Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
ABO CLINICAL QUALITY IMPROVEMENT (QI) APPLICATION Topic Quality Improvement Topic: Screen for IFIS Risk Factors Intraoperative floppy iris syndrome (IFIS) is characterized by a billowing of the iris stroma, iris prolapse, and progressive intraoperative mitosis. This triad is linked with current or past use of alpha-1 adrenergic receptor antagonists (?1ARAs), such as tamsulosin, terazosin, and doxazosin. These agents are commonly prescribed in men to reduce urinary outflow obstruction secondary to benign prostatic hyperplasia (BPH). It is hypothesized that (?-1ARAs) cross-react with receptors in the iris dilator muscle, leading to loss of iris muscle tone and atrophy. Patient exposure to (?-1ARAs) has been shown to increase the incidence of serious cataract surgery complications, even with experienced surgeons. Resident-performed cataract surgeries are traditionally associated with higher rates of complications (posterior capsular disruption, vitreous loss) than those performed by experienced surgeons. In a single hospital setting, complication rates in excess of 15% were observed for resident-performed (attendingsupervised) cataract surgery cases. This rate exceeded complication rates commonly reported for resident-performed cataract extractions. In order to reduce rates of cataract surgery complications, particular attention to screening for use of systemic (?-1ARAs) was instituted in patients scheduled for cataract surgery. If IFIS can be anticipated, potential surgical and pharmacologic interventions could be employed to potentially reduce the risk of intra-operative complications in resident-performed cataract surgeries. Determining if particular interventions prove useful in reducing complications and improving outcomes is important, because pre-operative discontinuation of (?-1ARAs) has not been shown to reduce the incidence of IFIS. What is the reach of this QI activity? National Please explain/identify: Alpha-1 adrenergic receptor antagonists (?-1ARAs), such as tamsulosin, terazosin and doxazosin, are commonly prescribed in men to treat urinary outflow obstruction due to benign prostatic hyperplasia (BPH). BPH is the most common disorder of the prostate. These medications (?-1ARAs) are now known to cause intraoperative floppy iris syndrome (IFIS), a condition known to make cataract surgery more complex and lead to a higher rate of surgical complications. This activity will evaluate if screening for (?-1ARAs) is worthwhile and determine if implementation of particular pharmacologic interventions (e.g., pre-operative atropine, intracameral epinephrine) and surgical strategies (e.g., use of iris hooks) leads to reduced surgical complications and improved cataract surgery outcomes. Please identify the funding source(s) for this QI activity? None Project Description 1. Describe the quality gap or issue addressed by this activity. (Included in your response to this question should be a description of the resources that informed your decision to pursue this topic, a description of what the literature says about the issue you identified, and the rationale for choosing to address this clinical QI project.) Resident-performed cataract surgeries are traditionally associated with higher rates of complications than those performed by more experienced surgeons. Recent reports of vitreous loss rates following resident cataract surgery have ranged from 1.9% to 14.7% (Quillen et al 2003; Bhagat N et al 2007; Randleman et al. 2007; Rogers et al 2009; Rutar et al. 2009). Over a greater than 6-month period, the resident complication rate at a single VA hospital rose above 15%. One policy that was implemented by the cataract attending staff to address the complication rate was to institute pre-operative screening for use of systemic alpha-1 adrenergic receptor antagonists (?-1ARAs), medications typically used to reduce urinary outflow obstruction in patients with benign prostatic hyperplasia (BPH). This was secondary to greater attention being placed on the role tamsulosin, an ?-1ARA, in causing intraoperative floppy iris syndrome (IFIS) (Chang et al 2005). IFIS, which is characterized by a billowing of the iris stroma, iris prolapse, and progressive intraoperative miosis, had been shown to lead to more complex cataract surgery and a higher rate of complications. Following the institution of screening for systemic ?-1ARAs, options for consideration of the surgical team included use of pharmacologic (e.g., preoperative topical atropine, intracameral epinephrine) and surgical (e.g., iris hooks) interventions. No specific intervention was mandated. This activity is designed to first to assess the prevalence of use of tamsulosin as well as other (?