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Outcomes of trabecular microbypass surgery: Comparison of resident trainees and attending surgeons
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ARTICLE
Outcomes of trabecular microbypass surgery: Comparison of resident trainees and attending surgeons Cindy X. Zheng, MD, Saumya Copparam, MD, Michael M. Lin, MD, Stephen J. Moster, MD, Carina T. Sanvicente, MD, L. Jay Katz, MD, M. Reza Razeghinejad, MD, Jonathan S. Myers, MD, Daniel Lee, MD
Purpose: To determine the efficacy, safety, and surgical outcomes of trabecular microbypass stent (iStent) surgery performed by resident trainees and attending surgeons.
Setting: Wills Eye Hospital, Philadelphia, Pennsylvania, USA. Design: Retrospective case series. Methods: Records of all patients who had microbypass stent surgery by a resident at Wills Eye Hospital were retrospectively reviewed. The attending-performed group included any patient who had a microbypass stent implanted by an attending surgeon on the same day a resident case was performed. Results: Between 2016 and 2018, 31 microbypass stents were implanted by a resident supervised by an attending and 93 microbypass stents were implanted by an attending surgeon on the day a resident case was performed. The mean follow-up was
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phthalmology residents are required to become proficient at glaucoma surgery during their training. The Accreditation Council for Graduate Medical Education (ACGME) requires residents to perform a minimum of 86 cataract extractions and 5 glaucoma surgeries, either filtering or shunting. The national ACGME case-log database reports that residents who completed training during the 2017 and 2018 academic year performed an average of 195.9 phacoemulsification procedures as well as 6.2 filtering, 6.6 shunting, and 3.0 other glaucoma surgeries.A Many studies have evaluated the outcomes of cataract surgery by residents in various settings.1–9 Several studies have also evaluated trabeculectomy10–13 and tube shunt surgery13–15 performed by residents. These studies found that cataract and glaucoma surgeries performed by
16.2 months G 17.9 (SD). The mean intraocular pressure (IOP) decreased from 16.0 G 4.6 mm Hg at baseline to 14.0 G 3.1 mm Hg at most recent follow-up visit in the resident group (P Z .02) and from 17.5 G 4.8 mm Hg to 15.1 G 4.3 mm Hg, respectively, in the attending group (P < .001). The final mean IOP and mean number of hypotensive medications were similar between the 2 groups (P Z .83 and P Z .12, respectively). Selfresolving hyphema occurred in 1 resident case and 2 attending cases. The resident group had 1 case of iridodialysis, which did not require additional surgery. One eye in the attending group ultimately required a trabeculectomy.
Conclusion: Microbypass stent implantation by resident trainees with attending supervision had similar efficacy and safety as surgery performed by attending surgeons. J Cataract Refract Surg 2019; 45:1704–1710 Q 2019 ASCRS and ESCRS
residents have had similar outcomes and complication rates as those performed by attending surgeons.11,12,14 In recent years, microinvasive or minimally invasive glaucoma surgery (MIGS) has emerged as an alternative to traditional glaucoma surgeries. The iStent trabecular microbypass stent (Glaukos Corp.) has become increasingly popular for patients with mild to moderate open-angle glaucoma (OAG). Phacoemulsification with microbypass stent implantation is more effective than cataract surgery alone in reducing intraocular pressure (IOP) and the number of postoperative hypotensive medications required.16–18 Given the growing popularity of the microbypass stent over the past few years, many resident training programs now teach its implantation, although this is not formally required by the Ophthalmology Residency Review Committee for the ACGME for residency graduation. Although
Submitted: May 21, 2019 | Final revision submitted: July 8, 2019 | Accepted: July 15, 2019 From Wills Eye Hospital, Philadelphia, Pennsylvania, USA. Presented as a poster at the annual meeting of the Association for Research in Vision and Ophthalmology, Vancouver, Canada, May 2019. Corresponding author: Cindy X. Zheng, MD, Wills Eye Hospital Glaucoma Research Center, 840 Walnut St, Ste 1140, Philadelphia, PA 19107, USA. Email: cindyzheng9@ gmail.com. Q 2019 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2019.07.021
TRABECULAR BYPASS SURGERY BY RESIDENTS VS ATTENDINGS
residents are now performing microbypass stent surgery as part of their training, to our knowledge an assessment of the outcomes has not been reported in the literature. The purpose of the present study was to evaluate the efficacy and safety of resident-performed iStent surgery. A secondary objective was to compare outcomes of surgery performed by resident trainees with those performed supervising attending surgeons.
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Data were analyzed using JASP softwareB (version 0.9.0.1) and SPSS software (version 25, IBM Corp.). Numerical data were analyzed using a paired Student t test analysis or Kruskal-Wallis test. Categorical data were analyzed using the Fisher exact test or chi-square test. Treatment comparisons of time to failure were assessed with Kaplan-Meier survival analysis. Data analysis was performed at 1 month, 3 months, 6 months, 12 months, and the final follow-up. Patients who did not have an office visit during those timepoints were censored from the data pool at that specific timepoint. A P value less than 0.05 was considered statistically significant.
