Search

To determine the effect of implementing standardized opioid prescribing guidelines on prescription patterns for acute pain after ophthalmic surgery in opioid-naïve patients.Quality improvement study.Ophthalmic surgeons in an academic department of ophthalmology.Postoperative opioid prescribing patterns were compared before and after the implementation of standardized opioid prescribing guidelines for ophthalmic surgery at an academic institution. Only prescriptions provided to opioid-naïve patients 18 years of age or older were included. Surgeons reached a consensus for standardized prescribing guidelines appropriate for the type of surgery within their subspecialty. Guidelines were disseminated in conjunction with postsurgical pain management education to all ophthalmologists in the department, including trainees. The frequency of opioid prescriptions, the quantity of opioid prescribed (converted to oral morphine equivalent [OME]), and opioid prescription refill rates were compared before and after intervention.Prescriptions with more than 80 OME, frequency of opioid prescriptions, mean OME, and refill rates.Of 5349 ophthalmic surgeries performed during the 2 assessment periods, 196 (3.7%) were associated with opioid prescriptions for acute postoperative pain. The frequency of opioid prescriptions decreased to 3.0% (81/2736) after intervention compared with 4.4% (115/2613) before intervention (P = 0.005). When opioids were prescribed, the mean OME decreased from 93 (range, 27-500) before intervention to 42 (range, 14-100) after intervention (P = 0.003). The number of prescriptions for more than 80 OME decreased from 56 (2.1%) before intervention to 4 (0.1%) after intervention (P0.001). Based on the standardized guidelines, 103 of the 115 (89.6%) preintervention opioid prescriptions would not have adhered to the guidelines, whereas 39 of the 81 (48.1%) postintervention prescriptions did not adhere to the guidelines (P0.001). The proportion of refill prescriptions did not differ before and after intervention (P = 0.44).The process of discussing postsurgical pain management and developing standardized opioid prescribing guidelines reduces overprescribing of opioids after ophthalmic surgery without increasing refill rates. Continued education is required to improve adherence to the prescribing guidelines further.

Patient safety focused on a reduction in both procedural and diagnostic error is the number one concern of the United States healthcare system in the 21st century. The American Board of Ophthalmology has a longstanding interest in patient safety, and in 2015, teamed with the American Academy of Ophthalmology to convene all ophthalmology subspecialties and other prominent national organizations to address patient safety in ophthalmology. This article reviews the topic and highlights concerns for ophthalmologists.

Objective To describe patient preferences regarding payment for blepharoplasty and blepharoptosis repair and physician practices before and after the 2009 change in reimbursement for these 2 procedures by the Centers for Medicare and Medicaid Services (CMS). Design Cross-sectional study. Participants Fifty patients presenting for functional blepharoplasty and blepharoptosis repair at an academic oculoplastic practice and 198 members of the American Society of Ophthalmic Plastic and Reconstructive Surgery. Methods A 5-question paper survey was administered to patients, and a 5-question web-based survey was distributed to 510 unique physician e-mail addresses obtained from the American Society of Ophthalmic Plastic and Reconstructive Surgery mailing list server in 2010. Main Outcome Measures The surveys elicited patient knowledge and attitudes regarding the reimbursement policy of the CMS and physician knowledge and behaviors before and after the reimbursement policy change. Results Ninety-one percent of patients would be opposed to having to pay out of pocket for blepharoplasty or having to wait at least 3 months after ptosis repair to have a blepharoplasty. When asked to choose between these options, 62% of the patients would rather have the 2 surgeries performed separately than pay out-of-pocket. Before the reimbursement policy change by the CMS, 77% of oculoplastic surgeons performed blepharoplasty and blepharoptosis repair in the same sitting, whereas 37% did so after the policy change ( P P P = 0.009). Conclusions Our study suggests that oculoplastic surgeons have made a change in the delivery of ptosis and blepharoplasty surgical services after the reimbursement policy change for these procedures by the CMS in 2009. This change, in which patients undergo separate surgical visits for ptosis repair and blepharoplasty, is not desirable to most patients.