-1ARAs) in order to determine if this element of pre-operative screening is worthwhile at this hospital. Secondly, the activity should assess whether additional interventions (pharmacologic and surgical) were, in fact, implemented in cases in which the patients were known to be on (?-1ARAs) relative to those not on these medications. Finally, the activity should address whether these interventions lead to lower complication rates, and to see if any particular intervention is more successful in reducing complications. 1. Quillen DA, Phipps SJ. Visual outcomes and incidence of vitreous loss for residents performing phacoemulsification without prior planned extracapsular cataract extraction experience. Am J Ophthalmol 2003; 135(5):732-3. 2. Bhagat N, Nissirios N, Potdevin L, et al. Complications in residentperformed phacoemulsification cataract surgery at New Jersey Medical School. Br J Ophthalmol 2007; 91(10):1315-7. 3. Randleman JB, Wolfe JD, Woodward M, et al. The resident surgeon phacoemulsification learning curve. Arch Ophthalmol 2007; 125(9):12159. 4. Rogers GM, Oetting TA, Lee AG, et al. Impact of a structured surgical curriculum on ophthalmic resident cataract surgery complication rates. J Cataract Refract Surg 2009; 35(11):1956-60. 5. Rutar T, Porco TC, Naseri A. Risk factors for intraoperative complications in resident-performed phacoemulsification surgery. Ophthalmology 2009; 116(3):431-6. 6. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005; 31(4):66473. 2. Describe the specific aim(s) of this activity (explanation of the numeric goals and importance to your work processes and your organization). This activity aims to evaluate several issues, including assessing the prevalence of use of systemic (?-1ARAs) in a VA patient population and whether screening of patients for use of systemic (?-1ARAs) with attention to potential surgical and pharmacologic interventions can lead to outcomes similar to patients without prior use of (?-1ARAs). The records of a consecutive series of patients undergoing cataract surgery at a single VA hospital will be studied. Based on the focus of patients potentially on (?1ARAs) for benign prostatic hyperplasia, the activity will include all male patients 50 years of age and above undergoing cataract surgery. To minimize any potential bias in the analysis, planned combined cases (e.g., cataract extraction/trabeculectomy) will not be included. Goals of this activity will include 1) whether complication rates less than 10% can be achieved for resident-performed (attending-supervised) cataract surgeries at this hospital, and 2) whether complication rates in patients on (?-1ARAs) can be no greater than in patients without any exposure to (?-1ARAs), and 3) whether particular pharmacologic or surgical interventions performed in patients on systemic (?-1ARAs) undergoing cataract surgery positively impacts outcomes and reduces complication rates. The activity ideally will assess at least 500 cataract cases and include at least 75 cases of patients on (?-1ARAs). Based on the number of cases performed annually and the criteria specified, this activity will encompass analysis of ~ 2-4 years of cataract surgery cases in order to draw meaningful conclusions and answer the aims of the activity. 3. Identify the measures that were evaluated in your workplace and provide a summary of pre- and post-intervention data for each measure. (Please provide source information for each measure.) Several measures will be evaluated in this activity. Measures will include complication rates, including vitreous loss rates, which will be obtained from operative notes. The need for reoperation within 90 days of cataract surgery will also be obtained from operative reports and patient records. Post-operative visual acuity (best corrected visual acuity, BCVA) will also be evaluated based on patient records. 4. What was the source of your data (check all that apply)? Electronic Medical Record Administrative Data 5. What methods were used for data collection (check all that apply)? Retrospective Chart Review Electronic Medical Record 6. What was the comparison group in this activity (e.g., a regional or national benchmark)? This activity will look at rates of cataract surgery complications in patients on systemic (?-1ARAs) and those who have not been exposed to these medications. This will be an internal comparison group. In addition, rates will also be compared to overall complication rates published in the peer-reviewed literature. In addition to complication rates, the overall use of (?-1ARAs) in this VA patient population will be compared to other published rates in the literature. 