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Endoscopic Diode-Laser Cyclophotocoagulation in the Management of Aphakic and Pseudophakic Glaucoma
Journal of AAPOS Volume 10 Number 1 February 2006 Relational Database Enhances ROP Scheduling, Follow-Up, Record-Keeping, and Education Robert W. Arnold, MD, Jack Jacob, MD; Providence Hospital NICU, Anchorage, AL Introduction: Screening by birth-demographics and meticulous consistent confirmatory exams allows one of the most cost-effective of all medical therapies for ROP. On the other hand, potential imperfect scheduling and follow-up combined with a potentially lifetime blinding condition makes coverage of NICU eye exams a medicolegal conundrum. Methods: A relational database was developed to model the best features of AAPOS Paperwork Exchange forms and was used in parallel with the existing paper system for the last year. Outcome data on the thoroughness of ROP exam delivery was prospectively collected and compared over the last 5 years. Results: The Glacier Medical Software allowed input of neonatal demographics, protocol scheduling, weekly scheduling of each patient to be examined based on an algorithm, tablet-PC exam data entry with retinal drawing, follow-up scheduling based on clinical guidelines and report generation for hospital and physician charting, billing, and parental education. Disease management decision support for therapy is built into the software program. The software reports the level of ROP severity and guideline adherence. Prior to 2002 scheduling, thoroughness was less than 90% with delays in the initial exam. Since the initiation of the paper-based design and use of the Glacier Medical Software, only a single baby was missed in the last six calendar quarters with no inadvertent delays in the timing of the initial exam. The average time to record an exam was 2 minutes for paper and for Glacier Medical Software. Conclusion: The Glacier Medical ROP software significantly reduced missed ROP exams and resulted in no inadvertent delays in initial exams. A consistent software program might enhance availability of coverage for at-risk premature infants. The Cost-Utility of Strabismus Surgery in Adults Cynthia L. Beauchamp, George R. Beauchamp, Joost Felius, David R. Stager Sr, Gary C. Brown, Melissa M. Brown; University of Texas Southwestern Medical Center, Retina Foundation of the Southwest, Center for Value-Based Medicine, Grapevine, TX. Introduction: Cost-utility analysis evaluates the cost of medical care in relation to the gain in quality-adjusted life-years (QALYs). Our purpose was to develop a cost model for surgical care for adult strabismus, to estimate the mean cost per case, to determine the associated gain in QALYs, and to perform cost-utility analysis. Methods: A generous cost model (ie, tending to overestimate cost) incorporated surgery, pre- and postoperative care, and a mean of 1.9 procedures per patient. The gain in QALYs was based on the improvement of utility on a scale from 0 (death) to 1 (perfect health). Utilities were measured through physician-conducted interviews employing a time trade-off question (seeking to estimate the portion of life expectancy a patient would be willing to trade for being rid of disease and associated effects). The interviews were conducted before and approximately 2 months after surgery in 36 strabismic patients (age 19 to 75 years). Results: The cost model resulted in an estimated total cost of $12,925 per case. A significant improvement of utility was found: 0.97 ⫾ 0.11 postoperatively versus 0.84 ⫾ 0.20 preoperatively (P ⫽ 0.0006). Based on the mean life expectancy of these patients, and under the assumption that the prolonged effect of this patient-perceived improvement in health status decreases in value by 3% annually, this resulted in a mean increase of 1.54 QALYs after surgery. The cost-utility of strabismus surgery was therefore $8,386/QALY. Discussion: In the US, treatments ⬍$50,000/QALY are generally considered “very cost-effective.” Strabismus surgery in adults falls well within this range.
Abstracts
63
Long-Term Motor and Sensory Outcomes Following Early Surgery for Infantile Esotropia Eileen E. Birch, PhD, David R. Stager, MD; Retina Foundation of the Southwest, Dallas, TX Introduction: The proper timing of surgery for infantile esotropia remains controversial; early surgery may yield better sensory outcomes, while later surgery may result in better alignment. Several recent studies reported promising sensory outcomes in small groups of children (N ⫽ 6 to 16) with surgery by 6 months of age. Here we present motor and sensory outcomes of a cohort of 50 consecutive children enrolled in a prospective study after surgery by 6 months of age and followed for 4 to 17 years. Methods: Angle of deviation, subsequent surgeries, postoperative treatment with spectacles, amblyopia, fusion, and stereopsis were evaluated during follow-up. Outcomes from the early surgery group were compared with a concurrently recruited cohort who had surgery at 7 to 12 months (N ⫽ 78). Results: On the initial visit, both cohorts had the same median angle of deviation (45 PD) and similar median refractive error (⫹2.50); the median angle of deviation increased by the final preoperative visit (55 PD). Postoperatively, both cohorts had alignment within 6 PD in 83 to 94% of cases on all visits. Both cohorts had similar rates of additional surgery for ET (28% versus 27%), XT (18% versus 18%), and vertical/oblique (30% versus 32%); 44% of both cohorts wore hyperopic correction postoperatively. Compared with the 7- to 12-month cohort, more children in the early surgery cohort had peripheral fusion (78% versus 64%; P ⬍ 0.05), central fusion (15% versus 2%; P ⬍ 0.01), stereopsis (52% versus 33%; P ⬍ 0.025), and random dot stereoacuity of 200 seconds or better (20% versus 9%; P ⬍ 0.05). Conclusion: Early surgery was associated with a higher prevalence of fusion and stereopsis, without adverse motor outcomes. Endoscopic Diode-Laser Cyclophotocoagulation in the Management of Aphakic and Pseudophakic Glaucoma B. Christian Carter, MD, David A. Plager, MD, Daniel