetes, 324 (60%) had not complied
with ADA guidelines. When compared with those with T2DM who
complied with ADA guidelines, noncompliers were more likely to
be younger (50-59 vs. 80+ years old: odds ratio [OR], 4.36; 95%
confidence interval [CI], 2.25-8.45), have never been advised by
a physician to have annual eye exams (OR, 2.20; 95% CI, 1.493.24), have no usual place for care (OR, 3.11; 95% CI, 1.65-5.88),
and have a glycosylated hemoglobin level ≥ 8.0% (OR, 2.17; 95%
CI, 1.11-4.25).
Conclusions: Our data suggest that similar to Hispanics and African
Americans, a majority of Chinese Americans with T2DM are not
receiving recommended vision care. This high rate of noncompliance
is unexpected given the high level of education of these Chinese
Americans. Intervention programs targeted at Chinese Americans
should focus on improving psychosocial predictors such as lower
intentions (e.g. personal agency), salience of the behavior (e.g.
recommendations from a physician), and local constraints instead of
systemic constraints (e.g. financial barriers, lack of insurance).
Commercial Relationships: Chunyi Hsu, None; Xuejuan Jiang,
None; Mina Torres, None; Rohit Varma, None
Support: grants EY-017337 from the National Eye Institute,
National Institute of Health, Bethesda, Maryland and an unrestricted
Departmental grant from Research to Prevent Blindness, New York,
NY 10022
Program Number: 5564 Poster Board Number: D0069
Presentation Time: 3:45 PM–5:30 PM
FDA Class I recalls of approved ophthalmic drugs and medical
devices from 2003–2015
Ankur Gupta1, Rushi K. Talati2, Steve Xu3, Comeron Ghobadi4.
1
Ophthalmology, Washington University in St. Louis, St. Louis,
MO; 2Ophthalmology, Northwestern University, Chicago, IL;
3
Northwestern University School of Medicine, Chicago, IL;
4
University of Chicago Pritzker School of Medicine, Chicago, IL.
Purpose: The strength of clinical data needed for novel therapeutics
to satisfy safety and efficacy thresholds for Food and Drug
Administration (FDA) approval has long remained controversial.
Although the traditional pre-market approval (PMA) process is the
most stringent regulatory system in place worldwide, there remains
significant weaknesses in the system. The continued development of
new technologies invariably places strain on the the FDA’s limited
resource capacity. We performed a retrospective, observational
study to assess high risk device recalls, regulatory trends, and policy
implications for the future.
Methods: This IRB-exempt study utilized the FDA Center for
Devices and Radiological Health database for Class I ophthalmic
device recalls from 2003 to 2015. Approval data and recall
characteristics were collected for each device. Additionally, reports
of adverse events related to the manufacturer’s reason for recall were
collected for each device using the FDA Manufacturer and User
Facility Device Experience database.
Results: Twelve Class I ophthalmic recall events were identified,
constituting 68,820,497 total products (Figure 1). Nine out of 12
recalls resulted in at least one documented report of patient injury.
Soft contact lenses, contact lens solution, and excimer laser systems
were the most commonly recalled device classes. Six recalls occurred
after 2011 (Figure 2). Five devices were cleared under the 510(k)
pathway, 5 were cleared under the PMA pathway, 1 was exempt, and
1 was marketed without clearance. Three recalls were attributed to
pre-market issues, 5 to post-market issues, and 4 were undetermined.
An average of 5,735,041 devices were recalled per event and all but 2
devices had a worldwide distribution at the time of recall.
Conclusions: It is important for ophthalmologists to understand
recent high risk device recalls within their field as well as the current
state of device regulation. Our results highlight the broad impact
ophthalmic recall events have for both manufacturers and consumers.
Although the absolute number of Class I recalls are low, the number
of devices and patients affected extends to tens of millions. In the
wake of recent legislation that further decreases evidence leading
to device approval, policy makers must strive to maintain stringent
approval and post-market surveillance standards in order to ensure
patient safety and confidence.
These abstracts are licensed under a Creative Commons Attribution-NonCommercial-No Derivatives 4.0 International License. Go to http://iovs.arvojournals.org/
to access the versions of record.
ARVO 2016 Annual Meeting Abstracts
Commercial Relationships: Ankur Gupta, None; Rushi K. Talati,
None; Steve Xu, None; Comeron Ghobadi, None
Program Number: 5565 Poster Board Number: D0070
Presentation Time: 3:45 PM–5:30 PM
Potential Microbial Contamination of Ophthalmic Solutions
Commonly Used in Ophthalmology Outpatient Settings
Nathan Harms1, Yasir J. Sepah1, Laura Creamer1, Salman Sarwar1,
Mohamed K. Soliman1, Mohammad A. Sadiq1, Aniruddha Agarwal1,
Angela Hewlett2, Diana V. Do1, James W. Gigantelli1, Quan
Dong Nguyen1. 1Ophthalmology, University of Nebraska Medical
Center, Omaha, NE; 2Department of Internal Medicine Division of
Infectious Diseases, University of Nebraska Medical Center, Omaha,
NE.
Purpose: To determine the rate of microbial contamination of three
commonly used eye drops following regular clinical use.
Methods: Bacterial cultures from 120 labeled bottles (stored at
room temperature in clinics) of Fluorescein Sodium, Proparacaine,
and Tropicamide were obtained at days 0, 28, 42, and 56 following
regular clinical use by plating 100 μl volume onto chocolate agar and
incubating at 37° C for 48 hours.
Results: Rates of bacterial contamination were found to be 1.66,
2.75, 0 and 0% at days 0, 28, 42 and 56, respectively.
Conclusions: Eye drops may be used safely for up to 56 days
(potentially longer with additional testing) following regular clinical
use without significant risk of microbial contamination, most likely
secondary to self-sterilizing property (presence of preservatives) of
the solutions.
Figure 1
Figure 2
Figure 1. One hundred twenty bottles of Fluorescein Sodium (n=40),
Proparacaine (n=40), and Tropicamide (n=40) placed into service
within Truhlsen Eye Institute were cultured, with rates of bacterial
contamination found to be 1.67 (n=2), 2.73 (n=3), 0, and 0% at
days 0, 28, 42, and 56, respectively. Of the solutions with positive
bacterial cultures (n=5), four were contaminated with coagulase
negative staphylococci and the remaining one with alpha hemolytic
streptococci, both considered to be normal ocular flora.
Commercial Relationships: Nathan Harms, None;
Yasir J. Sepah; Laura Creamer, None; Salman Sarwar, None;
Mohamed K. Soliman, None; Mohammad A. Sadiq, None;
Aniruddha Agarwal, None; Angela Hewlett, None; Diana V. Do,
None; James W. Gigantelli, None; Quan Dong Nguyen, None
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to access the versions of record.
ARVO 2016 Annual Meeting Abstracts
Program Number: 5566 Poster Board Number: D0071
Presentation Time: 3:45 PM–5:30 PM
Academic Ophthalmology Visit Length Prediction Models
Daria Spatar1, 3, Jonah Todd-Geddes2, Michael F. Chiang2,
Michelle Hribar2, Peter Graven2, Leah G. Reznick2, Thomas Yackel2.
1
Engineering and Technology Management, Portland State
University, Portland, OR; 2Oregon Health and Science University,
Portland, OR; 3DMiCE, Oregon Health and Science University,
Portland, OR.
Purpose: To build a model to predict visit lengths based on a priori
known visit characteristics for academic ophthalmology outpatient
clinics and to modify it for pediatric ophthalmology clinic.
Methods: Using electronic medical record (EHR) data for visits at
Oregon Health & Science University (OHSU) Casey Eye Institute
between 2/1/2006 and 10/1/2015, we estimated the statistical
relationship between visit length and various a priori known
visit characteristics for all subspeciality clinics. Length of visits
are estimated by a linear model including the following patient
predictors:
- average prior visit length; - diagnosis; - travel distance; subspecialty; - age; - visit type (new/return); - sex
- visit month, year and day of the week; - visited clinic volume
For the pediatric ophthalmology clinic we used EHR data from
1/1/2013 to 12/31/2014. We modified the initial model to look closely
at the exam time rather than the whole length of the visit. For this
linear model we chose the following predictors:
- age; - average prior exam length; - dilation status at visit; - visit type
(new return, pre-op, and post-op); - diagnosis; - volume of clinic day
Results: For the model including all the subspeciality clinics, average
prior visit length, age (especially those > 60), and the indication of a
new patient visit appear to have significant increasing effect on visit
length. The model has an R-squared of 0.251. It is able to correctly
predict 1 out of 4 actual visit lengths, which is considered good for
healthcare prediction models. The modified pediatric model has an
R-squared of 0.18. Significant predictors of the exam length are age,
prior exam length, dilation, visit type, and diagnoses of strabismus,
neurological disease and ROP. All of the variables have positive
coefficients, except of ROP diagnosis.