PATIENTS AND METHODS Institutional review board approval from Wills Eye Hospital was obtained for this retrospective study. The research adhered to the tenets of the Declaration of Helsinki and was performed in accordance with the regulations set forth by the U.S. Health Insurance Portability and Accountability Act. A computerized search of the billing database was performed for all patients with Current Procedural Terminology code for trabecular microbypass stent or iStent surgery (0191T) from 2013 to 2018. A chart review was performed on all patients who had iStent surgery at Wills Eye Hospital during this period. Any patient who had an iStent implanted by a resident was included in the study. The attending comparison group comprised any patient who had an iStent implanted by the supervising attending on the same day that a resident case was performed. The decision to place the microbypass stent before or after cataract extraction was based on the discretion of the operating surgeon. Any patient with previous incisional eye surgery, including corneal transplantation, trabeculectomy, tube shunt, vitrectomy, or ruptured globe repair, was excluded from the study. Any eye with a follow-up shorter than 3 months was also excluded. All resident microbypass stent surgeries were performed by a senior resident in his or her fourth year of postgraduate training under the direct supervision of a glaucoma subspecialty-trained attending or a comprehensive surgeon experienced with implanting microbypass stents. All residents participated in a 2-hour training session before performing surgery. This included a 1-hour didactic taught by glaucoma faculty followed by a practical component implanting the microbypass stent in eye models. Glaucoma faculty and Glaukos representatives were available during the session for 1-to-1 teaching. Baseline data collected from the last office visit before microbypass stent surgery included age, sex, race, type of glaucoma, severity of glaucoma, and eye laterality. The following data were recorded at baseline and each postoperative visit: corrected distance visual acuity (CDVA), IOP, glaucoma medications, and complications. Intraoperative details were collected, including the operative eye, location of the microbypass stent (eg, placement before or after phacoemulsification), and complications. Postoperative data were recorded at the follow-up examinations closest to 1 day, 1 week, 1 month, 3 months, 6 months, and 12 months as well as at the most recent visit. Additional procedures or surgeries after the microbypass stent surgery were also recorded. Snellen visual acuity was converted to logarithm of the minimum angle of resolution (logMAR) equivalents for data analysis. The primary outcome measures were the reduction in IOP and surgery success rate. The primary efficacy measure was an IOP reduction of at least 20% from baseline without the use of glaucoma medications and without additional glaucoma surgical procedures. The secondary efficacy measure was an IOP of 21.0 mm Hg or less with no glaucoma medications and without additional glaucoma procedures. An additional efficacy endpoint was an IOP of 21.0 mm Hg or less with the use of additional medications without additional glaucoma procedures. If there was an inadequate reduction in IOP at any timepoint after 3 months, the case was considered a failure even if the eye met success criteria at a later follow-up.
RESULTS A microbypass stent was successfully implanted in 32 eyes of 23 patients by a resident and 92 eyes of 74 patients by an attending surgeon on the same day a resident case was performed. One resident case was excluded for lack of followup data after 1 week postoperatively; thus, 31 eyes were included in the analysis. The resident group attempted to implant another microbypass stent but was unable to do so (discussed below); this patient data was not included in the analysis. All microbypass stents implanted were first generation. All cases were performed under topical anesthesia with intravenous sedation. Table 1 shows the patients’ demographic and preoperative characteristics. The most common underlying diagnosis was primary OAG. Most patients were women and white. Two patients (1.6%) had previous laser peripheral iridotomy with subsequent open angles and 21 patients (17.1%) had previous selective laser trabeculoplasty. All patients with previous laser procedures were in the attending group. No patient in either group had previous incisional intraocular surgery. Twenty-seven stents (87.1%) were placed before cataract extraction, and 4 (12.9%) were placed after cataract extraction in the resident group. In 14 cases (43.8%), it was the first time the resident had implanted the microbypass stent. The mean follow-up was 16.4 G 17.9 months. At the most recent follow-up visit, the mean CDVA was 0.11 G 0.13 logMAR (Snellen 20/25) in the resident group and 0.14 G 0.34 logMAR (Snellen 20/25) in the attending group (P Z .56). In the resident group, 29 of 31 eyes (93.5%) had a CDVA of 20/40 or better and 13 eyes (41.9%) had a CDVA of 20/20. Figure 1 shows the IOP in the resident group and attending group at each postoperative visit. The IOP at each time point was not significantly different between the 2 groups. The mean IOP decreased from 16.0 G 4.6 mm Hg at baseline to 14.0 G 3.1 mm Hg at the most recent follow-up visit in the resident group (P Z .02) and from 17.5 G 4.8 mm Hg to 15.1 G 4.3 mm Hg in the attending group (P ! .001). The mean change in IOP at the final follow-up visit compared with baseline was similar between the resident group (2.0 G 3.4 mm Hg) and attending group (2.4 G 5.3 mm Hg) (P Z .83). One eye in the attending group had IOP of 48.0 mm Hg 1 month postoperatively despite maximum medical therapy; that eye ultimately required trabeculectomy. No other eye required further surgical intervention. Figure 2 shows the mean number of Volume 45 Issue 12 December 2019