7. Will the identified measures address important issues for your processes of care and/or patients? Yes 8. Describe the process you went through to develop the QI plan and the tests of change that will be undertaken to improve care (i.e., quality improvement plan design, implementation, and re-evaluation). Resident-performed (attending-supervised) cataract surgeries are traditionally associated with higher rates of complications than those performed by more experienced surgeons. Over a greater than 6-month period, the residentperformed cataract surgery complication rate at a single VA hospital rose above 15%. This was a significantly greater rate than those for experienced surgeons and a greater rate than the published rates for resident-performed cataract surgeries at other institutes. One policy that was implemented by the cataract attending staff to address the complication rates was to institute pre-operative screening for current use or exposure to systemic (?-1ARAs). This was secondary to greater attention being placed on the role of (?-1ARA) in causing intraoperative floppy iris syndrome (IFIS), first reported in 2005 by Chang and Campbell, in causing surgical complications (Chang et al 2005). In addition, it was also believed that there would be a high rate of systemic (?-1ARAs) use for benign prostatic hyperplasia (BPH) in this patient population at a VA hospital. Instituting the screening was designed to provide the resident and attending surgeon additional information in planning the surgical case. Ultimately it was up to the surgical staff whether any additional intervention, such as placement of iris hooks or a Malyugin ring or intracameral injection of epinephrine, was performed to improve the stability of the pupil. It is important to identify if this patient population at a VA hospital does indeed have a high rate of exposure to systemic (?-1ARAs). It is also important to know, if with proper screening and planned intervention as deemed appropriate, whether resident-performed (attending-supervised) cataract surgery complication rates in patients on (?-1ARAs) can be maintained at similar rates to those in patients without systemic ?-1ARAs exposure. Given that a particular intervention was not mandated, it will also be interesting to discover through this activity whether a particular intervention, surgical or pharmacologic, may lead to lower complication rates. Identifying potential interventions in this patient population is important because pre-operative discontinuation of (?-1ARAs) has not been shown to decrease the incidence of IFIS (Chang et al 2007). 1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005; 31(4):664-73. 2. Chang DF, Osher RH, Wang L, Koch DD. Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (Flomax). Ophthalmology 2007; 114(5):957-64. 9. Present baseline data that supports the need Published reports estimate systemic use of (?-1ARAs) in approximately 5% of for your change concept, then specify the patients undergoing cataract surgery. Intraoperative floppy iris syndrome (IFIS) is intervention(s) that will be implemented in reported to occur in the majority of cases of patients on tamsulosin, an a1ARA your practice and why they were chosen. commonly prescribed to treat benign prostatic hyperplasia (BPH). IFIS is known to lead to more complex cataract surgery and a greater rate of surgical complications. Over a 6-month period, the complication rates of resident-performed (attending-supervised) cataract surgery exceeded 15% in a single VA hospital. With the goal of reducing this rate significantly, ideally below 10%, pre-operative screening for use of (?-1ARAs) was instituted. In a VA hospital setting, the initial hypothesis is that there is an even greater rate of (?-1ARAs) for systemic use for BPH than in the general population. The goal was to institute general screening for each cataract surgery patient in order to ensure optimal care for the patients. In addition, it is not clear if there is a particular intervention via surgical means (e.g. iris hooks) or pharmacologic means (e.g., pre-operative topical atropine, intracameral epinephrine) that reduces the incidence of IFIS and thereby reduces the rate of complications. No specific intervention was mandated, but the screening calls specific attention to the attending and surgical team to consider options for each case as deemed necessary. Project Outcomes/Results 1. Describe in detail your role in this activity (i.e., your role in identifying measures and reviewing data, identifying the QI topic, developing the QI plan, identifying interventions, implementing the QI plan and interventions into your practice, etc.). I have led the investigation into analyzing the role of exposure to systemic alpha-1 adrenergic receptor antagonists (?-1ARAs) on complication rates in resident-performed (attending-supervised) cataract surgery as well as the differential impact of specific interventions (pharmacological and mechanical) to reduce complication rates. I designed the current analysis evaluating cataract complication rates in patients with and without exposure to (?