Conclusions: Both the general and modified models identified age,
prior visit lengths, and visit type as main predictors of the visit and
exam lengths. The modified model had a lower value of R-squared
supposedly due to smaller dataset and fewer independent variables.
The modified model was consistent with the provider’s experience
and observations. While the current models’ predictive strength are
typical for healthcare models, we feel they can be improved. We are
investigating other factors, such as patient personality, as well as
considering other non-linear models. Accurately estimating patient
visit lengths can help anticipate clinic loads and improve clinic
efficiency.
Commercial Relationships: Daria Spatar, None;
Jonah Todd-Geddes; Michael F. Chiang, None; Michelle Hribar,
None; Peter Graven, None; Leah G. Reznick, None;
Thomas Yackel, None
Support: P30 EY010572, unrestricted grant from Research to
Prevent Blindness, NLM grant 5T15LM007088-24, NLM grant
K99LM012238
Program Number: 5567 Poster Board Number: D0072
Presentation Time: 3:45 PM–5:30 PM
Impact of visual impairment on quality of life and poverty
: Results from a 1 year follow up study in the Mwandama
Millennium Village (MVP)
Sangchul Yoon1, 2, Jihee Lee3, Youn Seung Kim2, Jin Kwan Park4,
Kyoung Yul Seo2. 1Ophthalmology, National Medical Center, Seoul,
Korea (the Republic of); 2Ophthalmology, Yonsei University College
of Medicine, Seoul, Korea (the Republic of); 3London School of
Economics, London, United Kingdom; 4Seoul National University
Graduate School of Public Health, Seoul, Korea (the Republic of).
Purpose: Prevention of blindness was not included in the millennium
development goals (MDGs) even though there are plenty of evidence
demonstrating the correlation between the property and blindness. We
have evaluated the disproportionate magnitude of the socio-economic
endowment of long-term community development project on blind
patients by measuring the effectiveness of surgical intervention.
Methods: The study is a one-year postoperative follow-up research
measuring the effect of cataract surgery in the impoverished area
conducted from in Mwandama MVP. Quality of Life along with
Expenditure and Self-rated Wealth was measured on Surgically
Treated Group (STG), Low Vision Group (LVG), and Normal Vision
Group (NVG). There were 167 (STG: 58, LVG: 48, NVG: 60) and
144 (STG: 49, LVG: 49, NVG: 44) village dwellers participated.
Difference in Differences (DID) was used for the analysis, and
demographic factors such as age, sex, and marital status along with
socio economic factors such as level of education, income, and
occupation were used as control variables.
Results: The basic demographic profiles of the cataract and normal
vision group were not significantly different. There was significant
increase in the score of EQ-5D and Visual Function related Quality
of Life (VFQoL) after a year of the surgery in the STG (p=0.012,
p=0.006), and the difference from NVG was not noticed at the
endline. Scores regarding expenditure was lower in the STG compare
to the LVG, but there was statistically significant increase in the
group (p=0.012) at the endline, which is not very different from
the one of NVG (p=0.64). NVG significantly tend to have more
assets tham the other groups (p=0.008) from the beginning, and
this fact does not change at the endline either. However, there has
been a drastic change in the self-related wealth within a year after
the surgery, which means subjective economical satisfaction of the
surgery is high (p=0.002).
Conclusions: Even at the height of a long-term development
program, the blind individuals received an out of proportion socioeconomic benefit. This study evaluated the economical effectiveness
of the cataract surgery by adopting DID model. Providing restoring
vision treatment can make more people receive the benefits and
achievement of community development projects, an in turn, it will
increase economic impact.
Commercial Relationships: Sangchul Yoon, None; Jihee Lee,
None; Youn Seung Kim, None; Jin Kwan Park, None; Kyoung
Yul Seo, None
Support: Korea International Cooperation Agency Private-Public
Partnership Program in 2014
Clinical Trial: National Health Science Research Committee
(NHSRC) Malawi, NHSRC #1228
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to access the versions of record.
ARVO 2016 Annual Meeting Abstracts
Program Number: 5568 Poster Board Number: D0073
Presentation Time: 3:45 PM–5:30 PM
Eyes of Africa: Establishing Comprehensive Ophthalmology
Clinical and Surgical Capabilities in Rural Malawi
William E. Sponsel2, 3, Rand R. Allingham1, Jeff Rogers5,
Elly Chemey5, Kate Coleman4, 6, Jenny Brockington5,
Yohann Chikwatu5, Melissa Murphy6. 1Ophthlamology, Duke
University, Durham, NC; 2University of Texas San Antonio, San
Antonio, TX; 3Vision Sciences, University of the Incarnate Word,
San Antonio, TX; 4Blackrock Clinic, Dublin, Ireland; 5Child Legacy
International, Boerne, TX; 6Right to Sight, Dublin, Ireland.
Purpose: 1% of Malawi’s population is bilaterally blind, 80%
by treatable conditions. The ratio of eye surgeons in sub-Saharan
Africa is <10-5 the level in developed nations, and glaucoma
prevalence >5-fold higher. With widespread poverty, energy
blackouts, paucity of surgeons, any prospect for evolving
subspecialty level care within the existing healthcare system
appears untenable. We attempt to bypass these barriers by creating
state-of-the-art facility in a self-sustaining site 40 minutes from
the national capital.
Methods: With generous donations from industry, Child Legacy
International (CLI; www.childlegacy.org), Sponsel Foundation,
Right to Sight, and the International Society for Glaucoma Surgery
(ISGS), have established state-of-the-art clinic (Fig 1) and operating
rooms (Fig 2). Eyes of Africa Center of Excellence (EOA Center)
is equipped to provide high standard care five days a week, staffed
by an Ophthalmologic Clinical Officer (OCO) and Ophthalmologic
Nurse (ON) with EMR. Wind and solar power provide electricity and
clean water 24/7. Patients requiring laser or surgery are scheduled
to see an ophthalmologist. 1/3 of patients seen in any day may
be patients brought to the facility by the MD; 2/3 must be OCOscheduled indigent patients.
Results: National University resident rotations with mentor
supervision is scheduled. SLT, YAG, diode, and argon lasers, OCT,
A-scan, FDT, CS, dual lanes, quality slit-lamps, phacos, posterior
vitrector, Zeiss xyz/zoom operating scopes are all functional and
in situ. Full time supervisor ophthalmologist is to be appointed in
2017. Local ophthalmologists and multinational eye teams from
ISGS are scheduled to work together in the state-of-the-art diagnostic
and therapeutic facilities. NIH-funded genetics research is under
approval. Prospective studies of SLT for POAG, and refractive
programs are under IRB review.
Conclusions: Malawi’s best clinicians can now apply modern
diagnostics and perform surgery at high standard with reliable
energy supply. International teams of expert surgeons, technicians,
nurses and optometrists will mentor and learn from local experts and
trainees to help jump-start the Malawi eye care system.
Eyes of Africa Clinic
One of the Child Legacy Hospital Eye ORs
Commercial Relationships: William E. Sponsel;
Rand R. Allingham, None; Jeff Rogers, None; Elly Chemey,
None; Kate Coleman, None; Jenny Brockington, None;
Yohann Chikwatu, None; Melissa Murphy, None
Program Number: 5569 Poster Board Number: D0074
Presentation Time: 3:45 PM–5:30 PM
Proportion of Medical Only versus Surgical Ophthalmology
Practices: Associations and Trends
Yvonne M. Buys, Jonathan A. Micieli. Ophthalmology & Vision
Sciences, University of Toronto, Toronto, ON, Canada.
Purpose: Ophthalmology is one of the few unique specialties
in medicine that provides the opportunity for primarily medical,
primarily surgical or combined medical and surgical practice
however, it remains unknown what proportion of ophthalmologists
have surgical vs medical only practices. The goal of this study was to
assess the yearly proportion of ophthalmologists with a medical only
practice over a 14-year period and the influence of gender and career
stage.