As part of the American Ophthalmological Society’s 150th birthday celebration in 2014, a representative from each subspecialty was invited to provide a brief account of the past, present, and future of his or her respective area of interest. Before offering my perspective on oculoplastic and orbital surgery, I must begin with a disclaimer. The historian C. B. McCullagh, in a thoughtful essay about bias in reporting historical events, opined that “both nature and history are sublime, and any account of them is inevitably selective.” Therefore, the topics that I have selected to feature inevitably reflect my personal biases. I have grouped 15 highlights into the following rubrics: 5 milestones before 1864 (the year the American Ophthalmological Society [AOS] was founded), 5 notable advances between 1864 and the present, and 5 challenges for oculoplastic and orbital surgery going forward. Longbefore anyoneknewabout cupping, the choroid, or the chiasm, surgeons were whittling away on the ocular adnexa.

Purpose The incidence of acquired nasolacrimal duct obstruction (NLDO) increases with age. Dacryocystorhinostomy, the definitive treatment for NLDO, has a high success rate (80%–100%) with a low complication rate (1%–6%), but surgical outcomes have not been reported previously specifically for an elderly population, in which there may be increased risk for intraoperative and postoperative complications. The purpose of this study was to examine surgical outcomes and complication rates of dacryocystorhinostomy in an elderly population. Design Retrospective cohort study. Participants Patients 80 years of age or older undergoing external dacryocystorhinostomy at the Mayo Clinic between January 1, 1990, and December 31, 2010, were compared with a matched control group of younger patients (40–79 years of age) undergoing external dacryocystorhinostomy by the same surgeons. Methods We reviewed the medical charts for patients as described above. Data abstracted from patient medical records included symptomatic relief and complications such as tube protrusion, infection, persistent bleeding, and return to operating room. Statistical analysis included a 2-sample t test to compare continuous variables, chi-square testing for categorical comparisons, and the generalized estimating equation model to control for nonindependence. Main Outcome Measures Primary end point was symptomatic improvement at last follow-up. Secondary end points included anatomic patency, adverse event rate, and return to operating room within 1 month of surgery. Results Forty-two dacryocystorhinostomies (32 patients) were performed in the elderly group. The control group comprised 73 dacryocystorhinostomies in 63 patients. Resolution of symptom rate at last follow-up was 64% in the elderly group versus 86% in the younger cohort ( P = 0.02). Although there was no difference between groups with respect to common postoperative complications, there was a higher rate of predefined serious complications in the elderly group (5 events vs. 1 event; P = 0.01). There was no difference between groups regarding need for additional eyelid surgery ( P = 0.30). Conclusions Although most elderly patients experience symptom resolution after dacryocystorhinostomy, the rate of symptom resolution was lower than that of younger patients. The risk of routine complications was similar between the groups. The risk of serious complications was higher in the elderly group.