E. Neely, MD, Derek T. Sprunger, MD, Naval Sondhi, MD, Gavin J. Roberts, MD; Indiana University, Indianapolis, IN Introduction: Endoscopic cyclophotocoagulation (ECP) has been shown to be a useful adjunct in the management of a variety of pediatric glaucomas. This study reports the efficacy and safety of this procedure for aphakic glaucoma. Methods: The charts were reviewed of all children under age 16 years who underwent ECP for aphakic glaucoma between April 1994 and November 2004. Endocyclophotoablation was performed with the Microprobe (Endo Optiks, Little Silver, NJ) integrated laser endoscope system on 36 eyes of 26 patients. Patients were followed for a minimum of 12 months or until a treatment failure had been declared. Treatment failure was defined as postoperative intraocular pressure (IOP) of ⬎24 mm Hg despite the addition of glaucoma medications or the occurrence of any visually significant complications. Aphakic eyes of patients with congenital glaucoma or an anterior segment dysgenesis were not included in the study group. Results: Mean follow-up period for study eyes was 42.4 months (range 0.17 to 129.3 months). Pretreatment IOP averaged 33.3 mm Hg in the 36 eyes, compared to a final postoperative average of 23.2 mm Hg. The average number of procedures per eye was 1.5. The mean arc of treatment on the first procedure was 229 degrees, while cumulative degrees of treatment at the study’s conclusion were 267 degrees. Overall success rate was 58% (21/36). Fifteen of 22 eyes (68%) that received one treatment only were deemed a success. A total of 39% (14/36) of eyes underwent further ECP. Significant complications occurred in two eyes that developed retinal detachments within the first postoperative month. Conclusions: Endocyclophotocoagulation is a useful tool in the treatment of aphakic glaucoma, with a low rate of visually significant complications. Retreatment of eyes did not significantly improve the overall success rate, nor did it increase the incidence of complications such as hypotony.
Abstracts
63
Long-Term Motor and Sensory Outcomes Following Early Surgery for Infantile Esotropia Eileen E. Birch, PhD, David R. Stager, MD; Retina Foundation of the Southwest, Dallas, TX Introduction: The proper timing of surgery for infantile esotropia remains controversial; early surgery may yield better sensory outcomes, while later surgery may result in better alignment. Several recent studies reported promising sensory outcomes in small groups of children (N ⫽ 6 to 16) with surgery by 6 months of age. Here we present motor and sensory outcomes of a cohort of 50 consecutive children enrolled in a prospective study after surgery by 6 months of age and followed for 4 to 17 years. Methods: Angle of deviation, subsequent surgeries, postoperative treatment with spectacles, amblyopia, fusion, and stereopsis were evaluated during follow-up. Outcomes from the early surgery group were compared with a concurrently recruited cohort who had surgery at 7 to 12 months (N ⫽ 78). Results: On the initial visit, both cohorts had the same median angle of deviation (45 PD) and similar median refractive error (⫹2.50); the median angle of deviation increased by the final preoperative visit (55 PD). Postoperatively, both cohorts had alignment within 6 PD in 83 to 94% of cases on all visits. Both cohorts had similar rates of additional surgery for ET (28% versus 27%), XT (18% versus 18%), and vertical/oblique (30% versus 32%); 44% of both cohorts wore hyperopic correction postoperatively. Compared with the 7- to 12-month cohort, more children in the early surgery cohort had peripheral fusion (78% versus 64%; P ⬍ 0.05), central fusion (15% versus 2%; P ⬍ 0.01), stereopsis (52% versus 33%; P ⬍ 0.025), and random dot stereoacuity of 200 seconds or better (20% versus 9%; P ⬍ 0.05). Conclusion: Early surgery was associated with a higher prevalence of fusion and stereopsis, without adverse motor outcomes. Endoscopic Diode-Laser Cyclophotocoagulation in the Management of Aphakic and Pseudophakic Glaucoma B. Christian Carter, MD, David A. Plager, MD, Daniel E. Neely, MD, Derek T. Sprunger, MD, Naval Sondhi, MD, Gavin J. Roberts, MD; Indiana University, Indianapolis, IN Introduction: Endoscopic cyclophotocoagulation (ECP) has been shown to be a useful adjunct in the management of a variety of pediatric glaucomas. This study reports the efficacy and safety of this procedure for aphakic glaucoma. Methods: The charts were reviewed of all children under age 16 years who underwent ECP for aphakic glaucoma between April 1994 and November 2004. Endocyclophotoablation was performed with the Microprobe (Endo Optiks, Little Silver, NJ) integrated laser endoscope system on 36 eyes of 26 patients. Patients were followed for a minimum of 12 months or until a treatment failure had been declared. Treatment failure was defined as postoperative intraocular pressure (IOP) of ⬎24 mm Hg despite the addition of glaucoma medications or the occurrence of any visually significant complications. Aphakic eyes of patients with congenital glaucoma or an anterior segment dysgenesis were not included in the study group. Results: Mean follow-up period for study eyes was 42.4 months (range 0.17 to 129.3 months). Pretreatment IOP averaged 33.3 mm Hg in the 36 eyes, compared to a final postoperative average of 23.2 mm Hg. The average number of procedures per eye was 1.5. The mean arc of treatment on the first procedure was 229 degrees, while cumulative degrees of treatment at the study’s conclusion were 267 degrees. Overall success rate was 58% (21/36). Fifteen of 22 eyes (68%) that received one treatment only were deemed a success. A total of 39% (14/36) of eyes underwent further ECP. Significant complications occurred in two eyes that developed retinal detachments within the first postoperative month. Conclusions: Endocyclophotocoagulation is a useful tool in the treatment of aphakic glaucoma, with a low rate of visually significant complications. Retreatment of eyes did not significantly improve the overall success rate, nor did it increase the incidence of complications such as hypotony.