-1ARAs), the outcome measures utilized, and the impact of specific interventions on complication rates. I was part of a small group of attending surgeons that had initially assessed methods to reduce cataract complication rates in our hospital and had implemented consistent screening for exposure to systemic a-1ARAs use prior cataract surgery. 2. Were other members from your care team involved in this activity? Yes If yes, please describe their role(s) in this activity. I was part of a small group of attending cataract surgeons that had reviewed complication rates and instituted screening for systemic ?-1ARA exposure at our hospital. The rest of this group is aware of but has not been directly involved with the subsequent design of this activity to evaluate the outcomes of that screening requirement. I did consult with a statistician at the university department to verify specific methodological questions in making comparisons for completion of this activity. In addition, a resident physician assisted in data collection for this activity as together we reviewed >1000 individual electronic patient records (operative reports and clinic visits). 3. Describe the impact this QI effort had on your practice and the care that you provided to your patients. Changes in clinical care were instituted due to a high rate of complications (>15%) in resident-performed (attending-supervised) cataract surgery at a particular VA hospital. Key to changes instituted to reduce complication rates (to less than 10%) were to screen every patient for use of systemic alpha-1 adrenergic receptor antagonists (?-1ARAs), agents typically prescribed to reduce urinary outflow obstruction secondary to benign prostatic hyperplasia (BPH). Current or past use of a-1ARAs has been linked to intraoperative floppy iris syndrome (IFIS) and has been shown to increase the incidence of cataract surgery complications, even with experienced surgeons. Given the patient population at a VA institute, there was also the belief that the exposure rate to ?-1ARAs would be even greater at our hospital than that typically reported in the literature in general ophthalmology practices. Screening for systemic use of ?-1ARAs was performed in the clinic setting and then reviewed in the pre-operative setting. No specific intervention was mandated, though the resident and attending team could consider potential pharmacologic (pre-operative topical atropine, intracameral epinephrine) and/or surgical (iris hooks, Malyugin ring) interventions to assist based on the knowledge of specific systemic medication exposure that increases the risk for IFIS and potential complications. The added time to screen for patients was minimal and there was adequate time in the pre-operative area to re-evaluate pupils and consider the need for possible interventions. Screening for these medications also allowed for additional discussion during the informed consent process based on increased risk for IFIS to occur in patients on systemic (?-1ARAs). Screening for systemic medications and a thoughtful discussion about any additional interventions that should be added to a surgical procedure designed to improve patient safety only benefited the patients. Screening for exposure to systemic (?-1ARAs) did increase the frequency of use of an intervention, either pharmacologic, surgical, or both to reduce the incidence of IFIS. The use of any intervention, pharmacologic or surgical, to improve pupil stability took place in 26.5% (86 out of 324) of patients with prior (?-1ARAs) exposure. This usage rate was 3-fold greater than the 8.3% rate of use of an intervention in patients without prior exposure to systemic (?-1ARAs). This substantial increase was an interesting finding of this activity, as no intervention was mandated with a positive screening for exposure to systemic (?-1ARAs). The aims of this activity were to evaluate if the overall complications rates were reduced as intended by the introduction of (?-1ARAs) screening and to assess if the rate of complications in patients on (?-1ARAs) could be no greater than in patients without any exposure to (?-1ARAs). Through this activity, we have demonstrated that the original goals were met, in that the overall surgical complication rates were significantly reduced as intended and the complication rate in the patients with exposure to (?-1ARAs) was similar to the rate in those patients without exposure to (?-1ARAs) (additional details provided in response to question #4 below). 4. What data can you provide to demonstrate that your change concept produced meaningful improvement in your current processes or patient outcomes? (I.e. percentage reduction in post-operative complication, percentage improvement in a specific cohort of patients etc.) The first hypothesis of the current activity was that the exposure rate to systemic (?