1930
CORRESPONDENCE
Figure 2. Intraoperative image during scleral depression (A: pars plana, B: ora serrata) using an indirect surgical lens and chandelier endoillumination.
During vitreous surgery, scleral depression is required for a very peripheral vitrectomy, but because of changes in ocular shape with scleral depression, IOL deformity and motion can occur. The IOL configuration and optic and haptic materials influence IOL behavior when the sclera is depressed. To evaluate potential problems with implanted IOLs during vitreous surgery, the entire IOL, including the optic and haptics, must be examined. For this reason, IOL observation using the indirect inverted contact lens and chandelier endoillumination is a useful method for IOL evaluation and should aid clinicians during this procedure. REFERENCES 1. Cherfan GM, Michels RG, de Bustros S, Enger C, Glaser BM. Nuclear sclerotic cataract after vitrectomy for idiopathic epiretinal membranes causing macular pucker. Am J Ophthalmol 1991; 111:434–438 2. Miyake K, Miyake C. Intraoperative posterior chamber lens haptic fixation in the human cadaver eye. Ophthalmic Surg 1985; 16:230–236 3. Apple DJ, Lim ES, Morgan RC, Tsai JC, Gwin TD, Brown SJ, Carlson AN. Preparation and study of human eyes obtained postmortem with the Miyake posterior photographic technique. Ophthalmology 1990; 97:810–816 4. Chew J, Werner L. Miyake-Apple preparation of postmortem eyes: technique and applications. Tech Ophthalmol 2006; 4:102–107
Inspecting the Inspector General’s report on cataract surgery in the United States Veterans Health Administration Paul B. Greenberg, MD, Benjamin K. Young, MS, Curtis E. Margo, MD, MPH, Dustin D. French, PhD A recent report from the Inspector General provides a timely snapshot of the state of cataract surgery in the United States Veterans Health Administration (VHA).A This is important not only to the 8.3 million veterans receiving care in the VHA,B but also to
ophthalmic graduate medical education programs as the VHA is the largest provider of health professions training in the U.S.C In addition, unlike the most recently published VHA cataract surgery outcomes, which were based on administrative data,1,2 the Inspector General's report used primary data abstracted from electronic medical records. The Inspector General's report was based on a random sample of 870 of the 38 451 patients who received cataract surgery in the VHA in 2011; 82.8% of the medical centers in which patients received cataract surgery trained ophthalmology residents. The data on the visual outcomes and endophthalmitis rates were of particular interest as they facilitated comparison with other large recently published studies of cataract surgery outcomes based on primary data (Table 1).3–5 However, several factors must be kept in mind when comparing these results. First, the Inspector General's report defined visual outcomes as any visual improvement as opposed to the more common benchmark of 20/40 or better. Second, the diabetic retinopathy status in the Inspector General's cohort of diabetic patients was not provided, although an estimated 14.0% of cataract surgery patients in the VHA have diabetic retinopathy.1 Third, 40.3% of the patients in the Inspector General's report had glaucoma, age-related macular degeneration (AMD), and/or diabetes mellitus compared with 18.3%3 and 15.3%4 in 2 of the comparison studies. Visual outcomes in all patients and in the cohorts of patients with diabetes and AMD were similar in the Inspector General's report and the comparison studies. Two results, however, merit further comment. The first concerns outcomes in glaucoma patients. In the Inspector General's report, 75.8% of glaucoma patients had visual improvement versus the 85.1% to 89.7% who achieved visual acuity of 20/40 or better in the comparison studies. One reason may be that patients in the VHA have more advanced glaucoma when they have cataract surgery. This delay would be
J CATARACT REFRACT SURG - VOL 39, DECEMBER 2013
1931
CORRESPONDENCE
Table 1. Cataract surgery outcomes in the VHA and selected studies.