Methods: Retrospective population-based study in Ontario, Canada,
a universal government funded healthcare system. Individual
ophthalmologists’ yearly billings, gender and year of medical school
graduation were accessed via the Medical Services database in
IntelliHEALTH Ontario from 1999-2013. A surgical ophthalmologist
was defined as one who performed 20 or more ophthalmological
surgical procedures. The yearly proportion of medical only vs
surgical ophthalmologists was obtained. The effect of gender and
career stage (early (<10 years from graduation), mid (10-45 years)
and late-career (>45 years)) was evaluated. In addition, productivity
of medical versus surgical ophthalmologists was compared based on
number of consultations and assessments.
Results: The number of practicing ophthalmologists in Ontario
increased from 410 in 1999 to 469 in 2013. The proportion of medical
only versus surgical ophthalmologists changed little over the 14-year
period, averaging 30.5% medical only and 69.5% surgical. Recent
graduates showed a decreasing trend towards performing surgery of
1.6% per year whereas late-career ophthalmologists demonstrated an
increasing trend of 1.5% per year. Female ophthalmologists were less
likely to perform surgery than male ophthalmologists but showed an
increasing surgical trend. Surgical ophthalmologists saw on average
1.6X the number of yearly consultations and assessments compared
to their medical peers. Late-career ophthalmologists saw significantly
fewer patients than their younger counterparts in each year studied.
Conclusions: A significant number of ophthalmologists have medical
only practices. A large majority of late-career ophthalmologists have
transitioned to a medical only practice. A decreasing trend in the
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to access the versions of record.
ARVO 2016 Annual Meeting Abstracts
proportion of young ophthalmologists performing surgery coincides
with a growth of late-career surgical ophthalmologists which may be
limiting surgical opportunities for new graduates.
Commercial Relationships: Yvonne M. Buys, None;
Jonathan A. Micieli, None
Program Number: 5570 Poster Board Number: D0075
Presentation Time: 3:45 PM–5:30 PM
Gerontology and low vision services provided by Australasian
optometrists
Barbara M. Junghans1, Anthea Cochrane3, Peter L. Hendicott2,
Anna Palagyi4, Robert J. Jacobs5. 1Optometry and Vision Science,
Univ of New South Wales, UNSW Sydney, NSW, Australia;
2
Optometry and Vision Science, Queensland University of
Technology, Kelvin Grove, QLD, Australia; 3Optometry and Vision
Sciences, University of Melbourne, Parkville, VIC, Australia; 4Injury
Division, The George Institute, Sydney, NSW, Australia; 5Optometry
and Vision Science, University of Auckland, Auckland, New Zealand.
Purpose: Anecdotally, few optometrists specialize in the care of
persons with permanent vision impairment by providing clinical
assessments, rehab services or training in adaptive technologies. Is
this due to inadequate training or is there some other reason? We
investigated optometrists’ practice preparedness and management
patterns for the older patient and those with low vision (LV).
Methods: Cross-institutional ethics approval was gained in 2009 to
survey all members of Optometry Australia and the New Zealand
Association of Optometrists. The survey covered 39 areas including
demographics and practice management, range of visual aids
prescribed and referral patterns to visual rehabilitation agencies.
Results: Of 359 responding optometrists, 56% had graduated
within the past 20 years, 41% were employees, and 26% were
practicing in rural areas. 12% of respondents did not cater at all
for elderly clients through longer consultations, physical access
assistance, or domiciliary visits, and 9% of respondents claimed
a lack of confidence to do so. Only 11% provided almost all LV
services (mainly older practitioners) and 58% essentially provided
no LV services. 59% of all respondents referred LV patients to a
rehabilitation agency, with 17% claiming this was due to lack of
ability to manage the patient themselves. Even the most active LV
care optometrists referred 9% of their LV patients to an agency.
Of respondents who did provide LV services, 91% prescribed high
addition spectacles, 75% hand magnifiers, 60% stand magnifiers, but
only approximately 10% prescribed hi-tech aids. Of all respondents,
13% use an ophthalmic assistant in providing LV aids. Alma-mater
did not affect prescribing habits significantly. Educationally, 24%
and 29% of all respondents (the majority of whom were younger
optometrists) indicated that an experience during optometric training
helped them decide to provide gerontological and LV services
respectively. Passion and empathy in teachers was reported as a
strong motivator for graduands to take up these fields of care. Lack of
experience with elderly and LV patients while at university appeared
to underpin the lack of confidence in many.
Conclusions: These data provide valuable insight into optometrists’
present capability to service an ageing population in Australasia,
and to support directions for curriculum review to ensure graduating
optometrists are appropriately skilled.
Commercial Relationships: Barbara M. Junghans;
Anthea Cochrane, None; Peter L. Hendicott, None; Anna Palagyi,
None; Robert J. Jacobs, None
Support: Australian Learning and Teaching Council Grant Ref:
DS8-628
Program Number: 5571 Poster Board Number: D0076
Presentation Time: 3:45 PM–5:30 PM
Direct-to-Consumer-Advertising in Ophthalmology
Cherie Fathy1, Sahar Kohanim2. 1Vanderbilt School of Medicine,
Nashville, TN; 2Ophthalmology, Vanderbilt Eye Institute, Nashville, TN.
Purpose: $4.3 billion were spent on Direct to Consumer
Advertisements (DTCA) in 2010, which reach a significant
proportion of consumers and may increase pharmaceutical sales.
DTCA for ophthalmologic conditions are present in popular print
media; however, it is unknown how common ophthalmologic
ads are in print media and what conditions are most commonly
covered. Opponents argue that exposure to these ads may increase
the likelihood of overprescribing, while proponents believe they
may encourage patients to engage in beneficial conversations with
their providers. We performed a content analysis to determine the
prevalence and content of DTCA for ophthalmologic products in
print media.
Methods: 3 consecutive issues of 49 popular magazines were
screened over a 3-month period for ophthalmologic advertisements.
Each ad was evaluated for the following variables: type of
advertisement, ophthalmologic condition covered, effectiveness
claims, the presence of advertising appeals, and scientific data.
Descriptive statistics were used to analyze the data.
Results: 19 (39%) magazines had ophthalmologic advertisements. 11
unique ads were identified. Most were drug or product-specific. The
median number of claims per advertisement was 4 (range, 1-11). The
most common appeals addressed effectiveness (n=6) and product’s
ease of use (n=5). None addressed curability. Refractive errors (n=5)
and Keratitis Sicca (n=3) were the most common ophthalmologic
conditions covered. 3 of 11 advertisements were gender-specific,
marketing cosmetic contact lenses or cosmetic eye cream for women.
Only 5 of the 11 ads referenced research studies and 5 encouraged
patients to seek more information from providers. None of the ads
provided data in the form of tables or figures. Only 2 ads provided
a risk profile for their products, which were in smaller font and
required a higher level of reading comprehension. All ads provided
patient support for more information, most commonly through the
Internet.
Conclusions: DTCA for ophthalmologic conditions are present
in popular print media, especially those targeting women. Our
results suggest that marketing is limited to a few disorders in
ophthalmology, which may not accurately reflect the most common
ocular conditions in the United States. Ads often encourage patients
to request prescriptions or more information from their providers.
Further research is needed on the quality of information of these
advertisements and their effect on the patient-physician relationship.
Commercial Relationships: Cherie Fathy; Sahar Kohanim, None
Program Number: 5572 Poster Board Number: D0077
Presentation Time: 3:45 PM–5:30 PM
Does Type of Health Insurance Coverage Affect How Patients
Newly Diagnosed with Open-angle Glaucoma are Managed?
Ari D. Schuman1, Chris A. Andrews1, Paula Anne Newman-Casey1,
Suzann Pershing3, 4, Joshua D. Stein1, 2. 1Department of
Ophthalmology and Visual Sciences, University of Michigan
Medical School, Ann Arbor, MI; 2Institute for Healthcare Policy
and Innovation, University of Michigan, Ann Arbor, MI; 3Byers Eye
Institute, Stanford University, Palo Alto, CA; 4VA Palo Alto Health
Care System, Palo Alto, CA.
Purpose: To determine what initial treatments are being given to
patients newly diagnosed with open angle glaucoma (OAG) and
whether they vary depending on type of health insurance coverage.
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ARVO 2016 Annual Meeting Abstracts
Methods: A large commercial insurance claims database
(OptumInsight) and the Medicaid Analytic Extract (MAX) were
queried to identify patients throughout the United States newly
diagnosed with OAG in 2008 and 2009 who had ≥1 year of
continuous enrollment in the plan after initial OAG diagnosis and
≥3 years of prior plan enrollment with no pre-existing record of any
glaucoma. These data were analyzed to determine the proportion
of patients receiving treatment, whether the initial treatment was
medical, laser, or incisional surgery, and the types of medications
prescribed. Among patients with commercial insurance, copays for
each medication class were examined to determine the extent patients
were prescribed the least expensive option.
