In a retrospective cohort study, researchers sought to explore the clinical features of patients with uveitis associated with latent tuberculosis. They also examined the effect of anti-TB treatment on uveitis outcomes.

The researchers looked at 199 eyes of 129 patients diagnosed with uveitis associated with latent TB (89 patients received anti-TB treatment, while 40 did not). They were evaluated for recurrence of disease following treatment. Information was gathered retrospectively regarding clinical outcome, vision and treatment. Outcome measures included best-corrected visual acuity and rate of disease recurrence.

The researchers treated the uveitis with local and systemic anti-inflammatory and immunosuppressive therapy in all patients. The mean change in BCVA following treatment was 4.5 ±1.4 letters over the follow-up period, with no difference between eyes of patients receiving ATT and those who did not. However, 68 eyes (34.9 percent) had a recurrence of uveitis (0.64 ±0.08 recurrences per year), with eyes of patients receiving ATT less likely to develop a recurrence compared to those not receiving ATT (29.5 percent vs. 48.2 percent). Eyes treated with ATT recurred at an estimated median of 120 months, compared with 51 months in eyes with no treatment (p=0.005).

Based on these results, the researchers concluded that treatment with ATT halved the risk of uveitis recurrence and delayed the onset of the first recurrence in eyes with uveitis associated with latent TB.

Am J Ophthalmol 2018;190:164-170.
Tomkins-Netzer O, Leong BCS, Zhang X, et al. 

Outcomes of Cataract Surgery in nAMD Patients 

Researchers from Australia evaluated the outcomes and predictive factors of visual acuity change after cataract surgery in patients who were being treated for neovascular age-related macular degeneration. 

In this retrospective, matched case-control study, researchers studied eyes undergoing cataract surgery that had been tracked since they first started treatment for nAMD. These eyes were compared with a cohort of unoperated phakic eyes being treated for nAMD matched for treatment duration before cataract surgery, baseline VA, age and length of follow-up.

The study included 124 patients who had cataract surgery and 372 matched controls. The mean VA gained was 10.6 letters (range: 7.8 to 13.2; p<0.001) 12 months after surgery; 26 percent had gained ≥3 lines, and 1.6 percent had lost ≥3 lines of VA. Visual acuity 12 months after surgery was higher in eyes that had cataract extraction compared with controls (65.8 ±17.1 vs. 61.3 ±20.8 letters, respectively, p=0.018). In the study group, the proportion of visits where the choroidal neovascular lesion was graded active and the mean number of injections were similar before and after surgery (p=0.506 and p=0.316, respectively), whereas both decreased in the control group, suggesting that surgery modestly increased the level of activity of the CNV lesion.

 Mean VA prior to surgery was lower in eyes that gained ≥15 letters compared with eyes that gained zero to 14 letters (40.2 ±21.4 vs. 62.1 ±15.1, p<0.001). Patients undergoing cataract surgery within the first six months of anti-VEGF therapy were more likely to lose rather than gain vision (20.8 percent lost vision vs. 12.8 percent and 4.4 percent gaining ≥15 or zero to 14 letters, respectively, p=0.023). Receiving an injection at least two weeks before surgery, age and the CNV lesion type had no discernible association with VA outcomes.

The researchers found evidence of a modest effect of cataract surgery on CNV lesion activity in eyes being treated for nAMD. Despite this, visual outcomes were favorable. Cataract surgery within six months of starting treatment for nAMD should be avoided if possible, the researchers say.

Am J Ophthalmol 2018;190:50-57.
Daien V, Nguyen V, Morlet N, et al.

Medical Professional Liability Claims

Researchers from the Duke University Medical Center, Durham, North Carolina, and the Physician Insurers Association of America, Rockville, Maryland, conducted a retrospective analysis of medical professional liability claims recorded by the PIAA’S Data Sharing Project over a 10-year period to examine the characteristics of these claims against ophthalmologists in the United States. 