Objective To evaluate the clinical features including eyelid excursion and management of Marcus Gunn jaw-winking synkinesis (MGJWS). Design Observational case series. Participants Forty-eight consecutive patients with MGJWS. Methods Clinical features and management of 48 patients with MGJWS were reviewed retrospectively. Upper eyelid excursion was measured and graded. Complications of surgical intervention were evaluated. Main Outcome Measures Resolution of MGJWS and symmetry of upper eyelids in primary position. Results Excursion of the ptotic eyelid with jaw movement in MGJWS was graded as mild ( Conclusions Most of the patients with MGJWS exhibited moderate eyelid excursion. Disabling of the involved levator muscle and bilateral frontalis suspension and, in selected cases, disabling of the involved levator muscle and unilateral frontalis suspension were effective in the treatment of MGJWS. Eyelash ptosis and loss of eyelid crease were the most common complications, each occurring in 10% of the patients. Financial Disclosure(s) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Purpose To evaluate intraobserver reliability and interobserver reliability of a computer-based digital image measurement of eyelid position in Graves' ophthalmopathy and to compare digital image measurement with clinical measurement. Design Cross-sectional study. Participants Eighty-four eyes of 42 patients with mild to moderate bilateral Graves' ophthalmopathy. Methods Digital images were created from 35-mm color slides of both eyes of participants and projected onto a 15-inch flat-screen computer monitor. Three observers (2 oculoplastic surgeons and 1 ophthalmology resident) independently recorded eyelid fissure height, margin–reflex distance, and inferior scleral show for each eye. Main outcome measures Intraobserver reliability and interobserver reliability of eyelid parameter measurements, as described by the intraclass correlation coefficient (ICC) and Bland–Altman plots. Agreement between digital image measurements of the investigators and clinical measurements taken on the same day as the photographs also was assessed. Results Excellent intraobserver agreement was found for the measurement of all eyelid parameters for all 3 investigators (ICC range, 0.93–0.99). Interobserver agreement for all eyelid parameters was also excellent for all investigators (ICC, 0.86–0.97). Agreement between the photographic and clinical measurements for eyelid parameters was fair to moderate (ICC range, 0.38–0.62). Conclusion Measurement of several eyelid parameters in Graves' ophthalmopathy patients from computer-based digital images is reliable. Associations between photographic and clinical measurements for all parameters are weaker. Relative to clinical measurements, the photographic technique offers the advantages of potential for masking and ease of transmission that might be useful in clinical trials.

Objective To determine whether long-term improvement could be observed after orbital radiotherapy for Graves' disease; in addition, to evaluate ancillary treatments needed for those who have received radiotherapy, to search for late-emerging adverse consequences of radiotherapy, and to relate orbital changes to serum levels of thyroid-stimulating immunoglobulin (TSI). Design Three-year follow-up of noncomparative interventional case series. Participants Forty-two patients. Intervention All patients had received orbital radiotherapy within 6 months of study entry. Twelve months after study entry, patients were free to select any additional treatment for their ophthalmopathy. Main outcome measures Need for surgery, steroid therapy, volume of extraocular muscles and fat, proptosis, area of diplopia fields and range of extraocular muscle motion, volume changes after decompression and correlations of eye findings with serum TSI levels, retinal status. Results Half of the patients elected to have a surgical procedure on their eyes or orbits. Among patients who were not decompressed, we found only slight improvement in some of the main outcome measures. TSI did not positively correlate with baseline status or with any observed change in major outcome measures. After orbital decompression, the volumes of both muscle and fat increase, but bony orbital volume increases more and proptosis diminishes. Retinal microvascular abnormalities consistent with radiation retinopathy developed de novo in five eyes of three patients within 3 years of radiation therapy. Conclusions In this 3-year uncontrolled follow-up phase, limited evidence for a clinically significant improvement was observed, which may be the result of treatment or of natural remission. In either case, the changes are of little clinical significance. Because it is neither effective nor innocuous, radiotherapy does not seem to be indicated for treatment of mild to moderate ophthalmopathy.

The primary testimony to a research study that involves patient volunteers and consumes public or private resources is publication in the peer-reviewed literature. Although a scientific article should be judged on it is own merits, subjectivity in study design by commercial entities, financial incentives for favorable interpretation by researchers, and other forms of bias by authors or peer reviewers may influence the final published work. The peer-reviewed literature rightfully has a powerful effect on decisions concerning both guidelines and funding of patient care, so journals strive to make their content valid and objective. Although it is widely agreed that “industry” involvement in ophthalmic research is necessary and desirable, it has been less enthusiastically but decidedly determined that full disclosure by all involved parties presently is the acceptable vehicle that permits the transference of study results into the peer-reviewed literature. Editors and readers recognize that several nonfinancial forms of bias, such as professional, intellectual, academic competition, or subtle prejudices based on personal experience can affect a study or peer review, but these will not be discussed further here. Only financial disclosure has emerged as an attainable goal over the past few decades, but the process has not been perfected either in concept or practice. The topic of financial conflicts remains contentious in medicine, with some finding the requested reporting burdensome and others still unsatisfied that disclosure is often translucent, at best. Some major journals still do not require financial disclosure, some do not define their disclosure policy, some disagree with commonly used definitions and terms, some do not request the disclosure until after an article has passed the peer review process, and nearly every journal has a different way of conveying or not conveying information about financial relationships to the reader. There is evidence, however, that readers are mindful of disclosure information and make judgments about an article’s quality based on it, having a preference for government-funded research compared with studies supported by industry. The New England Journal of Medicine and the Journal of the American Medical Association have led this movement in financial disclosure, catalyzed by embarrassing situations involving failure of forthright communication by their authors. As reviewed by Blum et al, there has been a concerted effort to protect the integrity and public trust in the peerreviewed literature by the Institute of Medicine, the International Committee of Medical Journal Editors (ICMJE), the World Association ofMedical Editors, the Council of Science Editors, the Committee on Publication Ethics, and others, each of which has drafted guidelines on disclosure as a means for improving transparency. A uniform ICMJE author disclosure form was suggested and then developed by the major international journals several years ago, and has now undergone a number of iterations following suggestions by