-1ARAs) in our patient population was higher than that typically reported in the literature. Four consecutive years of cataract surgery patients were assessed in order to meet our target goals of total cataract surgeries as well as exposure to systemic (?-1ARAs) in order to provide meaningful feedback. The electronic medical records of 1099 consecutive eyes of unique male patients 50 years or older undergoing cataract surgery at a single hospital were reviewed. In this review, 29.5% (324) of male patients 50 years or older had current or past use of (?-1ARAs). As hypothesized, this observed rate with our patient population far exceeds rates reported in the literature of approximately 3-5% (Chang et al. 2005, Chen et al. 2010). As described in the specific aims, a fundamental goal was to reduce the major complication rates from >15% to less than 10%. The secondary goal was to optimize cataract surgery performed in patients on (?-1ARAs) such that the complication rates in these patients was no greater than the complication rates in patients not exposed to (?-1ARAs). For purposes of this activity, major complications were defined to include vitreous loss, retained lens fragment, retinal detachment (within 90 days), and any need for reoperation within 90 days of initial cataract surgery. The overall major complication rate across all 1099 unique patients was 7.9% (87 eyes). Among the (?-1ARAs), the rate of major complications was 8.0% (26 eyes) and the rate among the non- ?-1ARAs was 7.9% (61 eyes). The most common major complication in both groups was vitreous loss. This data demonstrates that the rate of major complications in patients undergoing cataract surgery was almost reduced in half. In addition, the rate of major complications in patients exposed to (?-1ARAs) was no greater than the rate in those patients without prior exposure to (?-1ARAs) who underwent cataract surgery. The overall proportion of patients achieving post-operative BCVA of 20/40 or better within 90 days of surgery was also similar between those patients with prior (?-1ARAs) exposure (73.4%) and those patients without prior exposure to ?-1ARAs (70.6%, p=0.67). 1. Chang DF, Campbell JR. Intraoperative floppy iris syndrome associated with tamsulosin. J Cataract Refract Surg 2005; 31(4):664-73. 2. Chen AA, Kelly JP, Bhandari A, Wu MC. Pharmacologic prophylaxis and risk factors for intraoperative floppy-iris syndrome in phacoemulsification performed by resident physicians. J Cataract Refract Surg 2010; 36(6):898-905. Project Reflection 5. Reflecting on this self-directed clinical QI project, how do you plan to sustain your improvement? This activity has demonstrated the high rate of use of systemic ?-1ARAs in the patient population and reinforced the need to continue screening for ?-1ARAs. The use of screening for ?-1ARAs in conjunction with pre-operative assessments ultimately contributed to the use of an intervention, either pharmacologic or surgical, in 26.5% (86 out of 324) of eyes. This is considerably higher than the 8.3% usage rate (64 out of 775 eyes) of a pharmacologic and/or surgical intervention over the same period in patients that had not been exposed to ?-1ARAs. As described, no specific intervention was mandated. Nevertheless, numerical differences in the use of interventions were observed between the two groups. Surgical intervention (iris hooks or Malyugin ring) was used in 12% (n=39) of the eyes with systemic ?-1ARA use and in only 3.2% (n=25) of those not exposed to ?-1ARAs (p<0.001). Pharmacologic intervention (intracameral epinephrine, preoperative atropine) was performed in 16.4% (n=54) of patients with systemic ?-1ARAs exposure and in only 5.9% (n=46) of patients not exposed to systemic ?-1ARAs (p<0.001). Combined pharmacologic and mechanical surgical intervention was used in 2.2% (n=7 eyes) of ?-1ARAs treated patients relative to 0.9% (n=7 eyes) of non-?-1ARA exposed patients (p<0.001). Overall, it is key to continue to screen for systemic ?-1ARAs use. In the ?1ARAs patients in which a surgical (mechanical) intervention was utilized, there were major intraoperative complications in 2 out of 39 eyes (5.1%). In those patients exposed to ?-1ARAs who only received pharmacologic therapy, there were intraoperative complications in 5 out of 47 eyes (10.6%). While there was a numerically lower rate of complications in those eyes treated with mechanical surgical intervention (5.1%) relative to those treated with only a pharmacologic intervention (10.6%), this difference did not achieve statistical significance (p=0.46, Fishers exact test). These results however, are suggestive that a mechanical surgical intervention, such as iris hooks or a Malyugin ring, can often be quite useful in patients with exposure to ?