Results: Patients on Medicaid (n=4429) had a higher proportion
of treatment in the first year after diagnosis than 3947 patients with
commercial insurance (76.0% vs. 67.8%, p<.0001). Among the
patients receiving treatment, a similar proportion with commercial
insurance and Medicaid were initially treated with medications (92%
vs. 93%, respectively, p=.06). A greater proportion of patients with
commercial insurance with OAG were initially treated with beta
blockers (13.4% vs. 9.7%, p<.0001) while a greater proportion of
Medicaid enrollees with OAG were treated with PGAs (79% vs.
77%, p=.02) and α-agonists (8.1% vs. 5.1%, p<.0001). Xalatan was
the most commonly prescribed PGA for patients with commercial
insurance and was also the most expensive agent for those with
commercial insurance with a mean copay of $42.71. Lumigan
($30.70) and Travatan Z ($29.19), the other PGAs examined, had
lower mean copays.
Conclusions: Patients with Medicaid with OAG were more likely to
receive treatment in the year after initial diagnosis compared to those
with commercial insurance. While the reasons for this are unclear, it
may be due to lower copays for medications, more severe disease, or
less access to samples.
Commercial Relationships: Ari D. Schuman, None;
Chris A. Andrews; Paula Anne Newman-Casey, None;
Suzann Pershing, None; Joshua D. Stein, None
Support: The Kellog Foundation, Research to Prevent Blindness
"Physician Scientist" Award, NEI K12EY022299
Program Number: 5573 Poster Board Number: D0078
Presentation Time: 3:45 PM–5:30 PM
Eye health care delivery on Prince Edward Island: Does public
funding policy alter unequal diagnosis by geographic residence?
Yaping Jin1, 2, Richard Wedge3, Anam Khan2, Yvonne M. Buys1,
Sherif El-Defrawy1, Qishen Chen4, Graham E. Trope1.
1
Ophthalmology and Visual Science, University of Toronto, Toronto,
ON, Canada; 2Dalla Lana School of Public Health, University of
Toronto, Toronto, ON, Canada; 3Health PEI, Charlottetown, PE,
Canada; 4Geography and Environmental Management, University of
Waterloo, Waterloo, ON, Canada.
Purpose: To investigate geographic patterns of eye health care
delivery on Prince Edward Island (PEI).
Methods: We analyzed PEI physician billing data from 2010-2012
in five areas defined by postal codes (Charlottetown, Summerside,
Prince, Queens & Kings and Stratford). Examined eye conditions
(glaucoma, cataracts and diabetes) were identified by related ICD9 codes. Provincial-insured eye care services were recognized
using specialty codes. Postal codes were used to determine patient
residential location and place of eye care provider’s office. Agestandardized rates were computed for comparisons.
Results: During the study period there were 6 ophthalmologists
practicing on PEI, 5 (83%) with offices in Charlottetown. There
were 20 optometrists practicing on the island with offices across the
province. Stratford is closest and Prince farthest from Charlottetown.
Optometric services were not government-insured during the study
period. To receive provincially-insured eye care services, 54% of
islanders residing outside the Greater Charlottetown Area have to
travel to Charlottetown. The prevalence of glaucoma visits per 100
people aged 40+ was higher in Charlottetown (6.10) and Stratford
(6.38) and lower in the other areas with the lowest in Prince (3.85,
p<0.05). A similar pattern was seen with the prevalence of cataract
visits. Utilization of ophthalmologists per 100 people was also higher
in Charlottetown (10.44) and Stratford (10.90) and lower in the other
areas (7.74-8.92, p<0.05). The prevalence of diabetes visits per 100
people was higher in Prince (6.93) and Summerside (6.65) and lower
in the other areas (5.44-6.10, p<0.05). However, the utilization of eye
care services per 1000 diabetics in Charlottetown (6.58) and Stratford
(6.69) was twice the utilization rate in Prince (3.05, p<0.05).
Conclusions: Significantly higher utilization of ophthalmologists and
higher prevalence of eye care visits was found in Charlottetown and
its closest area Stratford where ophthalmologist offices were highly
concentrated, suggesting better patient access and better detection
of eye disease in these areas. Encouraging ophthalmologists to
work in other areas and/or providing public funding for services by
optometrists who work in all areas of PEI may alleviate the observed
discrepancy in eye care access and eye disease diagnosis induced by
geography.
Commercial Relationships: Yaping Jin, None; Richard Wedge,
None; Anam Khan, None; Yvonne M. Buys, None; Sherif ElDefrawy, None; Qishen Chen, None; Graham E. Trope, None
Support: CIHR HRA 126901
Program Number: 5574 Poster Board Number: D0079
Presentation Time: 3:45 PM–5:30 PM
Evaluation of access to eye care by driving time in the state of
Washington
Aaron Y. Lee1, Cecilia S. Lee1, Aaron P. Weingeist2,
Russell N. Van Gelder1. 1Department of Ophthalmology, University of
Washington, Seattle, WA; 2Clearview Eye & Laser, Seattle, WA.
Purpose: Access to eye care remains a challenge in geographically
disparate locations such as the state of Washington. The purpose of
this study was to determine access to eye care by measuring driving
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ARVO 2016 Annual Meeting Abstracts
distance between population centers and eye care providers in the
state of Washington.
Methods: The 2012 Medicare Provider Utilization and Payment
Data from the Centers for Medicare and Medicaid Services were
used to identify providers actively practicing as optometrists and
ophthalmologists. Open Street Map data for every road and its
associated speed limits were utilized in the state of Washington to
calculate the shortest path defined by driving time using Dijkstra’s
algorithm. The 2010 US Census geospatial data at block group
resolution was meshed with Open Street Map to calculate the shortest
path between populated areas and the nearest eye care provider.
Results: Of the 25,508 optometrists and 17,071 ophthalmologists in
the national Medicare Provider Utilization and Payment Data from
2012, a total of 665 optometrists and 332 ophthalmologists were
identified as practicing in the state of Washington. Over 2.6 x 105
driving routes were calculated and the shortest driving path and time
were collected for each optometrist to the nearest ophthalmologist.
Ninety percent of the population lives within 9.36 miles and 11.76
minutes of an eye care provider (Figure 1A,B). Driving routes
between eye care providers were calculated (Figure 2). 94.6%
and 97.6% of optometrists practice within 30 and 60 miles of an
ophthalmologist, respectively. 97.6% and 99.6% of optometrists
practice within 1 and 2 hours of an ophthalmologist. The median
distance and driving time to the nearest ophthalmologist were 1.81
miles and 2.16 minutes respectively (Figure 3A,B).
Conclusions: In the state of Washington, the majority of the
population lives within close proximity of an eye care provider.
Commercial Relationships: Aaron Y. Lee; Cecilia S. Lee, None;
Aaron P. Weingeist, None; Russell N. Van Gelder, None
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ARVO 2016 Annual Meeting Abstracts
Program Number: 5575 Poster Board Number: D0080
Presentation Time: 3:45 PM–5:30 PM
Environmental Life Cycle Assessment and Costs of
Phacoemulsification at Aravind Eye Hospital in Pondicherry,
India
Cassandra L. Thiel1, Emily Schehlein2, Osamah Saeedi2,
Joel S. Schuman3, Alan L. Robin2, 4, Rengaraj Venkatesh5, 6,
Ravindran R.D5, Ravilla D. Thulasiraj5. 1Civil and Environmental
Engineering, University of Pittsburgh, Pittsburgh, PA;
2
Ophthalmology, University of Maryland School of Medicine,
Baltimore, MD; 3Ophthalmology, University of Pittsburgh,
Pittsburgh, PA; 4Ophthalmology, Johns Hopkins University,
Baltimore, MD; 5Aravind Eye Care System, Madurai, India;
6
Glaucoma, Aravind Eye Hospital, Pondicherry, India.
Purpose: There are increasing concerns about the environmental
footprint and greenhouse gas emissions of healthcare, and the
operating room is of particular focus. The Aravind Eye Care System
has created an effective surgical model based on efficiency of time
and cost, but what is the environmental footprint of this model? This
study analyzes material use at Aravind Eye Hospital in Pondicherry
(AEH-PDY), India and calculates the environmental emissions
through Life Cycle Assessment (LCA).