Purpose To provide evidence-based clinical recommendations for treatment options and future prospects for the management of common malignant eyelid tumors, including global ratings for the strength of published evidence supporting them. Clinical relevance Approximately 5% to 10% of all skin cancers occur in the eyelid. Incidence studies indicate that basal cell carcinoma is the most frequent malignant eyelid tumor, followed by squamous cell carcinoma, sebaceous gland carcinoma, and malignant melanoma. Many therapeutic methods have been suggested to combat the morbidity and mortality associated with these lesions. Literature reviewed A MEDLINE and PubMed literature search (1966–1999) was conducted for English language abstracts and appropriate (selected) full-text references retrieved regarding treatment of malignant eyelid tumors. These sources then were used to prepare recommendations for patient care. Each recommendation was rated according to: (1) its importance in the care process and (2) the strength of evidence supporting the given recommendation. Results All recommendations were rated as level A (very important to patient-care outcome). For basal cell carcinoma, squamous cell carcinoma, and sebaceous gland carcinoma, the published evidence supporting two recommendations (Mohs' micrographic surgery or excision with frozen-section control) were graded as I (providing strong evidence in support of a recommendation). For sebaceous gland carcinoma, the recommendations also included conjunctival map biopsies. The published evidence supporting all other recommendations for these three eyelid tumors were graded II (substantial evidence in support of a recommendation), primarily because of the small numbers of patients in each clinical study. For malignant melanoma, the recommendation for therapy (i.e., excision with variable margins depending on tumor thickness) was based on published papers individually variably rated as I, II, and III, reflecting ongoing debate as to the best method of therapy. Conclusions Published reports regarding the treatment of malignant eyelid tumors include a myriad of treatment options. The strongest evidence favors complete surgical removal using histologic controls for verifying tumor-free margins of excision.

Context Although widely used for more than 85 years, the efficacy of radiotherapy for Graves’ ophthalmopathy (GO) has not been established convincingly. Objective To evaluate the efficacy of radiotherapy for GO. Design Prospective, randomized, internally controlled, double-blind clinical trial in a tertiary care academic medical center. Participants The patients were ethnically diverse males and females over age 30 seen in a referral practice. The patients had moderate, symptomatic Graves’ ophthalmopathy (mean clinical activity score, 6.2) but no optic neuropathy, diabetes, recent steroid treatment, previous decompression, or muscle surgery. Forty-two of 53 consecutive patients were enrolled after giving informed consent and fulfilling study entry criteria. Eleven eligible patients declined to participate because of inconvenience, desire for alternative therapy, or concern about radiation. Intervention One randomly selected orbit was treated with 20 Gy of external beam therapy; sham therapy was given to the other side. Six months later, the therapies were reversed. Main outcome measures Every 3 months for 1 year, we measured the volume of extraocular muscle and fat, proptosis, range of extraocular muscle motion, area of diplopia fields, and lid fissure width. Effective treatment for GO will modify one or more of these parameters. Results No clinically or statistically significant difference between the treated and untreated orbit was observed in any of the main outcome measures at 6 months. At 12 months, muscle volume and proptosis improved slightly more in the orbit that was treated first. Conclusions In this group of patients, representative of those for whom radiotherapy is frequently recommended, we were unable to demonstrate any beneficial therapeutic effect. The slight improvement noted in both orbits at 12 months may be the result of natural remission or of radiotherapy, but the changes are of marginal clinical significance.