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Table 1. Baseline characteristics of patients. Parameter Mean age (y) Race, n (%) White Black Asian Did not report Sex, n (%) Male Female Glaucoma type, n (%) Primary open angle PXF Pigmentary Ocular hypertension Normal tension Other Central corneal thickness (mm) CDVA LogMAR Snellen IOP (mm Hg) Mean G SD Range Glaucoma medications (n) Mean G SD Median Mean visual field mean defect (dB) G SD Mean OCT nerve fiber layer thickness (mm) G SD
Resident Surgeons (n Z 31)
Attending Surgeons (n Z 92)
Total Patients (N Z 123)
74.5 G 7.0
72.4 G 12.7
72.9 G 11.6
4 (12.9) 27 (87.1) 0 0
61 (66.3) 24 (26.1) 2 (2.2) 5 (5.4)
65 (52.8) 51 (41.5) 2 (1.6) 5 (4.1)
13 (41.9) 18 (58.1)
33 (35.9) 59 (64.1)
46 (37.4) 77 (62.6)
16 (51.6) 3 (9.7) 0 (0) 10 (32.3) 1 (3.2) 1 (3.2) 536 G 31
61 (66.3) 8 (8.7) 10 (10.9) 2 (2.2) 4 (4.3) 7 (7.6) 547 G 32
77 (62.6) 11 (8.9) 10 (8.1) 12 (9.8) 5 (4.1) 8 (6.5) 544 G 32
0.39 G 0.38 20/50
0.28 G 0.32 20/40
0.31 G 0.33 20/40
16.0 G 4.6 8, 28
17.5 G 4.8 10, 32
17.1 G 4.8 8, 32
2.0 G 1.0 2.0 6.8 G 6.6 74.6 G 12.5
1.9 G 1.1 2.0 6.8 G 4.6 72.6 G 12.2
1.9 G 1.1 2.0 6.8 G 5.2 73.3 G 12.3
P Value .37 !.001*
.55
!.001*
.11 .13
.13
.50
.98 .46
CDVA Z corrected distance visual acuity; IOP Z intraocular pressure; logMAR Z logarithm of the minimum angle of resolution; OCT Z optical coherence tomography; PXF Z pseudoexfoliation *Statistically significant
glaucoma medications in the resident group and attending group at each follow-up visit. The number of glaucoma medications at baseline and the final follow-up visit was similar between the 2 groups.
Figure 3 shows the Kaplan-Meier survival plot of the primary outcome (IOP reduction at least 20% from baseline without use of glaucoma medications); there was no statistically significant difference between resident cases
Figure 1. Mean intraocular pressure by group.
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Figure 2. Mean number of glaucoma medications by group (* Z P ! .05).
and attending cases (P Z .12). Figure 4 shows a similar analysis for the secondary outcome (IOP 21.0 mm Hg or less without medications) and Figure 5 for the other efficacy outcome (IOP 21.0 mm Hg or less with medications). The percentages of patients achieving an IOP reduction of 20% or more without medications, a reduction of 20% or more with medications, and an IOP of than 21.0 mm Hg or less at the most recent follow-up visit was similar between the resident group and attending group (Table 2). There were no intraoperative complications in the attending group. In the resident group, there was 1 case of 5 clock hours of iridodialysis during microbypass stent implantation that occurred when the patient suddenly moved her head while the injector was in the eye. An intraoperative decision was made to not implant
Figure 3. Kaplan-Meier survival plot showing percentage of patients with intraocular pressure reduction of at least 20% from baseline with no ocular hypertensive medications. Censored refers to the exclusion at a given timepoint of patients not seen in the relevant time window.
the microbypass stent. At the most recent follow-up 17 months after surgery, the patient had an IOP of 14.0 mm Hg with 2 glaucoma medications. She did not have prolonged postoperative inflammation, hemorrhage, or long-term complications other than the appearance of the eye. The patient was offered repair of the iridodialysis for cosmetic purposes but declined. Two cases of layered hyphema in the attending group and 1 case in the resident group were noted 1 day postoperatively. All cases of hyphema resolved by 1 month without complications. DISCUSSION As trabecular microbypass surgery has become increasingly popular over the past few years, teaching residents how to implant the stent and how to perform other MIGS surgery will gradually become more widespread. To our knowledge, this is the first study assessing resident outcomes after iStent implantation. Our analysis showed that resident-performed and attending-performed microbypass stent surgery had similar efficacy and safety. There was no statistically significant difference in visual acuity outcomes between the resident group and attending group. After surgery, 94% of eyes in the resident group had a CDVA of 20/40 or better and 42% of eyes of 20/20; these results are comparable to findings in other studies. A metaanalysis of 19 studies3 found that 87% of resident surgeries result in a CDVA of least 20/40, with 56% having 20/20 or better. The postoperative IOP was similar between the 2 groups at all follow-up timepoints. The mean IOP was approximately 14.0 to 15.0 mm Hg at the most recent follow-up in both groups, which is similar to findings in other studies, including a large meta-analysis by Le and Saheb.19 In a study by Fea,17 the mean IOP in the iStent group was 17.9 G 2.6 mm Hg at the 1-year follow-up. Another study20 found similar results, with a mean IOP of 17.0 G 2.8 mm Hg at the 1-year follow-up. Volume 45 Issue 12 December 2019
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Figure 4. Kaplan-Meier survival plot showing percentage of patients with intraocular pressure reduction to 21 mm Hg or less without ocular hypertensive medications.