Methods: We quantified and weighed surgical materials used in
phacoemulsification (phaco) at (AEH-PDY). Material flow maps
documented the reuse and disposal of all surgical materials for each
site; average costs of materials and their disposal were calculated
using hospital accounting records. Collected data were input into an
LCA framework using one phaco (one eye) as the functional unit
and the perioperative period as the study boundaries. Emissions
throughout materials’ life cycles were calculated using the robust
life cycle inventory database ecoinvent 3 and the global impact
assessment method CML-IA v3.02 World 2000.
Results: Key contributors to the life-cycle environmental footprint
of a single phaco at AEH-PDY include electricity, water use, and the
production of single-use materials (Fig 1). Carbon emissions from
surgical materials and their disposal (including reusable and singleuse items, Fig 2) average about 0.8kg CO2-eq per phaco, well below
the reported average of 63.5kg CO2-eq per phaco in the UK (Morris,
et al. 2013).
Conclusions: Results show that Aravind’s efficiency-focused surgical
model minimizes environmental emissions and costs associated with
phaco. Aravind’s current initiative to install solar photovoltaic panels
for electricity generation will likely further reduce their overall
footprint. Given Aravind’s proven surgical outcomes (Haripriya, et
al. 2012), other hospitals should consider components of this model
when attempting to reduce the environmental and cost burdens of
surgical care.
Life-Cycle Environmental Impacts of Phacoemulsification (Phaco)
at Aravind Eye Hospital, Pondicherry (AEH-PDY); *Cost does not
include water or capital equipment
Material Flow for Surgical Materials Used in Phacoemulsification
(Phaco) at Aravind Eye Hospital, Pondicherry (AEH-PDY); ROReverse Osmosis, IOL- Intraocular Lens, ETO- ethylene oxide
Commercial Relationships: Cassandra L. Thiel, None;
Emily Schehlein, None; Osamah Saeedi, None; Joel S. Schuman;
Alan L. Robin, Aerie, Biolight (C), Aerie, Glaukos (I), Aravind
Eye Care System (S); Rengaraj Venkatesh, Aravind Eye Care
System (S); Ravindran R.D, Aravind Eye Care System (S);
Ravilla D. Thulasiraj, Aravind Eye Care System (S)
Support: •Fulbright-Nehru Academic and Professional Excellence
Award (Research) 2014-2015
Program Number: 5576 Poster Board Number: D0081
Presentation Time: 3:45 PM–5:30 PM
Utility of the Postoperative Week 1 Examination and
Postoperative Month 1 Dilated Examination after Cataract
Surgery: A Pilot Study
Durga S. Borkar1, Emily Gross2, Tave A. van Zyl1, Sherleen Chen1,
Carolyn Kloek1, 2. 1Massachusetts Eye and Ear Infirmary, Boston,
MA; 2Harvard Medical School, Boston, MA.
Purpose: There is currently no preferred practice pattern for
postoperative evaluation after cataract surgery. The purpose of
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ARVO 2016 Annual Meeting Abstracts
this retrospective, observational study is to assess the utility of the
postoperative week 1(POW1) examination and postoperative month
1(POM1) dilated examination in the perioperative management of
patients undergoing cataract surgery.
Methods: Cases of cataract extraction by phacoemulsification
performed by a single surgeon on the Comprehensive Ophthalmology
Service at an academic practice in Boston, MA between 1/1/14 and
12/31/14 were reviewed. Detailed perioperative information was
collected. Patients without significant intraoperative complications
and a normal postoperative day 1(POD1) examination were included
in the final data analysis. Data from the POW1 exam was reviewed to
evaluate for a change in management from the initial plan on POD1.
Additionally, the results of the dilated fundus examination performed
at POM1 were reviewed.
Results: 150 cases were reviewed. Of these, 15 patients were
excluded. 5 patients had planned combined cataract extraction with
pars plana vitrectomy, and 10 patients did not have both a POW1
and POM1 examination. The study population of 135 patients
consisted of 83 women and 52 men ranging from 39 to 97 years old.
In this population, 26 patients (19%) did not have a normal POD1
examination. This was most commonly due to elevated intraocular
pressure in the operative eye. In the remaining 109 patients, the
exam was as expected for POD1, and the surgeon’s standard steroid,
NSAID, and antibiotic drop regimen was prescribed. At POW1, only
2 of these 109 patients had a change in postoperative management.
Both of these patients had a retinal detachment associated with
symptoms that prompted the patient to be seen prior to the scheduled
POW1 visit. Similarly, at POM1, the dilated fundus exam revealed
a new retinal finding in 1 asymptomatic patient. However, since
this patient had a trace epiretinal membrane in the operative eye
with a best-corrected visual acuity of 20/20, this did not change
postoperative management.
Conclusions: The results of this study suggest that the POW1
examination does not change postoperative management after
cataract surgery in asymptomatic patients with a normal POD1
examination. Similarly, dilation at POM1 did not reveal any
significant unexpected findings in asymptomatic patients.
Commercial Relationships: Durga S. Borkar, None; Emily Gross,
None; Tave A. van Zyl, None; sherleen chen; Carolyn Kloek, None
Program Number: 5577 Poster Board Number: D0082
Presentation Time: 3:45 PM–5:30 PM
Influence of gender and age on ophthalmologists’ billings from
1992-2014
Rana Greene, Yaping Jin, Ying Qi, Yvonne M. Buys. Ophthalmology,
University of Toronto, Toronto, ON, Canada.
Purpose: Physician resource management requires knowledge not
only of headcounts but also capacity of care which is commonly
reported as Full Time Equivalents (FTEs). Given the documented
feminization of the ophthalmology workforce and the 7-fold increase
in Canadian ophthalmologists aged ≥65 years since 1970, this study
evaluated the influence of gender and age on billing patterns as a
surrogate of capacity of care.
Methods: Yearly Ontario Health Insurance Plan (OHIP) billings of
all Ontario ophthalmologists from 1992-2014 were obtained from the
Institute for Clinical Evaluative Sciences for this retrospective cohort
study. Comparisons in yearly billings were made between genders
and among all age groups using 5 year increments. For comparison
similar data was evaluated for all Ontario physicians. Billing data was
adjusted to 2014 Canadian dollars to account for inflation.
Results: Median billings for ophthalmologists changed little from
1992-2005, then increased 1.8% yearly peaking in 2011 followed by
a 4.5% decrease to 2014. For all Ontario physicians median billings
decreased 0.67% yearly from 1992-2014. Median billings of female
ophthalmologists were less than male ophthalmologists however this
difference decreased over the study period with females billing 50.1%
of male ophthalmologists’ in 1992 increasing to 78.2% in 2014, a
1.4% yearly increase. In comparison for all Ontario physicians the
gender gap in billings changed little with female physicians’ median
billings averaging 63.6% of males. In terms of age, highest billing
was in the 35-54 year cohort. Although the lowest billing was in
those >75, this group had the largest increase with median billings
increasing 6.5X in the study period. In contrast those ≤35 were third
highest billers in 2004 but second lowest from 2009-2014 with a 51%
decrease in billings from 2004-2013. Those 70-74 had 115% increase
in yearly median billings from 2007-2014 billing more than those
≤35 from 2009-2014.
Conclusions: Median billings have decreased for Ontario
ophthalmologists since 2011. Female ophthalmologists are slowly
bridging the gender gap with median billings increasing from 50.1%
of male billings in 1992 to 78.2% in 2014. Ophthalmologists aged
35-54 had the highest yearly median billings. Median billings of
ophthalmologists aged >70 have increased while those ≤35 have
decreased from 2009 suggesting delayed retirement may be affecting
opportunities for recent graduates.
Commercial Relationships: Rana Greene, None; Yaping Jin,
None; Ying Qi, None; Yvonne M. Buys, None
Program Number: 5578 Poster Board Number: D0083
Presentation Time: 3:45 PM–5:30 PM
A major shift in ophthalmic surgical care in the United States
from hospital outpatient departments to ambulatory surgery
centers over the past decade
Brian C. Stagg1, Nidhi Talwar2, Cynthia Mattox4, Paul P. Lee2, 3,
Joshua D. Stein2, 3. 1Ophthalmology, Univ of Utah School of
Medicine, Salt Lake City, UT; 2Department of Ophthalmology and
Visual Sciences, University of Michigan, Medical School, Ann Arbor,
MI; 3Institute for Healthcare Policy and Innovation, University of
Michigan, Ann Arbor, MI; 4Department of Ophthalmology, New England
Eye Center, Tufts University School of Medicine, Boston, MA.
