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To compare the impact of first eye versus second eye cataract surgery on visual function and quality of life.Cohort study.A total of 328 patients undergoing separate first eye and second eye phacoemulsification cataract surgeries at 5 veterans affairs centers in the United States. Patients with previous ocular surgery, postoperative endophthalmitis, postoperative retinal detachment, reoperation within 30 days, dementia, anxiety disorder, hearing difficulty, or history of drug abuse were excluded.Patients received complete preoperative and postoperative ophthalmic examinations for first eye and second eye cataract surgeries. Best-corrected visual acuity (BCVA) was measured 30 to 90 days preoperatively and postoperatively. Patients completed the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ) 30 to 90 days preoperatively and postoperatively. The NEI-VFQ scores were calculated using a traditional subscale scoring algorithm and a Rasch-refined approach producing visual function and socioemotional subscale scores.Postoperative NEI-VFQ scores and improvement in NEI-VFQ scores comparing first eye versus second eye cataract surgery.Mean age was 70.4 years (±9.6 standard deviation [SD]). Compared with second eyes, first eyes had worse mean preoperative BCVA (0.55 vs. 0.36 logarithm of the minimum angle of resolution (logMAR), P0.001), greater mean BCVA improvement after surgery (-0.50 vs. -0.32 logMAR, P0.001), and slightly worse postoperative BCVA (0.06 vs. 0.03 logMAR, P = 0.039). Compared with first eye surgery, second eye surgery resulted in higher postoperative NEI-VFQ scores for nearly all traditional subscales (P0.001), visual function subscale (-3.85 vs. -2.91 logits, P0.001), and socioemotional subscale (-2.63 vs. -2.10 logits, P0.001). First eye surgery improved visual function scores more than second eye surgery (-2.99 vs. -2.67 logits, P = 0.021), but both first and second eye surgeries resulted in similar improvements in socioemotional scores (-1.62 vs. -1.51 logits, P = 0.255).Second eye cataract surgery improves visual function and quality of life well beyond levels achieved after first eye cataract surgery alone. For certain socioemotional aspects of quality of life, second eye cataract surgery results in comparable improvement to first eye cataract surgery.

To compare clinical outcomes of cataract surgery in eyes with and without pseudoexfoliation (PXF).Retrospective deidentified data analysis.A total of 123 PXF and 4776 non-PXF eyes of patients who underwent cataract surgery.We compared data on visual acuity, Visual Function Questionnaire (VFQ)-based quality of life, and complications in PXF and non-PXF eyes from the Veterans Affairs (VA) Ophthalmic Surgery Outcomes Data Project across 5 VA medical centres.Pupillary expansion devices were used in 31 (25.2%) PXF cases and 398 (8.4%) non-PXF cases (p0.0001). Capsular tension rings were used in 6 (4.9%) PXF cases and 55 (1.2%) non-PXF cases (p0.004). The following complications occurred more frequently in PXF cases: zonular dehiscence without vitrectomy (4 [3.3%] PXF cases vs 40 [0.8%] non-PXF cases p = 0.02), persistent inflammation (28 [24.1%] vs 668 [14.5%]; p = 0.007), and persistent intraocular pressure elevation (5 [4.3%] vs 68 [1.5%]; p = 0.03). Best corrected visual acuity (BCVA) improved in both groups after 1 month, but 87 (83.7%) PXF cases achieved postoperative BCVA better than or equal to 20/40 compared to 3991 (93.8%) non-PXF cases (p = 0.0003). There was no significant difference in the postoperative composite VFQ scores between PXF (82.1 ± 16.9) and non-PXF cases (84.2 ± 16.8, p = 0.09).Several complications occurred more frequently in the PXF group compared to the non-PXF group, and fewer PXF cases achieved BCVA better than or equal to 20/40. Despite this, both groups experienced similar improvement in vision-related quality of life after cataract surgery.