Figure 5. Kaplan-Meier survival plot showing percentage of patients with intraocular pressure reduction to 21 mm Hg or less with ocular hypertensive medications.
Our study found no difference in the reduction in IOP between the resident group and attending group. The primary and secondary endpoint results were similar between the 2 groups. However, the percentage of patients who met the primary and secondary endpoints was lower in our study than in other studies. A randomized controlled trial by Samuelson et al.16 found that the percentage of patients with an IOP reduction of 20% or more without medications was 66% and the percentage with an IOP of 21.0 mm Hg or less without medications was 72%. Craven et al.20 reported 20% and 61%, respectively. Although the percentage of patients who met the primary and secondary outcomes was lower in both groups in our study, these results were expected. The previous randomized control trials included a washout period requiring the unmedicated IOP to be at least 22.0 mm Hg with an average post-washout IOP of 25.4 G 3.6 mm Hg. Because we did not have a washout period before surgery, the patients’ baseline IOP was lower; thus, the patients were less likely to reach a 20% IOP reduction after surgery. Furthermore, the lack of a standardized protocol regarding medication re-initiation after surgery and the unknown equivalence in glaucoma severity and IOP goals between these study groups further limit conclusions based on medication use. The number of postoperative medications was slightly higher in the resident group than in the attending group
at the 1-month and 6-month follow-up visits; however, the number was similar between groups at the 1-year follow-up. For attending surgeons included in this study (J.S.M., M.R.R., D.L.), general practice patterns included a trial of no drops after postoperatively. The resident group had less long-term experience with implanting the iStent and might have been more hesitant to perform such a trial. The overall number of medications in both groups was slightly higher than in other studies. Craven et al.20 found a mean IOP of 17.0 G 2.8 mm Hg with a mean of 0.2 G 0.6 medications at 1 year. Fea17 found that a mean of 0.4 G 0.7 medications at 15 months. Our mean IOP was lower (14.8 G 3.2 mm Hg attending group; 14.0 G 3.1 mm Hg resident group) at 1 year; however, more medications were required. We speculate that our tertiary referral center might have a higher proportion of patients with more advanced glaucoma. As a result, our cohort might have included a greater proportion of patients with more progression of glaucoma requiring a lower target IOP and more medications to reach that IOP. Other studies12,14 have directly compared resident outcomes with attending outcomes for trabeculectomy and tube shunt surgery and found them to be similar between the groups. In a study of trabeculectomies performed at Birmingham and Midland Eye Hospital in the United Kingdom, Morell et al.12 reported surgical success (IOP
Table 2. Number of patients achieving IOP reduction endpoints at most recent follow-up visit. Patients, n (%) Parameter IOP reduction R20% without medications IOP %21 mm Hg without medications IOP %21 mm Hg with medications IOP Z intraocular pressure
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Resident Surgeons
Attending Surgeons
P Value
3 (10) 11 (35) 30 (97)
14 (15) 37 (40) 85 (92)
.17 .44 .66
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!21.0 mm Hg without progression) in 85% of resident cases and 92% of attending cases (P Z .96). Similarly, Kwong et al.11 found no statistical difference in the success rates of trabeculectomies performed by residents and casematched control trabeculectomies performed by attending surgeons at Jules Stein Eye Institute in Los Angeles, California, USA. A study by Thangamathesvaran et al.14 compared tube shunt surgery performed by residents with surgeries on case-matched controls performed by attendings. The attending group had a significantly lower IOP and number of medications at 3 months; however, there was no significant difference between the 2 groups at the 1-year follow-up visit. The baseline characteristics in our study, except for race, were similar between the attending group and resident group. The resident group had significantly more black patients, which might have confounded our results. Our resident clinic aims to help serve uninsured patients in Philadelphia, Pennsylvania, USA. Previous studies21,22 have shown variability in health insurance coverage between racial and ethnic groups, with black patients being less likely to have health insurance. Other studies have also shown that patients of resident physicians were more likely to be black.21 Regarding intraoperative complications, the resident group had 1 case of iridodialysis during microbypass stent implantation. This was caused when the patient suddenly moved her head during surgery. Because residents take longer to perform ophthalmic surgery and have less experience with patient movement, it is possible that the additional time required for surgery might result in more opportunity for additional complications secondary to patient movement. This patient had no major long-term complications. She did not have bothersome symptoms and declined cosmetic repair of the iridodialysis. The number of postoperative hyphema cases was similar between the 2 groups. The single case later requiring trabeculectomy for high IOP was in the attending group. This study did not address the learning curve of the iStent use after residency with regard to early cases in the absence of an attending surgeon. The literature on glaucoma surgery by recently graduated residents compared with that of established or older surgeons is lacking. A recent study of Canadian cataract surgeons23 found a higher rate of complications in the first year of independent practice. Further research is needed to determine the outcomes and complication rates of ophthalmologists performing microbypass stent implantation immediately after residency. Given the increasing popularity of microbypass stent implantation, residency is the optimum time to gain experience in performing angle surgery. Resident-performed iStent surgery resulted in to a decrease in the mean IOP and mean number of hypotensive medications compared with baseline. In our study, the efficacy and safety of microbypass stent were similar between cases
performed by resident trainees and those performed by attending surgeons.