-1ARAs who have the potential to develop IFIS. In order to sustain the improvement, it will be critical to ensure that all options are available to surgeons in the operating room in cases of potential IFIS. In addition, continued education of residents with the use of mechanical devices (iris hooks, Malyugin rings) may lead to even lower complication rates in the future. It will be important that all residents are sufficiently comfortable with the use of mechanical interventions such that these options are always considered and never ignored simply due to lack of comfort with the procedure. It is important to understand upon analyzing this data that there was potential for bias in that patients who may have had smaller pupils upon dilation, either on screening or in the operating room, may have been more likely to receive an intervention. Therefore, the eyes in which an intervention was performed may have already been the more challenging eyes on which to perform cataract extraction, and maintaining complication rates no greater than in the non- ?-1ARAs exposed patients was an accomplishment. 6. Was this clinical QI project beneficial to your processes, patient population or practice? The method of screening for ?-1ARAs contributed to reduced complication rates in resident-performed (attending-supervised) cataract surgery. The overall complication rate was reduced significantly and was within the range of complication rates reported by other teaching hospitals (Quillen et al 2003; Bhagat N et al 2007; Randleman et al. 2007; Rogers et al 2009; Rutar et al. 2009). While we expected a high rate of systemic ?-1ARAs exposure based on the patient population of our hospital, the finding that 29.5% of male patients 50 years of age or greater were currently on or had previously been treated with a systemic ?-1ARAs exceeded our estimates. This reaffirmed the worthwhile nature of screening for ?-1ARAs exposure in every potential surgical candidate. In addition to reducing the overall complication rate, the complication rate in patients previously exposed to ?-1ARAs was no greater than the complication rate in those not previously exposed to ?-1ARAs. This was achieved without mandating a particular intervention but rather by simply making sure the surgical team was aware of the prior exposure to ?-1ARAs, and that careful pupillary examination and operative planning needed to take place with the anticipation that IFIS may occur during cataract extraction. The numerically lower rate of complications in cases in which iris hooks or a Malyugin ring were implemented relative to pharmacologic intervention alone was of note despite not reaching statistical significance. The numerical differences in the interventions were also important given that the cases in which these interventions were utilized may have been the most challenging. For the patients in our hospital, this demonstrates the need to always have these devices available in the operating room. Perhaps, even more important than having these devices available, this activity has taught us that it is critical to make sure that every resident is taught to use these devices and has enough experience with these interventions to be comfortable with use of mechanical surgical interventions. Despite the expected learning curve inherent with learning to implement these mechanical surgical interventions (iris hooks, Malyugin rings), there was no increase in risk of complications from use of these devices, in many cases for the first time. In fact, the use of these interventions numerically reduced the rate of complications. 3. Quillen DA, Phipps SJ. Visual outcomes and incidence of vitreous loss for residents performing phacoemulsification without prior planned extracapsular cataract extraction experience. Am J Ophthalmol 2003; 135(5):732-3. Bhagat N, Nissirios N, Potdevin L, et al. Complications in resident-performed phacoemulsification cataract surgery at New Jersey Medical School. Br J Ophthalmol 2007; 91(10):1315-7. Randleman JB, Wolfe JD, Woodward M, et al. The resident surgeon phacoemulsification learning curve. Arch Ophthalmol 2007; 125(9):1215-9. Rogers GM, Oetting TA, Lee AG, et al. Impact of a structured surgical curriculum on ophthalmic resident cataract surgery complication rates. J Cataract Refract Surg 2009; 35(11):1956-60. Rutar T, Porco TC, Naseri A. Risk factors for intraoperative complications in resident-performed phacoemulsification surgery. Ophthalmology 2009; 116(3):431-6. 7. Please describe any lessons learned about your work processes by participating in this self-directed clinical QI project? The findings of this project were very informative. First, this activity did in fact demonstrate that with knowledge of a patient being exposed to systemic ?-1ARAs, the surgical team was in fact more likely to utilize an additional intervention, either pharmacologic, surgical, or both. This was evidenced by an intervention being used in 26.5% of eyes in patients exposed to ?-1ARAs as compared to 8.3% of eyes in which patients did not have prior exposure to ?