To explore the association of American Society of Anesthesiologists (ASA) classification with cataract surgery outcomes.Five Veterans Affairs Medical Centers, United States.Retrospective observational cohort study.The study analyzed the outcomes of cataract surgery cases. Corrected distance visual acuity (CDVA), unanticipated events, and vision-related quality of life (VRQL) were assessed using the National Eye Institute Visual Function Questionnaire (NEI-VFQ), comparing ASA classes I through IV. For some analyses, ASA classes I and II were designated as Group A and ASA classes III and IV were designated Group B.Of the 4923 cases, 875 (17.8%) were in Group A, 4032 (81.9%) were in Group B, and 16 (0.3%) had missing data. The mean CDVA and mean composite NEI-VFQ score improved after cataract surgery in both groups (P .0001); however, Group A had a better mean postoperative CDVA and postoperative VFQ composite scores than Group B (P .0001, both outcomes). A higher ASA class was associated with an increased risk for 2 unanticipated events; that is, clinically significant macular edema (CSME) (Group A: 4 [0.47%] versus Group B: 50 [1.28%]; adjusted odds ratio [OR], 3.02; 95% confidence interval [CI], 1.02-13.05; P = 0.04) and readmission to the hospital within 30 days (2 [0.23%] versus 56 [1.41%]; OR, 8.26; 95% CI, 1.71-148.62; P = .004) CONCLUSIONS: Among United States veterans, the ASA classification could be an important predictor of VRQL and visual outcomes. In this cohort, it was associated with an increased risk for 2 serious unanticipated events-CSME and readmission to the hospital-both costly, unwanted outcomes.Dr. Vollman is a consultant to Forsight Vision5. None of the authors has a financial or proprietary interest in any material or method mentioned.