WHAT WAS KNOWN Ophthalmology resident trainees are required to become proficient in cataract and glaucoma surgery during their training. Studies have shown that residents have similar outcomes to those of attending surgeons for cataract, trabeculectomy, and tube shunt surgery.
WHAT THIS PAPER ADDS Surgical implantation of a microbypass stent by a resident supervised by an attending surgeon improved visual acuity, decreased the mean intraocular pressure, and decreased the mean number of glaucoma medications at final follow-up compared with baseline. Surgical outcomes and safety of microbypass stent implantation by resident trainees were similar to those of attending surgeons.
REFERENCES 1. Menda SA, Driver TH, Neiman AE, Blumberg S, Naseri A, Stewart JM. Risk factors for return to the operating room after resident-performed cataract surgery. Semin Ophthalmol 2018; 33:210–214 2. Finn AP, Borboli-Gerogiannis S, Brauner S, Peggy Chang H-Y, Chen S, Gardiner M, Greenstein SH, Kloek C, Miller JW, Chen TC. Assessing resident cataract surgery outcomes using Medicare physician quality reporting system measures. J Surg Educ 2016; 73:774–779 3. Moustafa GA, Borkar DS, McKay KM, Eton EA, Koulisis N, Lorch AC, Kloek CE, the PCIOL Study Group. Outcomes in resident-performed cataract surgeries with iris challenges: results from the Perioperative Care for Intraocular Lens Study. J Cataract Refract Surg 2018; 44:1469–1477 4. Payal AR, Gonzalez-Gonzalez LA, Chen X, Cakiner-Egilmez T, Chomsky A, Baze E, Vollman D, Lawrence MG, Daly MK. Outcomes of cataract surgery with residents as primary surgeons in the Veterans Affairs Healthcare System. J Cataract Refract Surg 2016; 42:370–384 5. Schmidt CM, Sundararajan M, Biggerstaff KS, Orengo-Nania S, Coffee RE, Khandelwal SS. Indications and outcomes of resident-performed cataract surgery requiring return to the operating room. J Cataract Refract Surg 2016; 42:385–391 6. Puri S, Kiely AE, Wang J, Woodfield AS, Ramanathan S, Sikder S. Comparing resident cataract surgery outcomes under novice versus experienced attending supervision. Clin Ophthalmol 2015; 9:1675–1681 7. Moore DB, Slabaugh MA. Surgical outcomes and cost basis for residentperformed cataract surgery in an uninsured patient population. JAMA Ophthalmol 2013; 131:891–897 8. Hashemi H, Mohammadpour M, Jabbarvand M, Nezamdoost Z, Ghadimi H. Incidence of and risk factors for vitreous loss in residentperformed phacoemulsification surgery. J Cataract Refract Surg 2013; 39:1377–1382 9. Khatibi A, Naseri A, Stewart JM. Rate of rhegmatogenous retinal detachment after resident-performed cataract surgery is similar to that of experienced surgeons [letter]. Br J Ophthalmol 2008; 92:438 10. Chan CK, Lee S, Sangani P, Lin L-W, Lin MS, Lin SC. Primary trabeculectomy surgery performed by residents at a county hospital. J Glaucoma 2007; 16:52–56 11. Kwong A, Law SK, Kule RR, Nouri-Mahdavi K, Coleman AL, Caprioli J, Giaconi JA. Long-term outcomes of resident- versus attendingperformed primary trabeculectomy with mitomycin C in a United States residency program. Am J Ophthalmol 2014; 157:1190–1201 12. Morrell AJ, Searle AET, O’Neill EC. Trabeculectomy as an introduction to intraocular surgery in an ophthalmic training program. Ophthalmic Surg 1989; 20:557–560 13. Connor MA, Knape RM, Oltmanns MH, Smith MF. Trainee glaucoma surgery: experience with trabeculectomy and glaucoma drainage devices. Ophthalmic Surg Lasers Imaging 2010; 41:523–531