-1ARAs. It was also informative to assess what would take place in a situation in which information was provided to the surgical team, but no specific guidance was mandated. While there was a threefold greater use of an intervention in ?-1ARAs patients relative to those without ?-1ARAs exposure, the vast majority (63.5%) of cataract surgeries in these patients were still performed without any additional pharmacologic or surgical intervention to mitigate potential IFIS. The reason that the majority of cases with prior ?1ARAs exposure still did not receive an additional intervention intended to mitigate IIFIS may be based on limited published data on specific interventions that effectively reduce complications secondary to IFIS. In addition, it may also point to the potential that clinical examination of a pupil that appears to dilate sufficiently may provide a surgical team false confidence that IFIS will not be an issue and therefore an additional intervention early on during surgery is not performed. It was surprising that a surgical intervention, consisting of either placement of iris hooks or a Malyugin ring, was only used in 12% of eyes. While the use of this surgical intervention did not achieve a statistically lower complication rates than pharmacologic interventions, it certainly had a numerically lower rate of complications. The relative infrequent use of iris hooks or a Malyugin ring may reflect a general lack of experience or comfort with placing iris hooks or a Malyugin ring to aid in cataract surgery. This points out the need to ensure that every resident surgeon is comfortable with these procedures in the future, so that there is never a decision to avoid an intervention due to lack of prior experience. It is critical that both iris hooks and Malyugin rings are available in the operating rooms for use. It is also important that residents are trained on and comfortable with the use of both iris hooks and Malyugin rings should there be situations in the future where only one of these options is available for use. 8. What do you plan to do next to improve i.e. reduce variation in your processes of care? The overall goal was to assess if screening for systemic ?-1ARAs was worthwhile and whether complication rates in patients on ?-1ARAs could be maintained at a rate no higher than those patients without exposure to ?1ARAs. Given the high rate of systemic ?-1ARAs exposure seen in this project (29.5%), it becomes clear that this type of screening should remain part of the pre-operative screening protocol. Based on the lack of a statistical difference between surgical and pharmacologic interventions in overall complication rates, it is difficult to require a specific intervention going forward. In addition, there was the potential for bias towards particular interventions based on pupil exam and physician preference within this retrospective analysis. Therefore, requiring that all surgeries require a specific intervention performed as part of the regimen does not make sense at this time. Reflecting on this activity, it does become clear that decisions in the operative setting may be made based on resident comfort with a particular intervention/procedure. It is clear that in teaching residents it is our obligation to ensure that residents are taught and become both comfortable and adept at a wide array of procedures. Once resident physicians become facile with placement of iris hooks or a Malyugin ring, these interventions can be performed without complications and without adversely impacting the length of a case. It will be important that each resident is specifically taught how to address non-standard cases such that they have more tools at their disposal for both preventing complications and addressing complications when they arise. Developing better ways of teaching surgical techniques is the next step at continuing to reduce variations and improve process for the benefits of patients. 9. Please describe whether or not you found participation in the self-directed clinical QI project to be meaningful, impactful and a valuable use of your time. This was a highly valuable activity. This activity provided the format and impetus to complete a thorough analysis on patient care activities. It provided the avenue to analyze hundreds of patients in a manner that often does not take place in clinical practice. Physicians often have impressions and anecdotal evidence, but this activity furnished the mechanism to dive deeper into understanding the impact of changes and interventions on clinical practice. While we had believed that complication rates had improved, we still did not have the breakdown of complications relative to systemic ?-1ARAs history. In addition, this activity allowed us to further compare the impact of specific interventions on complication rates.