Objective To determine the frequency of ophthalmic abnormalities in patients with cutaneous T-cell lymphoma (mycosis fungoides and Sezary syndrome) and T-cell lymphoma involving the skin and to describe the clinical course of the disease with selected examples. Design Retrospective, clinic-based, cross-sectional study. Participants A computerized diagnostic retrieval system was used to identify all patients with T-cell lymphoma involving the skin who were examined at the Mayo Clinic (Rochester, Minnesota) between January 1, 1976 and December 31, 1990. The medical records of affected patients were reviewed. Main outcome measures Identification of ophthalmic abnormalities. Results During the 15-year interval from 1976 through 1990, cutaneous T-cell lymphoma was diagnosed in 2155 patients. Of these, 42 (1.95%; 26 male and 16 female) had at least one ophthalmic abnormality attributable to the disease. The diagnoses in these 42 patients were mycosis fungoides in 19, clinical variants of T-cell lymphoma of the skin (most commonly peripheral T-cell lymphoma) in 11, and Sezary syndrome in 12. Cicatricial eyelid ectropion was the most common finding, affecting 17 (40.4%) of the 42 patients. Thirty-seven patients had findings that, although probably not a direct consequence of cutaneous T-cell lymphoma, have been cataloged in previous studies. Conclusion Although ophthalmic abnormalities in patients with cutaneous T-cell lymphoma are relatively uncommon, the manifestations of the disease are diverse and frequently difficult to treat.

Systematic reviews are valuable because they collect and critically assess all evidence that fits prespecified criteria to answer a clinical question, which may relate to the cause, diagnosis, prognosis, prevention, or treatment of various diseases and conditions. A systematic review may contain a meta-analysis, which uses statistical methods to combine results from similar but independent studies. Systematic reviews and meta-analyses are proliferating in the literature because of increasing reliance on them for health care practice and policy. In vision research alone, approximately 1000 such publications had been identified as of March 2012, of which approximately 60 were published in Ophthalmology. In 2012, this journal received more than 40 systematic review submissions. However, not all systematic reviews are conducted and reported rigorously. For instance, we have observed application, and possible perpetuation, of inappropriate statistical methods among systematic reviews on glaucoma drugs and deficient methodology in a large proportion of glaucoma and age-related macular degeneration systematic reviews. Furthermore, systematic reviews on related or identical topics have been conducted by author teams with no rationale for duplicating the efforts or perhaps unintentionally, leading to “avoidable wasteful research.” Ophthalmology has a long history of providing evidencebased clinical information and is committed to ensuring that the systematic reviews it publishes are trustworthy. A member of the editorial board is responsible for managing systematic reviews and we have updated the Journal’s “Guide for Authors” to include specific instructions for preparing such manuscripts (online Appendix; available at http:// aaojournal.org). In developing these guidelines, which also should serve as a useful reference for peer reviewers, we have adhered to several recent standards in conducting and reporting systematic reviews published by wellrespected groups and organizations. Transparent, accurate, and complete reporting will ultimately help our readers to determine the scientific validity and applicability of a systematic review. In addition to the specifics outlined in the “Guide for Authors,” the following criteria are relevant to the consideration, evaluation, and acceptance of systematic reviews and meta-analyses in Ophthalmology. First, authors are expected to identify all existing systematic reviews on related or identical topics within the past several years and justify why a new review is needed (e.g., new evidence that changes the conclusion or limitations in the previous reviews). A manuscript is unlikely to be considered for publication if the same or a substantially overlapping body of literature is used to reach a similar conclusion as in a previously published systematic review. Authors are