Purpose: Utilization of ambulatory surgery centers (ASCs) is an
alternative to traditional hospital outpatient departments (HOPDs)
for ophthalmic surgery. The purpose of this study is to explore trends
over the past decade in use of ASCs versus HOPDs for various types
of ophthalmic surgeries among enrollees in a nationwide managed
care network.
Methods: Claims data from 2001-2012 capturing patients enrolled
in a large U.S. managed-care network were analyzed to identify all
patients undergoing incisional ophthalmic surgery (cataract surgery,
strabismus surgery, cornea surgery, glaucoma surgery, and retina
surgery). For each type of ophthalmic surgery, we identified whether
it took place at an ASC or HOPD. Each year from 2001-2012,
we determined the proportion of each type of ophthalmic surgery
performed at ASCs versus HOPDs.
Results: A total of 413530 patients underwent ≥1 type of incisional
ophthalmic surgery during 2001-2012. The mean number of cataract,
strabismus, cornea, glaucoma, and retina surgeries performed
annually were 41526, 2626, 2381, 1096, and 5503, respectively. From
2001 to 2012, the proportion of cataract surgeries performed at ASCs
increased 59% (from 43.7% to 69.7%), the proportion of strabismus
surgeries performed at ASCs increased 153% (from 15.2% to 38.5%),
the proportion of cornea surgeries performed at ASCs increased
55% (from 27.4% to 42.4%), the proportion of glaucoma surgeries
performed at ASCs increased 32% (from 43.1% to 56.8%), and the
proportion of retina surgeries performed at ASCs increased by nearly
2 fold (from 14.0% to 41.7%).
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ARVO 2016 Annual Meeting Abstracts
Conclusions: Over the past decade the proportion of ophthalmic
surgeries performed at ASCs has increased substantially. Over two
thirds of cataract surgeries are now performed at ASCs and surgeons
are increasingly using ASCs for subspecialty ophthalmic surgeries as
well. Future analyses need to explore the impact of this shift in care
on patient outcomes, patient satisfaction, and costs.
Commercial Relationships: Brian C. Stagg, None; Nidhi Talwar,
None; Cynthia Mattox, None; Paul P. Lee, None; Joshua D. Stein,
None
Support: Kellogg Foundation, Research to Prevent Blindness
Program Number: 5579 Poster Board Number: D0084
Presentation Time: 3:45 PM–5:30 PM
Retinal Surgery Case Selection and Safety in an Ambulatory
Surgery Center versus Hospital
Chase Miller1, Llewelyn Rao1, Joan Hornik1, Douglas Rowland2, 3.
1
Retina Associates of Cleveland, Cleveland, OH; 2DY Rowland
Associates, Cleveland Heights, OH; 3Department of Epidemiology
and Biostatistics, Case Western Reserve University School of
Medicine, Cleveland, OH.
Purpose: There has been a migration of retinal surgical cases over
the past decade to ambulatory surgery centers (ASCs) from hospital
outpatient surgery departments (HOPDs) due to increased efficiency.
We evaluated retinal surgery case selection and safety in an ASC
versus an HOPD.
Methods: We retrospectively analyzed retinal surgical case selection
and safety in a large single retinal specialty practice over a 5-year
period (7-1-10 to 6-30-15). The total number of cases done at an
ASC and an HOPD were reviewed and categorized by common
procedural terminology (CPT), and the 10 most common CPT codes
were analyzed. Categorical data were summarized by counts and
percents. Relative frequencies of procedures were compared by
the chi-square test of contingency table data or Fisher’s exact test.
We assessed safety through review of medical incident reports and
hospital admissions related to the procedures. Rates of incidents
were calculated along with 95% confidence intervals (95% CIs) by
the modified Wald method. Proportions of incidents were compared
by Fisher’s exact test for all procedures, combined, as well for
subgroupings, elective and emergent. We also reviewed the reasons
that cases were scheduled at the HOPD over the ASC for the most
recent 18 months (1-1-14 to 6-30-15).
Results: Total ASC cases numbered 5737 vs HOPD 213. There
was a significant (p < .001) difference in the relative frequencies of
procedures at ASC vs HOPD for all 10 of the most common retinal
surgery CPT codes. For safety, the rate of medical incidents was 7 in
5,737 procedures (0.12%) (95% CI: 0.05% to 0.26%) at ASCs and 0
in 213 procedures (0%) (95% CI: 0.00% - 2.13%) at HOPD. For all
procedures aggregated, as well as for each subgrouping, elective and
emergent, 95% CIs of ASCs and hospitals overlapped. Examining
these data with Fisher’s exact test, there were no statistically
significant differences in medical incidents, either for all procedures
combined (p = .21) or for the subgroupings, elective and emergent (p
> .99 for each subgrouping). There were 43 cases performed at the
HOPD over the last 18 months: 30 scheduling conflicts, 6 insurance
requirements, 5 pediatric cases, and 2 medical indications.
Conclusions: There was significantly more utilization of the ASC
over the HOPD for all categories of retinal surgery cases, elective and
emergent, with no apparent medical safety concerns.
Commercial Relationships: Chase Miller; Llewelyn Rao,
Cleveland Eye and Laser Surgery Center (I); Joan Hornik, None;
Douglas Rowland, None
Program Number: 5580 Poster Board Number: D0085
Presentation Time: 3:45 PM–5:30 PM
Analysis of the cost savings from applying optical coherence
tomography (OCT) to guide treatment for choroidal
neovascularization
Kevin D. Frick1, Sissi Sun1, David Huang2. 1Johns Hopkins Carey
Business School, Baltimore, MD; 2Oregon Health Science University,
Portland, OR.
Purpose: We compare the cost per patient per month (PMPM)
of using OCT to guide treatment decisions before administering
ranibizumab with the cost of not using OCT and administering
ranibizumab every month as recommended by the FDA for
the treatment of choroidal neovascularization (CNV). We use
a population of 143,000 Medicare patients being treated with
ranibizumab for CNV in 2012.
Methods: In the Centers for Medicare and Medicaid Services 2012
database, the average amount that is paid to the manufacturer is
$391.41 for a 0.1 mg dose of ranibizumab. The actual amount paid
to physician is the manufacturer price plus 6%, or $414.89. The
most common dosage is 0.5mg, making the average $2,074.45. This
service is provided to Medicare patients under Medicare’s Part B
program for physician services, outpatient allied health services and
drugs provided as part of a procedure. Medicare patients have to pay
a 20% co-payment for this service. The Medicare payment amount
for per OCT scan is $44.56. The billing codes are called “HCPCS
codes” within the Medicare system. For OCT, the HCPCS code is
“computerized ophthalmic diagnostic imaging, posterior segment;
retina”, 92134. The percent of doses avoided is from a literature
review of PubMed. Using the FDA-recommended 12 injections per
year to equal 100%, an average non-injection rate of 44.3% is found
with OCT performed. This allows patients to avoid unnecessary
injections almost one-half of the time.
Results: The cost of providing the FDA-recommended monthly dose
of 0.5mg ranibizumab to 143,000 patients would be $296,646,350/
month. The cost of using OCT to guide treatment decisions–assuming
monthly OCT scans–would be $6,372,080. When providing the dose
of ranibizumab to only 79,651 individuals per month, the cost of the
injections is $165,232,017. The total cost when using OCT on all
patients and administering only the necessary doses of ranibizumab is
$171,604,097. The cost saving for a population of 143,000 patients is
$125,042,253, or $874 PMPM.
Conclusions: The use of OCT to guide treatment decisions for
patients with CNV saves momey and improves the quality of the
patient care experience. This combination suggests supporting
reimbursement for this use of the technology and promoting its
use by ophthalmologists. If ophthalmologist income is at risk the
payment system could be redesigned as pay for performance.
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ARVO 2016 Annual Meeting Abstracts
were significantly associated with variation in these VA outcomes.
Significant variation between centers persisted even after adjusting
for these factors.
Conclusions: There are differences in VA outcomes between centers
in the UK. These differences are influenced, but not completely
explained, by factors such as patient age, starting VA, number of
injections and visits. These data provide an indication of the VA
outcomes that are achievable in real world settings.
Commercial Relationships: Gerald Liew, None; Aaron Y. Lee,
None; Javier Zarranz-Ventura, None; Catherine A. Egan, None;
Robert Johnston, Medisoft (I); Adnan Tufail, None
Commercial Relationships: Kevin D. Frick, Vision Impact Institute
(S); Sissi Sun, None; David Huang, Optovue, Inc. (F), Optovue, Inc.