[Image: see text] Second Edition Editorial Committee: Helen K. Li, MD (Chair), Mark Horton, OD, MD (Co-chair), Sven-Erik Bursell, PhD, Jerry Cavallerano, OD, PhD, Ingrid Zimmer-Galler, MD, Mathew Tennant, MD Writing Committees: Clinical: Jerry Cavallerano, OD, PhD (Chair), Ingrid Zimmer-Galler, MD Technology: Sven-Erik Bursell, PhD (Chair), Michael Abramoff, MD, PhD, Edward Chaum, MD, PhD, Debra Cabrera DeBuc, PhD Operations: Mark Horton, OD, MD (Chair), Helen K. Li, MD, Tom Leonard-Martin, PhD, MPH, Mathew Tennant, MD, Marc Winchester, BA Other Contributors: Reviewers [R], ATA Standard and Guidelines Committee Members [SG], ATA Staff [S] Nina Antoniotti, RN, MBA, PhD [Chair, SG] Jordana Bernard, MBA [S] David Brennan, MSBE [SG] Anne Burdick, MD, MPH [SG] Jerry Cavallerano, OD, PhD [SG] Brian Grady, MD [SG] Tom Hirota, DO [SG] Elizabeth Krupinski, PhD [Vice Chair, SG] Cindy K. Leenknecht, MS, APRN-CS, CCRP [SG] Jonathan Linkous, MPA [S] Lou Theurer [SG] Jill Winters, PhD, RN [SG] First Edition American Telemedicine Association, Ocular Telehealth Special Interest Group, and the National Institute of Standards and Technology Working Group American Telemedicine Association Executive Committee: Jonathan D. Linkous, Richard Bakalar, MD, Adam Darkins, MD, Col. Ronald K. Poropatich, MD American Telemedicine Association Ocular Telehealth Special Interest Group: Jerry Cavallerano, OD, PhD (Chair), Mary G. Lawrence, MD, M.P.H. (Vice Chair) Editorial Committee: Helen K. Li, MD (Co-chair), Mathew Tennant, MD (Co-chair), Sven Bursell, PhD, Jerry Cavallerano, OD, PhD, Mark Horton, OD, MD, Richard Bakalar, MD Writing Committees: Clinical: Jerry Cavallerano, OD, PhD (Chair), Mary G. Lawrence, MD, MPH, Ingrid Zimmer-Galler, MD, COL Wendall Bauman, MD Technology: Sven Bursell, PhD (Chair), W. Kelly Gardner Operations: Mark Horton, OD, MD (Chair), Lloyd Hildebrand, MD, Jay Federman, MD National Institute of Standards and Technology: Lisa Carnahan Veterans Administration: Peter Kuzmak, John M. Peters, Adam Darkins, MD At Large Group Participants: Jehanara Ahmed, MD, Lloyd M. Aiello, MD, Lloyd P. Aiello, MD, PhD, Gary Buck, Ying Ling Chen, PhD, Denise Cunningham, CRA, RBP, M.Ed., Eric Goodall, Ned Hope, Eugene Huang, PhD, Larry Hubbard, MAT, Mark Janczewski, MD, J.W.L. Lewis, PhD, Hiro Matsuzaki, COL Francis L. McVeigh, OD, Jordana Motzno, Diane Parker-Taillon, Robert Read, Peter Soliz, PhD, Bernard Szirth, PhD, COL Robert A. Vigersky, MD, COL Thomas Ward, MD American Telemedicine Association Administrative Contributor: Catherine Diver : 1. PREAMBLE; 2. INTRODUCTION; 3. BACKGROUND: a. The Diabetic Retinopathy Study; b. Early Treatment Diabetic Retinopathy Study; c. Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications; d. The United Kingdom Prospective Diabetes Study; e. The Diabetic Retinopathy Clinical Research Network; 4. PRINCIPLES OF A TELEHEALTH DR PROGRAM: a. Mission; b. Vision; c. Goals; d. Guiding Principles; 5. ETHICS; 6. CLINICAL VALIDATION: a. Category 1; b. Category 2; c. Category 3; d. Category 4; 7. COMMUNICATION; 8. PERSONNEL QUALIFICATIONS: a. Medical Care Supervision; b. Patient Care Coordinator; c. Image Acquisition; d. Image Review and Evaluation; e. Information Systems; 9. EQUIPMENT SPECIFICATIONS: a. Interoperability; b. Image Acquisition; c. Compression; d. Data Communication and Transmission; e. Computer Display; f. Archiving and Retrieval; g. Security; h. Reliability and Redundancy; i. Documentation; j. Image Analysis; 10. LEGAL REQUIREMENTS: a. Health Insurance Portability and Accountability Act; b. Privileging and Credentialing; c. Stark Act and Self-Referrals; d. State Medical Practice Acts/Licensure; e. Tort Liability; f. Duty; g. Standards of Care; h. Consent; 11. QUALITY CONTROL; 12. OPERATIONS; 13. CUSTOMER SUPPORT: a. Originating Site; b. Transmission; c. Distant Site; 14. FINANCIAL FACTORS: a. Reimbursement; b. Grants; c. Federal Programs; d. Other Financial Factors; e. Equipment Cost; 15. SUMMARY: REFERENCES. APPENDIX; 1. Interoperability; 2. Digital Imaging and Communications in Medicine (DICOM) Metadata; 3. Computer-Aided Detection; 4. Health Insurance Portability and Accountability Act; 5. Privileging and Credentialing; 6. Quality Control; 7. Operational Specifications; 8. Customer Support; 9. Reimbursement. ABBREVIATIONS. GLOSSARY.

PURPOSE To determine if cataract surgery on eyes with AMD confers as much functional visual improvement as surgery on eyes without retinal pathology. METHODS This is a retrospective analysis of 4924 cataract surgeries from the Veterans Healthcare Administration Ophthalmic Surgical Outcomes Data Project (OSOD). We included cases of eyes with AMD that had both preoperative and postoperative NEI-VFQ-25 questionnaires submitted and compared their outcomes with controls without retinal pathology. We excluded patients with other retinal pathologies (740 patients). The analyses compared changes in visual acuity and overall functional visual improvement and its subscales using t-tests, multivariate logistic regressions, and linear regression modeling. RESULTS Preoperative and postoperative questionnaires were submitted by 58.3% of AMD and 63.8% of no retinal pathology cases (controls). Analysis of overall score showed that cataract surgery on eyes with AMD led to increased visual function (13.8 ± 2.4 NEI-VFQ units, P < 0.0001); however, increases were significantly less when compared with controls (-6.4 ± 2.9 NEI-VFQ units, P < 0.0001). Preoperative best-corrected visual acuity (preBCVA) in AMD was predictive of postoperative visual function (r = -0.38, P < 0.0001). In controls, postoperative visual function was only weakly associated with preBCVA (r = -0.075, P = 0.0002). Patients with AMD with vision of 20/40 or better had overall outcomes similar to controls (-2.2 ± 4.7 NEI-VFQ units, P = 0.37). CONCLUSIONS Cataract surgery on eyes with AMD offers an increase in functional visual improvement; however, the amount of benefit is associated with the eye's preBCVA. For eyes with preBCVA of 20/40 or greater, the improvement is similar to that of patients without retinal pathology. However, if preBCVA is less than 20/40, the amount of improvement was shown to be significantly less and decreased with decreasing preBCVA.

