A retrospective review of cataract surgery patients with wet age-related macular degeneration suggests that cataract surgery leads to vision improvement and does not appear to contribute to worsening of wet AMD. However, anatomic changes based on optical coherence tomography analysis suggest a subclinical susceptibility to postoperative cystoid macular edema or exacerbation of choroidal neovascularization.

The review was performed on consecutive patients with wet AMD (n=40) who underwent cataract surgery at the midpoint of a one-year study window. A control arm (n=42) included wet AMD eyes treated with anti-vascular endothelial growth factor injections that did not undergo cataract surgery for the one-year period. Best-corrected visual acuity, number of anti-VEGF injections and OCT features were compared between the control and trial arms.

Best-corrected visual acuity was equivalent in the first half of the study and became significantly better in the surgical group vs. the non-surgical group (0.23 ±0.65 vs. 0.11 ±0.59 logMAR improvement, p=0.049). There was no change in the number of injections given six months before vs. after the midpoint in the surgical group (p=0.921). The mean OCT central retinal thickness became greater in the postsurgical eyes compared to nonsurgical eyes (265.4 ±98.4 μm vs. 216.4 ±58.3 μm, p=0.048).
Am J Ophthalmol 2015;160:3:487-492.
^{Saraf S, Ryu C, Ober M.}


A New Botulinum Toxin A Forehead Lift
A study investigating the safety and efficacy of microdroplet cosmetic periocular botulinum toxin A used to treat eyebrow depressors while leaving brow elevators untreated has concluded that the treatment results in an aesthetic improvement to the face and periocular area without the forehead paralysis associated with conventional treatment.

Patients were treated with 33 U onabotulinum toxin injected in microdroplets of 10 to 20 μl. Sixty to 100 injections of microdroplets were needed to complete a treatment pattern concentrated at the brow, glabella and crows feet area. The forehead was not treated. Patients who returned between 10 and 45 days were studied with image analysis.

There were 563 consecutive microdroplet treatments on 227 unique patients (female: n=175, mean age: 46 ±4 years; male: n=52, mean age: 44 ±8 years). The incidence of ptosis was 0.2 percent and transient. Forty-nine patients returned for a follow-up visit between 10 and 45 days and were included for image analysis to compare the before and after results of treatment. Photonumeric scales for forehead lines, brow ptosis and brow furrow all showed statistically significant improvements.
Ophthal Plast Reconstr Surg 2015;31:263-268.
^{Steinsapir K, Rootman D, Wulc A, Hwang C.}


Medicare Payment and Service Volume for Retina Procedures
New York researchers found no evidence suggesting an association between Medicare payment and service volume for the three highest-volume retina procedures from 2005 through 2009.

The researchers used Medicare Part B carrier data for all 50 states and the District of Columbia, controlling for time-invariant carrier-specific characteristics, national trends in service volume, Medicare beneficiary population, number of ophthalmologists and income per capita. The main outcome measures were Medicare payment-service volume elasticities, defined as the percentage of change in service volume per 1 percent change in Medicare payment for the three highest volume retina procedures: intravitreal injection (Current Procedural Terminology code 67028); laser treatment for retinal edema (CPT code 67210); and laser treatment for proliferative retinopathy (CPT code 67228).

For all three retina procedures, the regression coefficients representing the Medicare payment-service volume elasticity were non-significant: intravitreal injection elasticity, -0.75 (95 percent confidence interval, -1.62 to 0.13; p=0.09); laser treatment for retinal edema elasticity, 0.14 (95 percent CI, -0.38 to .065; p=0.59); and laser treatment for proliferative retinopathy elasticity, 0.05 (95 percent CI, -0.26 to 0.35; p=0.77).
Ophthalmology 2015;122:1609-1614.
^{Gong D, Jun L, Tsai J.}


Effects of Personalized Diabetes Risk Assessment During Ophthalmic Visits
Researchers investigating whether or not point-of-care measurement of hemoglobin A1c (HbA1c) level and personalized diabetes complication risk assessments improved glycemic control determined that there was no intervention benefit compared with usual care over the span of a year.

Investigators in ophthalmology offices at 42 sites were randomly assigned to provide either study-prescribed augmented diabetes assessment and education or the usual care. Adults with type 1 or 2 diabetes were enrolled into two cohorts: those with a more-frequent-than-annual follow-up (502 control participants and 488 intervention participants) and those with an annual follow-up (368 control participants and 388 intervention participants). Enrollment in the clinical trial was from April 2011 through January 2013.

The study-prescribed augmented diabetes assessment intervention included point-of-care measurements of HbA1c; blood pressure and retinopathy severity; an individualized estimate of the risk of retinopathy progression derived from the findings of ophthalmologic visits; structured comparison and review of past and current clinical findings; and structured education with immediate assessment and feedback regarding participant understanding. These interventions were performed at enrollment and at routine ophthalmic follow-up visits scheduled at least 12 weeks apart. The main outcomes and measures were mean change in HbA1c and level from baseline to one-year follow-up. Secondary outcomes included body mass index, blood pressure and responses to diabetes self-management practices and attitudes surveys.

In the cohort with more-frequent-than-annual follow-ups, the mean (SD) change in HbA1c level at one year was -0.1 percent (1.5 percent) in the control group and -0.3 percent (1.4 percent) in the intervention group (adjusted mean difference, -0.09 percent [95 percent confidence interval, -0.29 percent to 0.12 percent], p=0.35). In the cohort with annual follow-ups, the mean (SD) change in HbA1c level was 0.0 percent (1.1 percent) in the control group and -0.1 percent (1.6 percent) in the intervention group (mean difference, -0.05 percent [95 percent CI, -0.27 percent to 0.18 percent], p=0.63). Results were similar for all secondary outcomes. These data suggest that optimizing glycemic control remains a substantive challenge requiring interventional paradigms other than those examined in this study.
JAMA Ophthalmol 2015;133:8:888-896.
^{Aiello L, Ayala A, Antoszyk A, Arnold-Bush B, Baker C, et al.}


Index to Estimate the Efficiency Of an Ophthalmic Practice
California researchers developed and evaluated an efficiency index that estimates the performance of an ophthalmologist’s practice as a function of cost, number of patients receiving care and quality of care. This metric provides a broad overview of performance for a variety of ophthalmology specialties as estimated by resources used and a preliminary measure of quality of care provided.

The adjusted number of patients, adjusted costs, quality and efficiency index were calculated via a retrospective review of data from 36 ophthalmology subspecialty practices at a university-based eye institute from October 2011 to September 2012. The efficiency index (E) was defined as a function of adjusted number of patients (N_a), total practice adjusted costs (C_a) and preliminary measure of quality (Q). Constant b limits E between zero and one. Constant y modifies the influence of Q on E. Relative value units and geographic cost indices determined by the Centers for Medicare & Medicaid Services for 2012 were used to calculate adjusted costs. The efficiency index is expressed as the following: E=b(N_a/C_a)Qy. Independent, masked auditors reviewed 20 random patient medical records for each practice and filled out three questionnaires to obtain a process-based quality measure.

The median adjusted number of patients was 5,516 (interquartile range: 3,450 to 11,863), the median adjust cost was 1.34 (IQR: 0.99 to 1.96), the median quality was 0.89 (IQR: 0.79 to 0.91) and the median value of the efficiency index was 0.26 (IQR: 0.08 to 0.42).

The results of the efficiency index could be used in future investigations to determine its sensitivity to detect the impact of interventions on a practice such as training modules or practice restructuring.
JAMA Ophthalmol 2015;133:8:924-929.
^{Chen A, Kim EA, Aigner D, Afifi A, Caprioli J.}