Study* VHA (2013) report from the Inspector GeneralA
Data Source Medical records
Lundstr€ om (2013)3
National registry
Jaycock (2009)4
National database
Forooghian (2010)5
Medical records
Size 870
368 256 35 029 21 088 11 299 40 758 1 036 1 798 3 416 1 939
Patient Cohort
Any Visual Improvement (%)
Corrected Distance Visual Acuity of 20/40 or Better (%)
Endophthalmitis Rate (%)
All patients
87.2
d
0.58
Diabetes only Glaucoma only AMD only All patients DR only Glaucoma only AMD only All patients DR only Glaucoma only AMD only AMD only
84.7 75.8 79.9 92.6 d d d d d d d 71.7
d d d 89.0 83.7 89.7 80.7 91.4† 75.9† 85.1† 74.8† d
d d d 0.044 d d d d d d d d
AMD Z age-related macular degeneration; DR = diabetic retinopathy; VHA Z Veterans Health Administration *First author † Reported as best-measured visual acuity (BMVA); Jaycock et al.4 found that BMVA was a suitable approximation for corrected distance visual acuity
problematic given the intraocular pressure–lowering effect of cataract surgery.D Another reason may be related to the VHA's training mission: Glaucoma patients may present more challenges to resident surgeons during cataract surgery, resulting in higher complication rates and poorer visual outcomes.2 The second concerns the postoperative endophthalmitis rates. In the Inspector General's report, 0.58% of patients had postoperative endophthalmitis versus 0.044% in a recent comparison study.3 One of the patients was treated with topical antibiotics only, which makes the diagnosis of endophthalmitis unlikely or the management inappropriate. Without this patient, however, the endophthalmitis rate was still 0.46%, an unacceptably high rate compared with current standards. The reason for this finding is unclear. The higher burden of illness in VHA patients1 and the involvement of resident surgeons in VHA cataract surgeries2 are possible factors. Regardless, postoperative endophthalmitis in the VHA warrants further study, especially given emerging practice patterns such as the use of intracameral antibiotics that have the potential to reduce the rates of this devastating complication.D In summary, pending the release and publication of the VHA Ophthalmic Surgery Outcomes Database pilot project,A the Inspector General's report provides a useful perspective on the state of cataract surgery in the VHA and underscores the importance of further investigating (1) the visual outcomes of glaucoma patients, (2) the rates of postoperative endophthalmitis,
and, equally important, (3) how current resident training practices may affect cataract surgery complications. Disclaimer: The views expressed in this article are those of the authors' and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. REFERENCES 1. Greenberg PB, Tseng VL, Wu W-C, Liu J, Jiang L, Chen CK, Scott IU, Friedmann PD. Prevalence and predictors of ocular complications associated with cataract surgery in United States veterans. Ophthalmology 2011; 118:507–514 2. French DD, Margo CE, Campbell RR. Do ophthalmology training programs affect corrective procedure rates after cataract surgery? Am J Med Qual 2013; 28:250–255 €m M, Barry P, Henry Y, Rosen P, Stenevi U. 3. Lundstro Visual outcome of cataract surgery; study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery. J Cataract Refract Surg 2013; 39:673–679; erratum, 971 4. Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, Galloway P, Canning C, Sparrow JM. the UK EPR user group. The Cataract National Dataset electronic multicentre audit of 55 567 operations: updating benchmark standards of care in the United Kingdom and internationally. Eye 2009; 23:38–49. Available at: http://www.nature.com/eye/journal/v23/n1/pdf/ 6703015a.pdf. Accessed September 10, 2013 n E, Clemons TE, Ferris FL 3rd, Chew EY, 5. Forooghian F, Agro for the AREDS Research Group. Visual acuity outcomes after cataract surgery in patients with age-related macular degeneration: Age-Related Eye Diseases Study report no. 27. Ophthalmology 2009; 116:2093–2100
J CATARACT REFRACT SURG - VOL 39, DECEMBER 2013
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CORRESPONDENCE
OTHER CITED MATERIAL A. Department of Veterans Affairs, Office of Inspector General. Healthcare Inspection; Evaluation of Cataract Surgeries and Outcomes in Veterans Health Administration Facilities. Washington, DC, VA Office of Inspector General, March 28, 2013 (Report No. 11-02487-158). Available at: http://www.va.gov/ oig/pubs/VAOIG-11-02487-158.pdf. Accessed September 10, 2013 B. Department of Veterans Affairs, Veterans Benefits Administration. Trends in the Utilization of VA Programs and Services: FY2000 to FY2010. National Center for Veterans Analysis and Statistics. Washington, DC, U.S. Department of Veterans Affairs, January 2012. Available at: http://www.va.gov/vetdata/
docs/QuickFacts/Utilization_quickfacts_Fy2010_v5.pdf. Accessed September 10, 2013 C. Department of Veterans Affairs, Office of Academic Affiliations. Resources for Clinical Trainees. Washington, DC, U.S. Department of Veterans Affairs, August 15, 2013. Available at: http:// www.va.gov/OAA/resources_trainees.asp. Accessed September 10, 2013 D. American Academy of Ophthalmology. Cataract in the Adult Eye; Preferred Practice Patterns. San Francisco, CA, American Academy of Ophthalmology, 2011. Available at: http://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx? cidZa80a87ce-9042-4677-85d7-4b876deed276. Accessed July 2, 2013
J CATARACT REFRACT SURG - VOL 39, DECEMBER 2013
CORRESPONDENCE
Figure 2. Intraoperative image during scleral depression (A: pars plana, B: ora serrata) using an indirect surgical lens and chandelier endoillumination.