(R), Carl Zeiss Meditec, Inc. (P), Optovue, Inc. (I), Optovue, Inc. (P)
Program Number: 5581 Poster Board Number: D0086
Presentation Time: 3:45 PM–5:30 PM
Inter-Center Variation in Visual Acuity and Establishing RealWorld Measures of Care: Results from the UK Neovascular AMD
Database Report 4
Gerald Liew1, Aaron Y. Lee2, Javier Zarranz-Ventura3,
Catherine A. Egan4, Robert Johnston3, Adnan Tufail4.
1
Ophthalmology, University of Sydney, Sydney, NSW, Australia;
2
University of Washington, Seattle, WA; 3Gloucestershire Hospitals
NHS Foundation Trust, Cheltenham, United Kingdom; 4Moorfields
Eye Hospital NHS Foundation Trust, London, United Kingdom.
Purpose: Although international variations in visual acuity (VA)
outcomes of eyes treated for neovascular age-related macular
degeneration (nAMD) are well documented, intra-country intercenter regional variations are not known. This data is important for
national quality outcome indicators.
Methods: Multi-center national database study of 13 geographically
distinct centers involving 5,811 treatment naive eyes of 5,205 patients
receiving 36,206 ranibizumab injections in the UK. Participating
centers used 3 monthly loading injections + pro-re-nata (PRN) retreatment regimens.
Results: Mean starting VA between centers varied from 48.9 to 59.9
ETDRS letters. Mean VA change from baseline to 12 months varied
from +6.9 letters to -0.6 letters (mean of +2.5 letters). By contrast
inter-center variation in VA change from the end of the loading
phase to 12 months varied from +2.6 to -3.4 letters (mean of -1.5
letters). The proportion of eyes achieving VA of 70 letters or more
varied between 21.9 and 48.7% at 12 months. Median number of
injections at each center varied from 5 to 8 with an overall median
of 6, and median number of visits from 9 to 12 with a median of
11. Age, starting VA, number of injections and visits but not gender
Program Number: 5582 Poster Board Number: D0087
Presentation Time: 3:45 PM–5:30 PM
Lifetime Costs and QALYs for POAG patients, early stage
versus moderate stage treatment:A Preliminary Discrete Event
Simulation cohort study
Hla M. Htoon1, 9, Duc Quang Nguyen2, Baskaran Mani7, 9,
Steffen Bayer3, Sean S. Lam4, Monisha E. Nongpiur7, 9, Tin Aung7, 8,
Eranga N. Vithana6, 9, Ecosse L. Lamoureux5, 3, David Matchar3.
1
Statistics, Singapore Eye Research Institute, Singapore, Singapore;
2
Industrial and Systems Engineering, National University of
Singapore, Singapore, Singapore; 3HSSR, Duke-NUS, Singapore,
Singapore; 4SingHealth Health Services Research Centre, Singapore,
Singapore; 5Health Services Research, Singapore Eye Research
Institute, Singapore, Singapore; 6Laboratory Translational Research,
Singapore Eye Research Institute, Singapore, Singapore; 7Glaucoma,
Singapore Eye Research Institute, Singapore, Singapore; 8Glaucoma,
Singapore National Eye Centre, Singapore, Singapore; 9Eye ACP,
Duke-NUS, Singapore, Singapore.
Purpose: To compare the lifetime costs and quality-adjusted life
years(QALYs)of primary open-angle glaucoma(POAG)patients
commencing treatment at early (mild) and moderate stages in
Singapore
Methods: The model was structured as a patient-level discrete
event simulation, based on the van Gestel et.al.’s model(2012)
which tracked the natural course of POAG. POAG was defined as
glaucomatous optic neuropathy with compatible visual field loss.
Stages of POAG were defined as per the mean deviation values on
automated perimetry viz.mild(early)≥-6dB, moderate<-6dB to -12dB,
and severe ≤-12dB. Life time costs included direct costs(consultation,
medication, laser, surgical, hospitalization, and low vision care costs).
QALYs were assessed using the Health Utility Index Mark3(HUI3).
Data parameters were estimated from a Singapore POAG cohort
where possible;otherwise literature estimates were used. Validation was
performed based on outputs with the cohort data. Heterogeneous cohorts
of 3000 patients were simulated; and lifetime costs and QALYs were
accumulated. Probabilistic sensitivity analysis was used to estimate
confidence ranges(CR). Sensitivity analysis was performed to account
for a presumed 10-year lead-time bias for individuals with mild disease,
and the possibility that due to selection bias the moderate cohort
had more severe disease(adjusted by increasing the hazard ratio for
worsening disease in the mild cohort to1.03)
Results: Patients with initial early POAG and who progressed to
moderate stage had higher lifetime QALYs(1.51=19.7 95%CR
19.7-19.77compared to those who were initially moderate and
progressed -18.22;95%CR 18.2-18.26). There was a similar pattern
of lower costs for initial early POAG (S$-14,941=S$33,960;95%CR
33,866-34,054 compared to those who commenced treatment at
a moderate stage -S$48,901;95%CR 48,789-49,012). The trend
for lower lifetime costs and higher QALYs remained even after
sensitivity analysis(Table). Cost and QALYs for baseline and
sensitivity results are shown graphically(Figure)
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ARVO 2016 Annual Meeting Abstracts
Conclusions: Early treatment of POAG appears to have lower life
time costs and higher QALYs compared to initiating treatment at a
moderate stage. Our data suggest that early treatment is cost effective,
perhaps even economically dominant;however, we cannot exclude the
possibility that individuals with moderate POAG at onset of treatment
have a more aggressive and costly disease
Commercial Relationships: Hla M. Htoon, None; Duc
Quang Nguyen, None; Baskaran Mani, None; Steffen Bayer,
None; Sean S. Lam, None; Monisha E. Nongpiur, None; Tin Aung,
None; Eranga N. Vithana, None; Ecosse L. Lamoureux, None;
David Matchar, None
Support: SHF/HSR081/2014
Program Number: 5583 Poster Board Number: D0088
Presentation Time: 3:45 PM–5:30 PM
Cost-effectiveness of FDA-approved anti-VEGF treatments for
diabetic macular edema
Steve Duff1, Nancy Holekamp2, Yamina Rajput3. 1Veritas Health
Economics Consulting, Carlsbad, CA; 2Pepose Vision Institute,
Chesterfield, MO; 3Genentech, Inc., South San Francisco, CA.
Purpose: Diabetic macular edema (DME) is a complication of
diabetic retinopathy that can lead to vision loss if untreated. Visual
impairment and blindness due to DME have become escalating
clinical and economic issues as the number of diabetic patients
increases worldwide. This study evaluates the relative differences
in the costs and quality-adjusted life years (QALYs) of the two
approved anti–vascular endothelial growth factor (VEGF) therapies,
aflibercept and ranibizumab, in patients with DME.
Methods: A model was developed using one-year patient-level visual
acuity (VA) data from the DRCR.net Protocol T study—a head-tohead randomized controlled trial of anti-VEGF treatments for DME.
In addition to the costs of treatment with aflibercept (2.0 mg) or
ranibizumab (0.3 mg) (given at baseline and up to every 4 weeks
using defined retreatment criteria), VA-related medical costs and
QOL were simulated based on 8 VA health states. Costs (2015 USD)
for treatments, adverse events (AEs) and VA-related resources were
based on Medicare reimbursement and literature. VA-related utilities
were determined by a published algorithm. Costs and QALYs were
quantified for two patient groups based on baseline VA: 20/40 or
better and 20/50 or worse.
Results: One-year total costs (for treatment, AE management, and
visual impairment) and QALYs for ranibizumab vs. aflibercept
were: $16,624 vs. $24,460 and 0.767 vs. 0.767 in the better VA
group and $20,141 vs. $30,416 and 0.710 vs. 0.720 in the worse
VA group. Comparing aflibercept to ranibizumab, the incremental
cost-effectiveness ratio (ICER) was $964,607/QALY in the worse
VA group which far exceeds conventional ICER thresholds for
recommended product adoption. An ICER was not calculated in
the better VA group because ranibizumab is less costly and equally
effective. While ICERs were sensitive to assumptions about the
relative weighting of the better- and worse-seeing eye on patient
outcomes, conclusions remained unchanged.