To report the ocular injuries sustained by survivors of the April 15, 2013, Boston Marathon bombing and the April 17, 2013, fertilizer plant explosion in West, Texas.Multicenter, cross-sectional, retrospective, comparative case series.Seventy-two eyes of 36 patients treated at 12 institutions were included in the study.Ocular and systemic trauma data were collected from medical records.Types and severity of ocular and systemic trauma and associations with mechanisms of injury.In the Boston cohort, 164 of 264 casualties were transported to level 1 trauma centers, and 22 (13.4%) required ophthalmology consultations. In the West cohort, 218 of 263 total casualties were transported to participating centers, of which 14 (6.4%) required ophthalmology consultations. Boston had significantly shorter mean distances to treating facilities (1.6 miles vs. 53.6 miles; P = 0.004). Overall, rigid eye shields were more likely not to have been provided than to have been provided on the scene (P0.001). Isolated upper body and facial wounds were more common in West largely because of shattered windows (75.0% vs. 13.6%; P = 0.001), resulting in more open-globe injuries (42.9% vs. 4.5%; P = 0.008). Patients in Boston sustained more lower extremity injuries because of the ground-level bomb. Overall, 27.8% of consultations were called from emergency rooms, whereas the rest occurred afterward. Challenges in logistics and communications were identified.Ocular injuries are common and potentially blinding in mass-casualty incidents. Systemic and ocular polytrauma is the rule in terrorism, whereas isolated ocular injuries are more common in other calamities. Key lessons learned included educating the public to stay away from windows during disasters, promoting use of rigid eye shields by first responders, the importance of reliable communications, deepening the ophthalmology call algorithm, the significance of visual incapacitation resulting from loss of spectacles, improving the rate of early detection of ocular injuries in emergency departments, and integrating ophthalmology services into trauma teams as well as maintaining a voice in hospital-wide and community-based disaster planning.

To estimate the prevalence of untoward events during cataract surgery with the use of pupillary expansion devices and intraoperative floppy iris (IFIS).Retrospective analysis of 4923 cataract surgery cases from the Veterans Affairs Ophthalmic Surgical Outcomes Data Project.Outcomes from 5 Veterans Affairs medical centers were analyzed, including use of alpha-blockers (both selective and nonselective), IFIS, intraoperative iris trauma, intraoperative iris prolapse, posterior capsular tear, anterior capsule tear, intraoperative vitreous prolapse, and use of pupillary expansion devices. P values were calculated using the χ(2) test.A total of 1254 patients (25.5%) took alpha-blockers preoperatively (selective, 587; nonselective, 627; both, 40). Of these 1254 patients, 428 patients (34.1%) had documented IFIS. However, 75.2% of patients with IFIS (428/569) had taken alpha-blockers preoperatively (P.00001). A total of 430 patients (8.7%) had a pupillary expansion device used during their cataract surgery, of which 186 patients (43.4%) had IFIS (P.0001). Eighty-six patients with IFIS had at least 1 intraoperative complication and 39 patients with IFIS had more than 1 intraoperative complication (P.001).The use of either selective or nonselective alpha-antagonists preoperatively demonstrated a significant risk of IFIS. Nonselective alpha-antagonists caused IFIS at a higher prevalence than previously reported. This study did demonstrate statistically significant increased odds of surgical complications in patients with IFIS vs those without IFIS in all groups (those taking selective and nonselective alpha-antagonists and also those not taking medications).