During vitreous surgery, scleral depression is required for a very peripheral vitrectomy, but because of changes in ocular shape with scleral depression, IOL deformity and motion can occur. The IOL configuration and optic and haptic materials influence IOL behavior when the sclera is depressed. To evaluate potential problems with implanted IOLs during vitreous surgery, the entire IOL, including the optic and haptics, must be examined. For this reason, IOL observation using the indirect inverted contact lens and chandelier endoillumination is a useful method for IOL evaluation and should aid clinicians during this procedure. REFERENCES 1. Cherfan GM, Michels RG, de Bustros S, Enger C, Glaser BM. Nuclear sclerotic cataract after vitrectomy for idiopathic epiretinal membranes causing macular pucker. Am J Ophthalmol 1991; 111:434–438 2. Miyake K, Miyake C. Intraoperative posterior chamber lens haptic fixation in the human cadaver eye. Ophthalmic Surg 1985; 16:230–236 3. Apple DJ, Lim ES, Morgan RC, Tsai JC, Gwin TD, Brown SJ, Carlson AN. Preparation and study of human eyes obtained postmortem with the Miyake posterior photographic technique. Ophthalmology 1990; 97:810–816 4. Chew J, Werner L. Miyake-Apple preparation of postmortem eyes: technique and applications. Tech Ophthalmol 2006; 4:102–107
Inspecting the Inspector General’s report on cataract surgery in the United States Veterans Health Administration Paul B. Greenberg, MD, Benjamin K. Young, MS, Curtis E. Margo, MD, MPH, Dustin D. French, PhD A recent report from the Inspector General provides a timely snapshot of the state of cataract surgery in the United States Veterans Health Administration (VHA).A This is important not only to the 8.3 million veterans receiving care in the VHA,B but also to
ophthalmic graduate medical education programs as the VHA is the largest provider of health professions training in the U.S.C In addition, unlike the most recently published VHA cataract surgery outcomes, which were based on administrative data,1,2 the Inspector General's report used primary data abstracted from electronic medical records. The Inspector General's report was based on a random sample of 870 of the 38 451 patients who received cataract surgery in the VHA in 2011; 82.8% of the medical centers in which patients received cataract surgery trained ophthalmology residents. The data on the visual outcomes and endophthalmitis rates were of particular interest as they facilitated comparison with other large recently published studies of cataract surgery outcomes based on primary data (Table 1).3–5 However, several factors must be kept in mind when comparing these results. First, the Inspector General's report defined visual outcomes as any visual improvement as opposed to the more common benchmark of 20/40 or better. Second, the diabetic retinopathy status in the Inspector General's cohort of diabetic patients was not provided, although an estimated 14.0% of cataract surgery patients in the VHA have diabetic retinopathy.1 Third, 40.3% of the patients in the Inspector General's report had glaucoma, age-related macular degeneration (AMD), and/or diabetes mellitus compared with 18.3%3 and 15.3%4 in 2 of the comparison studies. Visual outcomes in all patients and in the cohorts of patients with diabetes and AMD were similar in the Inspector General's report and the comparison studies. Two results, however, merit further comment. The first concerns outcomes in glaucoma patients. In the Inspector General's report, 75.8% of glaucoma patients had visual improvement versus the 85.1% to 89.7% who achieved visual acuity of 20/40 or better in the comparison studies. One reason may be that patients in the VHA have more advanced glaucoma when they have cataract surgery. This delay would be
J CATARACT REFRACT SURG - VOL 39, DECEMBER 2013
1931
CORRESPONDENCE
Table 1. Cataract surgery outcomes in the VHA and selected studies.