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14. Thangamathesvaran L, Crane E, Modi K, Khouri AS. Outcomes of residentversus attending-performed tube shunt surgeries in a United States residency program. J Curr Glaucoma Pract 2018; 12:53–58 15. Desai RU, Pekmezci M, Tam D, Song J, Lin SC. Resident-performed Ahmed glaucoma valve surgery. Ophthalmic Surg Lasers Imaging 2010; 41:222–227 16. Samuelson TW, Katz LJ, Wells JM, Duh Y-J, Giampocaro JE, for the US iStent Study Group. Randomized evaluation of the trabecular micro-bypass stent with phacoemulsification in patients with glaucoma and cataract. Ophthalmology 2011; 118:459–467 17. Fea AM. Phacoemulsification versus phacoemulsification with microbypass stent implantation in primary open-angle glaucoma; randomized double-masked clinical trial. J Cataract Refract Surg 2010; 36:407–412 18. Malvankar-Mehta MS, Iordanous Y, Chen YN, Wang WW, Patel SS, Costella J, Hutnik CML. iStent with phacoemulsification versus phacoemulsification alone for patients with glaucoma and cataract: a meta-analysis. PLoS One 2015; 10 (7):e0131770 19. Le K, Saheb H. iStent trabecular micro-bypass stent for open-angle glaucoma. Clin Ophthalmol 2014; 8:1937–1945 20. Craven ER, Katz LJ, Wells JM, Giamporcaro JE, for the iStent Study Group. Cataract surgery with trabecular micro-bypass stent implantation in patients with mild-to-moderate open-angle glaucoma and cataract: twoyear follow-up. J Cataract Refract Surg 2012; 38:1339–1345 21. Yancy WS Jr, Macpherson DS, Hanusa BH, Switzer GE, Arnold RM, Buranosky RA, Kapoor WN. Patient satisfaction in resident and attending ambulatory care clinics. J Gen Intern Med 2001; 16:755–762 22. Sohn H. Racial and ethnic disparities in health insurance coverage: dynamics of gaining and losing coverage over the life-course. Popul Res Policy Rev 2017; 36:181–201 23. Campbell RJ, El-Defrawy SR, Gill SS, Whitehead M, Campbell EL, Hooper PL, Bell CM, ten Hove M. New surgeon outcomes and the effectiveness of surgical training; a population-based cohort study. Ophthalmology 2017; 124:532–538; erratum, 1879
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OTHER CITED MATERIAL A. Accreditation Council for Graduate Medical Education. Ophthalmology. Case Logs Statistical Reports. National Data Report. 2010-2018. Available at: https://www.acgme.org/Data-Collection-Systems/Case-LogStatistical-Reports. Accessed August 29, 2019 B. Jeffreys’s Amazing Statistics Program. JASP 0.10.2. Available at: https: //jasp-stats.org/download/. Accessed August 29, 2019
Disclosures: Dr. Myers has received grants and personal fees from Aerie Pharmaceuticals, Alcon Laboratories, Inc., Allergan, Inc., and Glaukos Corp. He has received consultation fees from Iridex Corp. and MicroOptx and grant support from Bausch & Lomb, Inc., Diopsys, Inc., Novartis Corp., and Sight Sciences. Dr. Katz has received grants and consultation fees from Aerie Pharmaceuticals, Alcon Laboratories, Inc., Allergan, Inc., Bausch & Lomb, Inc., Diopsys, Inc. and Mati Therapeutics, Inc. He has received consultation fees from Aerpio Therapeutics, Inc., Alimera Sciences, and Glaukos Corp. and grant support from Heidelberg Engineering, Inc. He has ownership interest in Aerie Pharmaceuticals, Glaukos Corp., Mati Therapeutics, Inc., and Olleyes, Inc. None of the other authors has a financial or proprietary interest in any material or methods mentioned.
First author: Cindy X. Zheng, MD Wills Eye Hospital, Philadelphia, Pennsylvania, USA
ARTICLE
Outcomes of trabecular microbypass surgery: Comparison of resident trainees and attending surgeons Cindy X. Zheng, MD, Saumya Copparam, MD, Michael M. Lin, MD, Stephen J. Moster, MD, Carina T. Sanvicente, MD, L. Jay Katz, MD, M. Reza Razeghinejad, MD, Jonathan S. Myers, MD, Daniel Lee, MD
Purpose: To determine the efficacy, safety, and surgical outcomes of trabecular microbypass stent (iStent) surgery performed by resident trainees and attending surgeons.