The authors compared ophthalmology and all health care specialties for physician demographics, prevalence and costs associated with closed claims and resolution of claims. They also compared the most prevalent chief medical factor, presenting medical condition, operative procedure, outcomes and resolution of ophthalmology claims between two periods: 2006 to 2010 and 2011 to 2015.

The data showed that:

• only 24 percent of closed claims against ophthalmologists resulted in payment;

• two-thirds were dropped, withdrawn or dismissed;

• ninety percent of claims that received a verdict were favorable toward the ophthalmologist;

• cataract and cornea surgeries were the most prevalent and most costly operative procedures, accounting for half of all claims and $47,641,376 and $32,570,148 in total paid indemnity, respectively;

• average indemnity was higher for corneal procedures ($304,476) than vitreoretinal procedures ($270,141) or oculoplastic procedures on the eyelid ($222,471) or orbit and eyeball ($183,467);

• the prevalence and cost of claims related to endophthalmitis declined from the 2006 to 2010 period (n=38/1,160 [3.3 percent]; average indemnity, $516,875) to the 2011 to 2015 period (n=26/1,165 [2.2 percent]; average indemnity, $247,083); and

• the average indemnity paid ($280,227 vs. $335,578) and amount spent on legal defense ($41,450 vs. $46,391) was slightly lower among ophthalmologists compared with all health-care specialties, respectively.

Based on these results, the researchers concluded that ophthalmology has a relatively low number of malpractice claims reported compared with other health-care specialties and shows less spending on average indemnity and defense. 

Further studies are needed to investigate the reasons for the higher prevalence of claims related to cataract and corneal surgeries and the higher average indemnity paid for corneal procedures relative to vitreoretinal or oculoplastic procedures.

Ophthalmology 2018;125:631-641
Thompson AC, Parikh PD, Lad EM

Primary Tube vs. Trabeculectomy Follow-up

In an effort to report one-year treatment outcomes in the Primary Tube Versus Trabeculectomy study, researchers conducted a multicenter, randomized clinical trial of 242 eyes of 242 patients with medically uncontrolled glaucoma and no previous incisional ocular surgery, including 125 in the tube group and 117 in the trabeculectomy group.

Patients were enrolled at 16 clinical centers and assigned randomly to treatment with a tube shunt (350-mm2 Baerveldt glaucoma implant) or trabeculectomy with mitomycin C. Primary outcome measures were intraocular pressure, glaucoma medical therapy, visual acuity, visual fields, surgical complications and failure defined as IOP of more than 21 mmHg; IOP reduced by less than 20 percent  from baseline; IOP of 5 mmHg or less; reoperation for glaucoma; or loss of light-perception vision.

The cumulative probability of failure during the first year of follow-up was 17.3 percent in the tube group and 7.9 percent in the trabeculectomy group (p=0.01; hazard ratio, 2.59; 95 percent confidence interval, 1.20 to 5.60). Mean  IOP was 13.8 ±4.1 mmHg in the tube group and 12.4 ±4.4 mmHg in the trabeculectomy group at one year (p=0.01). The number of glaucoma medications was 2.1 ±1.4 in the tube group and 0.9 ±1.4 in the trabeculectomy group (p<0.001). Postoperative complications developed in 36 patients (29 percent) in the tube group and 48 patients (41 percent) in the trabeculectomy group (p=0.06). Serious complications requiring reoperation or producing a loss of two Snellen lines or more occurred in one patient (1 percent) in the tube group and eight patients (7 percent) in the trabeculectomy group (p=0.03).

According to these researchers, trabeculectomy with MMC had a higher surgical success rate than tube shunt implantation after one year in the PTVT Study. Lower IOP with use of fewer glaucoma medications was achieved after trabeculectomy with MMC compared with tube shunt surgery during the first year of follow-up. However, the frequency of serious complications producing vision loss or requiring reoperation was lower after tube shunt surgery than trabeculectomy with MMC.

Ophthalmology 2018;125:650-663
Gedde SJ, Feuer WJ, Shi W, et al.