Study* VHA (2013) report from the Inspector GeneralA
Data Source Medical records
Lundstr€ om (2013)3
National registry
Jaycock (2009)4
National database
Forooghian (2010)5
Medical records
Size 870
368 256 35 029 21 088 11 299 40 758 1 036 1 798 3 416 1 939
Patient Cohort
Any Visual Improvement (%)
Corrected Distance Visual Acuity of 20/40 or Better (%)
Endophthalmitis Rate (%)
All patients
87.2
d
0.58
Diabetes only Glaucoma only AMD only All patients DR only Glaucoma only AMD only All patients DR only Glaucoma only AMD only AMD only
84.7 75.8 79.9 92.6 d d d d d d d 71.7
d d d 89.0 83.7 89.7 80.7 91.4† 75.9† 85.1† 74.8† d
d d d 0.044 d d d d d d d d
AMD Z age-related macular degeneration; DR = diabetic retinopathy; VHA Z Veterans Health Administration *First author † Reported as best-measured visual acuity (BMVA); Jaycock et al.4 found that BMVA was a suitable approximation for corrected distance visual acuity
problematic given the intraocular pressure–lowering effect of cataract surgery.D Another reason may be related to the VHA's training mission: Glaucoma patients may present more challenges to resident surgeons during cataract surgery, resulting in higher complication rates and poorer visual outcomes.2 The second concerns the postoperative endophthalmitis rates. In the Inspector General's report, 0.58% of patients had postoperative endophthalmitis versus 0.044% in a recent comparison study.3 One of the patients was treated with topical antibiotics only, which makes the diagnosis of endophthalmitis unlikely or the management inappropriate. Without this patient, however, the endophthalmitis rate was still 0.46%, an unacceptably high rate compared with current standards. The reason for this finding is unclear. The higher burden of illness in VHA patients1 and the involvement of resident surgeons in VHA cataract surgeries2 are possible factors. Regardless, postoperative endophthalmitis in the VHA warrants further study, especially given emerging practice patterns such as the use of intracameral antibiotics that have the potential to reduce the rates of this devastating complication.D In summary, pending the release and publication of the VHA Ophthalmic Surgery Outcomes Database pilot project,A the Inspector General's report provides a useful perspective on the state of cataract surgery in the VHA and underscores the importance of further investigating (1) the visual outcomes of glaucoma patients, (2) the rates of postoperative endophthalmitis,
and, equally important, (3) how current resident training practices may affect cataract surgery complications. Disclaimer: The views expressed in this article are those of the authors' and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. REFERENCES 1. Greenberg PB, Tseng VL, Wu W-C, Liu J, Jiang L, Chen CK, Scott IU, Friedmann PD. Prevalence and predictors of ocular complications associated with cataract surgery in United States veterans. Ophthalmology 2011; 118:507–514 2. French DD, Margo CE, Campbell RR. Do ophthalmology training programs affect corrective procedure rates after cataract surgery? Am J Med Qual 2013; 28:250–255 €m M, Barry P, Henry Y, Rosen P, Stenevi U. 3. Lundstro Visual outcome of cataract surgery; study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery. J Cataract Refract Surg 2013; 39:673–679; erratum, 971 4. Jaycock P, Johnston RL, Taylor H, Adams M, Tole DM, Galloway P, Canning C, Sparrow JM. the UK EPR user group. The Cataract National Dataset electronic multicentre audit of 55 567 operations: updating benchmark standards of care in the United Kingdom and internationally. Eye 2009; 23:38–49. Available at: http://www.nature.com/eye/journal/v23/n1/pdf/ 6703015a.pdf. Accessed September 10, 2013 n E, Clemons TE, Ferris FL 3rd, Chew EY, 5. Forooghian F, Agro for the AREDS Research Group. Visual acuity outcomes after cataract surgery in patients with age-related macular degeneration: Age-Related Eye Diseases Study report no. 27. Ophthalmology 2009; 116:2093–2100
J CATARACT REFRACT SURG - VOL 39, DECEMBER 2013
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CORRESPONDENCE
OTHER CITED MATERIAL A. Department of Veterans Affairs, Office of Inspector General. Healthcare Inspection; Evaluation of Cataract Surgeries and Outcomes in Veterans Health Administration Facilities. Washington, DC, VA Office of Inspector General, March 28, 2013 (Report No. 11-02487-158). Available at: http://www.va.gov/ oig/pubs/VAOIG-11-02487-158.pdf. Accessed September 10, 2013 B. Department of Veterans Affairs, Veterans Benefits Administration. Trends in the Utilization of VA Programs and Services: FY2000 to FY2010. National Center for Veterans Analysis and Statistics. Washington, DC, U.S. Department of Veterans Affairs, January 2012. Available at: http://www.va.gov/vetdata/
docs/QuickFacts/Utilization_quickfacts_Fy2010_v5.pdf. Accessed September 10, 2013 C. Department of Veterans Affairs, Office of Academic Affiliations. Resources for Clinical Trainees. Washington, DC, U.S. Department of Veterans Affairs, August 15, 2013. Available at: http:// www.va.gov/OAA/resources_trainees.asp. Accessed September 10, 2013 D. American Academy of Ophthalmology. Cataract in the Adult Eye; Preferred Practice Patterns. San Francisco, CA, American Academy of Ophthalmology, 2011. Available at: http://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx? cidZa80a87ce-9042-4677-85d7-4b876deed276. Accessed July 2, 2013
J CATARACT REFRACT SURG - VOL 39, DECEMBER 2013