To compare visual acuity outcomes, vision-related quality of life, and complications related to cataract surgery in eyes with and without glaucoma.Retrospective cohort study.Cataract surgery outcomes in cases with and without glaucoma from the Veterans Affairs Ophthalmic Surgical Outcomes Data Project were compared.We identified 608 glaucoma cases and 4306 controls undergoing planned cataract surgery alone. After adjusting for age, pseudoexfoliation, small pupil, prior ocular surgery, and anterior chamber depth, we found that glaucoma cases were more likely to have posterior capsular tear with vitrectomy (odds ratio [OR] 1.8, P = .03) and sulcus intraocular lens placement (OR 1.65, P = .03) during cataract surgery. Glaucoma cases were more likely to have postoperative inflammation (OR 1.73, P.0001), prolonged elevated intraocular pressure (OR 2.96, P = .0003), and additional surgery within 30 days (OR 1.92, P = .03). Mean best-corrected visual acuity (BCVA) and Visual Function Questionnaire (VFQ) scores significantly improved after cataract surgery in both groups (P.0001), but there were larger improvements in BCVA (P = .01) and VFQ composite scores (P.0001) in the nonglaucoma vs the glaucoma group. A total of 3621 nonglaucoma cases (94.1%) had postoperative BCVA 20/40 or better, compared to 466 glaucoma cases (89.6%) (P = .0003).Eyes with glaucoma are at increased risk for complications and have more modest visual outcomes after cataract surgery compared to eyes without glaucoma. Despite this, glaucoma patients still experience significant improvement in vision-related outcomes after cataract extraction. Further study is needed to explore potential factors that influence cataract surgery outcomes in glaucomatous eyes.

To examine circumstances surrounding suboptimally timed retinal photocoagulation, we reviewed the medical records of 238 patients who had received photocoagulation for diabetic retinopathy at one of three large referral centers. Forty-three percent (95% confidence interval, 36% to 49%) of cases were rated as probably or definitely suboptimally timed (i.e., patient could have benefited from earlier photocoagulation). About one third of cases were due to patients going many years without screening (> 3 years), and two thirds were associated with surveillance problems (failures to achieve close follow-up for known retinopathy). We found that suboptimal timing of photocoagulation was common but was not due to patients going between 13 and 36 months between screening visits, suggesting that current performance measures, which focus on annual retinal examinations, may be requiring wasteful care while not addressing a major quality problem.

Telehealth holds the promise of increased adherence to evidenced-based medicine and improved consistency of care. Goals for an ocular telehealth program include preserving vision, reducing vision loss, and providing better access to medicine. Establishing recommendations for an ocular telehealth program may improve clinical outcomes and promote informed and reasonable patient expectations. This document addresses current diabetic retinopathy telehealth clinical and administrative issues and provides recommendations for designing and implementing a diabetic retinopathy ocular telehealth care program. The recommendations also form the basis for evaluating diabetic retinopathy telehealth techniques and technologies. Recommendations in this document are based on careful reviews of current evidence, medical literature and clinical practice. They do not, however, replace sound medical judgment or traditional clinical decision-making. "Telehealth Practice Recommendations for Diabetic Retinopathy" will be annually reviewed and updated to reflect evolving technologies and clinical guidelines.

Purpose To report the ocular injuries sustained by survivors of the April 15, 2013, Boston Marathon bombing and the April 17, 2013, fertilizer plant explosion in West, Texas. Design Multicenter, cross-sectional, retrospective, comparative case series. Participants Seventy-two eyes of 36 patients treated at 12 institutions were included in the study. Methods Ocular and systemic trauma data were collected from medical records. Main Outcome Measures Types and severity of ocular and systemic trauma and associations with mechanisms of injury. Results In the Boston cohort, 164 of 264 casualties were transported to level 1 trauma centers, and 22 (13.4%) required ophthalmology consultations. In the West cohort, 218 of 263 total casualties were transported to participating centers, of which 14 (6.4%) required ophthalmology consultations. Boston had significantly shorter mean distances to treating facilities (1.6 miles vs. 53.6 miles; P = 0.004). Overall, rigid eye shields were more likely not to have been provided than to have been provided on the scene ( P P = 0.001), resulting in more open-globe injuries (42.9% vs. 4.5%; P = 0.008). Patients in Boston sustained more lower extremity injuries because of the ground-level bomb. Overall, 27.8% of consultations were called from emergency rooms, whereas the rest occurred afterward. Challenges in logistics and communications were identified. Conclusions Ocular injuries are common and potentially blinding in mass-casualty incidents. Systemic and ocular polytrauma is the rule in terrorism, whereas isolated ocular injuries are more common in other calamities. Key lessons learned included educating the public to stay away from windows during disasters, promoting use of rigid eye shields by first responders, the importance of reliable communications, deepening the ophthalmology call algorithm, the significance of visual incapacitation resulting from loss of spectacles, improving the rate of early detection of ocular injuries in emergency departments, and integrating ophthalmology services into trauma teams as well as maintaining a voice in hospital-wide and community-based disaster planning.