Conclusions: Although anti-VEGF treatments for DME are
associated with high costs, the increase comes with improved visual
acuity and QOL benefits. Treatment with aflibercept is more costly
than with ranibizumab and yields only similar or nominal increases in
QALYs. Therefore, based solely on this health economic analysis of
FDA-approved anti-VEGF treatments, aflibercept is not cost-effective
when compared to ranibizumab for DME patients based on one-year
results.
Commercial Relationships: Steve Duff, Genentech, Inc. (C);
Nancy Holekamp, Genentech, Inc. (C); Yamina Rajput, Genentech,
Inc.
Support: Genentech, Inc., South San Francisco, CA, provided
support for the study and participated in the study design; conducting
the study; and data collection, management, and interpretation.
Clinical Trial: NCT01627249
Program Number: 5584 Poster Board Number: D0089
Presentation Time: 3:45 PM–5:30 PM
Cost Savings Enabled by Automated Diabetic Retinopathy
Screening in a UK-like screening program
Malavika Bhaskaranand, Chaithanya Ramachandra, Sandeep Bhat,
Kaushal Solanki. Eyenuk, Inc., Woodland Hills, CA.
Purpose: Current diabetic retinopathy (DR) screening setups employ
fully manual grading of retinal images and therefore cannot scale
to meet the needs of the large, growing diabetic population. Cost
savings enabled by EyeArt – a fully-automated, high-throughput,
cloud-based DR screening system – are demonstrated for a grading
setup similar to the UK NHS Diabetic Eye Screening Program.
Methods: In the manual grading system, all patient episodes are
reviewed by level 1 graders who identify normal patients and
recommend re-screening in 12 months. All other episodes are
forwarded to level 2 outcome graders who determine referral status or
re-screening interval based on the DR severity and surrogate markers
for clinically significant macular edema (CSME).
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ARVO 2016 Annual Meeting Abstracts
EyeArt automatically analyzes multiple fundus images captured
during a patient episode and generates a screening recommendation,
while flagging external eye images and poor quality images. We
evaluate cost savings enabled by EyeArt when level 1 graders are
replaced by EyeArt and patient episodes recommended for referral by
EyeArt are forwarded to the level 2 outcome graders.
For this analysis, costs associated with manual grading and quality
assurance (QA) grading in UK sterling for the year 2005-06; number
of QA reviews per grader per year; and performance of level 1
graders are obtained from Scotland et. al (Br J Ophthalmol 2010;
94:712-719). The DR severity prevalence rates are from Kapetanakis
et. al (J Med Screening 2015; 22(3):112-118).
Results: Assuming the annual number of DR screening episodes to
be 2.7 million based on the current diabetic population in the UK, the
annual cost of fully manual grading is estimated to be £12,000,709
(level 1 grading cost=£7,992,000; level 2 grading cost=£2,784,409;
QA cost=£1,224,300).
EyeArt achieves 85% sensitivity at 86% specificity at detecting
episodes with pre-proliferative/proliferative DR or surrogate markers
for CSME on a real-world dataset with 2045 episodes. Therefore,
with EyeArt replacing level 1 graders, the level 2 grading cost is
£3,626,974 and with QA review of 6% of episodes, the QA cost
is £528,000. Therefore without considering the cost of EyeArt
or the benefits of EyeArt’s higher sensitivity compared to level 1
graders, the economic value added by level 1 automated grading is
£7,627,054.
Conclusions: Automated DR screening using EyeArt can provide
significant cost savings in DR screening programs.
Commercial Relationships: Malavika Bhaskaranand, Eyenuk,
Inc. (P), Eyenuk, Inc.; Chaithanya Ramachandra, Eyenuk, Inc.,
Eyenuk, Inc. (P); Sandeep Bhat, Eyenuk, Inc. (P), Eyenuk, Inc.;
Kaushal Solanki, Eyenuk, Inc., Eyenuk, Inc. (P)
Support: Research reported in this publication was supported by the
National Institute Of Biomedical Imaging And Bioengineering of the
National Institutes of Health under Award Number R44EB013585.
The content is solely the responsibility of the authors and does not
necessarily represent the official views of the National Institutes of
Health.
Program Number: 5585 Poster Board Number: D0090
Presentation Time: 3:45 PM–5:30 PM
Generic glaucoma medication costs: a 2 year analysis
Eunmee Yook, Robert D. Fechtner, Albert S. Khouri. Dept of
Ophthalmology & Visual Science, Rutgers, Hoboken, NJ.
Purpose: Generic medication use has become mainstream with
recent health care changes, however prescribers may not be aware
of price fluctuations of medications over time. We conducted a
prospective, observational study to analyze variations of generic
glaucoma medication costs for 2014-2015.
Methods: Cash “out of pocket” prices were collected from 5
national pharmacy chains (pharmacy A,B,C,D,E) after inquiries
were made over telephone and web search. Medications included: 1)
Latanoprost, 2) Timolol, 3) Dorzolamide, 4) Timolol /dorzolamide,
5) Brimonidine 0.15% 6) Brimonidine 0.2%. Data from 2015 was
adjusted by the U.S. inflation rate for statistical purposes. Means,
standard deviation, and percent change were calculated. Data from
2014 and 2015 were analyzed using Student T-Test.
Results: Means and standard deviation (SD) for medication costs
are shown in table 1. We found that all 6 generic medications had
increased in cost at a greater rate than the national inflation rate (P =
0.0098). When looking at each of the medication costs, the percent
increase in cost ranged from 2.9% to 45%. Comparisons were also
made between 2014 and 2015 for each pharmacy. Variation ranged
1.5% at pharmacy E to 22% at Pharmacy C. Comparing 2014 and
inflation-adjusted 2015 prices, Timolol 0.5% had the greatest increase
of 45%, then Brimonidine 0.2% with a 33% increase, Brimonidine
0.15% with a 10% increase, Latanoprost with a 6% increase,
Dorzolamide with a 5.9% increase, and Timolol/dorzolamide with
a 2.9% increase. Additionally, the increase in prices were variable
across different pharmacies.
Conclusions: The change in cost of 6 generic glaucoma medications
across 5 national pharmacies was significant and very variable. The
increase in cost of most generic medications significantly surpassed
inflation. Cash paying patients and providers are encouraged to
explore costs of different medications at various pharmacies in order
to lower health care costs.
Table 1. 2015 costs, mean, standard deviation (SD)
Table 2. Amount and percentage increase in costs from 2014
Commercial Relationships: Eunmee Yook, None;
Robert D. Fechtner, None; Albert S. Khouri, None
Program Number: 5586 Poster Board Number: D0091
Presentation Time: 3:45 PM–5:30 PM
The Cost of Glaucoma Medications Among Patients with Open
Angle Glaucoma in a Clinical Population: A Pilot Study
Roy Tan, Owen Kim Hee. Ophthalmology, Tan Tock Seng Hospital
(National Health Group), Singapore, Singapore.
Purpose: Glaucoma medication plays a major role in the treatment
of patients with glaucoma, leading to increase burden of cost both to
individuals, and society. Our study aims to study the cost of glaucoma
medications among patient with open angle glaucoma, and to stratify
according to the severity of the glaucoma.
Methods: Patients with open angle glaucoma who were diagnosed at
least five years prior, were studied. The glaucoma medications given
during the years of follow up were analysed and the cost burden of
glaucoma medications were calculated base on the current cost. The
patients were stratified according to severity of glaucoma base on the
Brusini Glaucoma Staging System.
Results: There were a total of 76 patients with open angle glaucoma
studied. Based on the Bascom Palmer Glaucoma Staging System,
there were 2 patients in severity stage 0, 12 patients in stage 1, 13
patients in stage 2, 11 patients in stage 3, 16 patients in stage 4 and
21 patients in stage 5. The cost of medication per annum per patient
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ARVO 2016 Annual Meeting Abstracts
for each stage is as follows – Stage 0, S$0; Stage 1, S$81.39; Stage 2,
S$246.37; Stage 3, S$354.33; Stage 4, S$289.28; Stage 5, S$312.98.
Conclusions: The cost burden of glaucoma medication is high among
the moderate to advance stages of glaucoma. Further analysis should
be done on the cost of other procedural and surgical treatment of
glaucoma, and to analyse the cost burden of medication versus nonmedication treatment.
Commercial Relationships: Roy Tan, None; Owen Kim Hee
These abstracts are licensed under a Creative Commons Attribution-NonCommercial-No Derivatives 4.0 International License. Go to http://iovs.arvojournals.org/
to access the versions of record.