Setting: Wills Eye Hospital, Philadelphia, Pennsylvania, USA. Design: Retrospective case series. Methods: Records of all patients who had microbypass stent surgery by a resident at Wills Eye Hospital were retrospectively reviewed. The attending-performed group included any patient who had a microbypass stent implanted by an attending surgeon on the same day a resident case was performed. Results: Between 2016 and 2018, 31 microbypass stents were implanted by a resident supervised by an attending and 93 microbypass stents were implanted by an attending surgeon on the day a resident case was performed. The mean follow-up was
O
phthalmology residents are required to become proficient at glaucoma surgery during their training. The Accreditation Council for Graduate Medical Education (ACGME) requires residents to perform a minimum of 86 cataract extractions and 5 glaucoma surgeries, either filtering or shunting. The national ACGME case-log database reports that residents who completed training during the 2017 and 2018 academic year performed an average of 195.9 phacoemulsification procedures as well as 6.2 filtering, 6.6 shunting, and 3.0 other glaucoma surgeries.A Many studies have evaluated the outcomes of cataract surgery by residents in various settings.1–9 Several studies have also evaluated trabeculectomy10–13 and tube shunt surgery13–15 performed by residents. These studies found that cataract and glaucoma surgeries performed by
16.2 months G 17.9 (SD). The mean intraocular pressure (IOP) decreased from 16.0 G 4.6 mm Hg at baseline to 14.0 G 3.1 mm Hg at most recent follow-up visit in the resident group (P Z .02) and from 17.5 G 4.8 mm Hg to 15.1 G 4.3 mm Hg, respectively, in the attending group (P < .001). The final mean IOP and mean number of hypotensive medications were similar between the 2 groups (P Z .83 and P Z .12, respectively). Selfresolving hyphema occurred in 1 resident case and 2 attending cases. The resident group had 1 case of iridodialysis, which did not require additional surgery. One eye in the attending group ultimately required a trabeculectomy.
Conclusion: Microbypass stent implantation by resident trainees with attending supervision had similar efficacy and safety as surgery performed by attending surgeons. J Cataract Refract Surg 2019; 45:1704–1710 Q 2019 ASCRS and ESCRS
residents have had similar outcomes and complication rates as those performed by attending surgeons.11,12,14 In recent years, microinvasive or minimally invasive glaucoma surgery (MIGS) has emerged as an alternative to traditional glaucoma surgeries. The iStent trabecular microbypass stent (Glaukos Corp.) has become increasingly popular for patients with mild to moderate open-angle glaucoma (OAG). Phacoemulsification with microbypass stent implantation is more effective than cataract surgery alone in reducing intraocular pressure (IOP) and the number of postoperative hypotensive medications required.16–18 Given the growing popularity of the microbypass stent over the past few years, many resident training programs now teach its implantation, although this is not formally required by the Ophthalmology Residency Review Committee for the ACGME for residency graduation. Although
Submitted: May 21, 2019 | Final revision submitted: July 8, 2019 | Accepted: July 15, 2019 From Wills Eye Hospital, Philadelphia, Pennsylvania, USA. Presented as a poster at the annual meeting of the Association for Research in Vision and Ophthalmology, Vancouver, Canada, May 2019. Corresponding author: Cindy X. Zheng, MD, Wills Eye Hospital Glaucoma Research Center, 840 Walnut St, Ste 1140, Philadelphia, PA 19107, USA. Email: cindyzheng9@ gmail.com. Q 2019 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2019.07.021
TRABECULAR BYPASS SURGERY BY RESIDENTS VS ATTENDINGS
residents are now performing microbypass stent surgery as part of their training, to our knowledge an assessment of the outcomes has not been reported in the literature. The purpose of the present study was to evaluate the efficacy and safety of resident-performed iStent surgery. A secondary objective was to compare outcomes of surgery performed by resident trainees with those performed supervising attending surgeons.
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Data were analyzed using JASP softwareB (version 0.9.0.1) and SPSS software (version 25, IBM Corp.). Numerical data were analyzed using a paired Student t test analysis or Kruskal-Wallis test. Categorical data were analyzed using the Fisher exact test or chi-square test. Treatment comparisons of time to failure were assessed with Kaplan-Meier survival analysis. Data analysis was performed at 1 month, 3 months, 6 months, 12 months, and the final follow-up. Patients who did not have an office visit during those timepoints were censored from the data pool at that specific timepoint. A P value less than 0.05 was considered statistically significant.
PATIENTS AND METHODS Institutional review board approval from Wills Eye Hospital was obtained for this retrospective study. The research adhered to the tenets of the Declaration of Helsinki and was performed in accordance with the regulations set forth by the U.S. Health Insurance Portability and Accountability Act. A computerized search of the billing database was performed for all patients with Current Procedural Terminology code for trabecular microbypass stent or iStent surgery (0191T) from 2013 to 2018. A chart review was performed on all patients who had iStent surgery at Wills Eye Hospital during this period. Any patient who had an iStent implanted by a resident was included in the study. The attending comparison group comprised any patient who had an iStent implanted by the supervising attending on the same day that a resident case was performed. The decision to place the microbypass stent before or after cataract extraction was based on the discretion of the operating surgeon. Any patient with previous incisional eye surgery, including corneal transplantation, trabeculectomy, tube shunt, vitrectomy, or ruptured globe repair, was excluded from the study. Any eye with a follow-up shorter than 3 months was also excluded. All resident microbypass stent surgeries were performed by a senior resident in his or her fourth year of postgraduate training under the direct supervision of a glaucoma subspecialty-trained attending or a comprehensive surgeon experienced with implanting microbypass stents. All residents participated in a 2-hour training session before performing surgery. This included a 1-hour didactic taught by glaucoma faculty followed by a practical component implanting the microbypass stent in eye models. Glaucoma faculty and Glaukos representatives were available during the session for 1-to-1 teaching. Baseline data collected from the last office visit before microbypass stent surgery included age, sex, race, type of glaucoma, severity of glaucoma, and eye laterality. The following data were recorded at baseline and each postoperative visit: corrected distance visual acuity (CDVA), IOP, glaucoma medications, and complications. Intraoperative details were collected, including the operative eye, location of the microbypass stent (eg, placement before or after phacoemulsification), and complications. Postoperative data were recorded at the follow-up examinations closest to 1 day, 1 week, 1 month, 3 months, 6 months, and 12 months as well as at the most recent visit. Additional procedures or surgeries after the microbypass stent surgery were also recorded. Snellen visual acuity was converted to logarithm of the minimum angle of resolution (logMAR) equivalents for data analysis. The primary outcome measures were the reduction in IOP and surgery success rate. The primary efficacy measure was an IOP reduction of at least 20% from baseline without the use of glaucoma medications and without additional glaucoma surgical procedures. The secondary efficacy measure was an IOP of 21.0 mm Hg or less with no glaucoma medications and without additional glaucoma procedures. An additional efficacy endpoint was an IOP of 21.0 mm Hg or less with the use of additional medications without additional glaucoma procedures. If there was an inadequate reduction in IOP at any timepoint after 3 months, the case was considered a failure even if the eye met success criteria at a later follow-up.