To develop a method for the evaluation of visual function in subjects with cataracts, the authors identified 20 visual activities and categorized them into five subscales (distance vision, near vision, glare disability, night driving, and daytime driving) that comprised the Activities of Daily Vision Scale (ADVS). Each subscale in the ADVS was scored between 100 (no visual difficulty) and 0 (inability to perform the activity because of visual difficulty). In 334 subjects scheduled for cataract extraction (mean age 75 +/- 9 years, 67% women), ADVS scores (mean +/- standard deviation) for each subscale ranged from 44 +/- 31 for night driving to 72 +/- 24 for near vision activities. When administered by telephone, inter-rater reliability coefficients (r) were 0.82 to 0.97 (P < 0.001) for each of the subscales, and test-retest reliability was 0.87 for the scale overall. Cronbach's coefficient alpha was very high for both the in-person (alpha = 0.94) and telephone (alpha = 0.91) formats. Criterion validity, the correlation between visual loss and ADVS score, was -0.37 (P < 0.001) when the ADVS was administered in person and -0.39 (P < 0.001) when it was administered by telephone. Content validity as assessed with factor analysis showed that 88% of the variance of the principal components weighted on one factor. The authors conclude that substantial visual disability is not captured by routine visual testing and that the ADVS is a reliable and valid measure of patient's perception of visual functional impairment.

This volume is the result of an international effort to create a comprehensive approach to the management of visual disabilities in children. The expertise of contributors from Great Britain, Europe, the United States, and Canada is used. The editors have recognized that children with visual impairments present one of the greatest challenges to health and education professionals, as well as to the family and its interaction with society. Current educational issues and technical innovations are lucidly discussed, as is the need for the management of children with visual impairments by a team requiring cooperation between health professionals, teachers, social workers, and the family. Each chapter includes a bibliography with pertinent references. Specific case studies that give a more personal view of the many problems children with visual disabilities face are presented throughout the book. Recommendations for handling specific problems are enumerated. Because two thirds of children with visual impairments also

Objective: To measure the effect of cataract extraction and lens implantation on elderly persons' health-related quality of life and on their ability to perform visual activities. Design: Evaluations of health status were conducted preoperatively and at 3 and 12 months after surgery on patients scheduled for cataract extraction. Setting: Patients were enrolled from the General Eye Service of the Massachusetts Eye and Ear Infirmary and 33 Boston practices. Patients: The cohort consisted of 464 patients aged 65 years or older who were identified from the surgical schedule of the Massachusetts Eye and Ear Infirmary. At 3 to 12 months after surgery, 458 (99%) of the participants were successfully contacted. Health-related quality of life data were available for 419 (90%) to assess changes after surgery. Main Outcome Measures: Ophthalmologic examinations were performed preoperatively and during the follow-up period. The Activities of Daily Vision Scale (ADVS) and the Medical Outcomes Study 36-item short form (SF-36) were administered before surgery and at 3 and 12 months postoperatively to assess changes in health status. Results: At 12 months after surgery, 95% of patients had improved Snellen visual acuity, 80% had improved ADVS scores, but only 36% had improved SF-36 physical functioning. Average scores on seven of eight SF-36 sub-scales worsened at 12 months. Patients with improved ADVS scores had significantly smaller declines across all SF-36 dimensions except for role limitations due to emotional problems. Conclusion: Improved visual function after cataract surgery was associated with better health-related quality of life, suggesting that age-related declines in health may be attenuated by improvements in visual function.