RESULTS A microbypass stent was successfully implanted in 32 eyes of 23 patients by a resident and 92 eyes of 74 patients by an attending surgeon on the same day a resident case was performed. One resident case was excluded for lack of followup data after 1 week postoperatively; thus, 31 eyes were included in the analysis. The resident group attempted to implant another microbypass stent but was unable to do so (discussed below); this patient data was not included in the analysis. All microbypass stents implanted were first generation. All cases were performed under topical anesthesia with intravenous sedation. Table 1 shows the patients’ demographic and preoperative characteristics. The most common underlying diagnosis was primary OAG. Most patients were women and white. Two patients (1.6%) had previous laser peripheral iridotomy with subsequent open angles and 21 patients (17.1%) had previous selective laser trabeculoplasty. All patients with previous laser procedures were in the attending group. No patient in either group had previous incisional intraocular surgery. Twenty-seven stents (87.1%) were placed before cataract extraction, and 4 (12.9%) were placed after cataract extraction in the resident group. In 14 cases (43.8%), it was the first time the resident had implanted the microbypass stent. The mean follow-up was 16.4 G 17.9 months. At the most recent follow-up visit, the mean CDVA was 0.11 G 0.13 logMAR (Snellen 20/25) in the resident group and 0.14 G 0.34 logMAR (Snellen 20/25) in the attending group (P Z .56). In the resident group, 29 of 31 eyes (93.5%) had a CDVA of 20/40 or better and 13 eyes (41.9%) had a CDVA of 20/20. Figure 1 shows the IOP in the resident group and attending group at each postoperative visit. The IOP at each time point was not significantly different between the 2 groups. The mean IOP decreased from 16.0 G 4.6 mm Hg at baseline to 14.0 G 3.1 mm Hg at the most recent follow-up visit in the resident group (P Z .02) and from 17.5 G 4.8 mm Hg to 15.1 G 4.3 mm Hg in the attending group (P ! .001). The mean change in IOP at the final follow-up visit compared with baseline was similar between the resident group (2.0 G 3.4 mm Hg) and attending group (2.4 G 5.3 mm Hg) (P Z .83). One eye in the attending group had IOP of 48.0 mm Hg 1 month postoperatively despite maximum medical therapy; that eye ultimately required trabeculectomy. No other eye required further surgical intervention. Figure 2 shows the mean number of Volume 45 Issue 12 December 2019
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Table 1. Baseline characteristics of patients. Parameter Mean age (y) Race, n (%) White Black Asian Did not report Sex, n (%) Male Female Glaucoma type, n (%) Primary open angle PXF Pigmentary Ocular hypertension Normal tension Other Central corneal thickness (mm) CDVA LogMAR Snellen IOP (mm Hg) Mean G SD Range Glaucoma medications (n) Mean G SD Median Mean visual field mean defect (dB) G SD Mean OCT nerve fiber layer thickness (mm) G SD
Resident Surgeons (n Z 31)
Attending Surgeons (n Z 92)
Total Patients (N Z 123)
74.5 G 7.0
72.4 G 12.7
72.9 G 11.6
4 (12.9) 27 (87.1) 0 0
61 (66.3) 24 (26.1) 2 (2.2) 5 (5.4)
65 (52.8) 51 (41.5) 2 (1.6) 5 (4.1)
13 (41.9) 18 (58.1)
33 (35.9) 59 (64.1)
46 (37.4) 77 (62.6)
16 (51.6) 3 (9.7) 0 (0) 10 (32.3) 1 (3.2) 1 (3.2) 536 G 31
61 (66.3) 8 (8.7) 10 (10.9) 2 (2.2) 4 (4.3) 7 (7.6) 547 G 32
77 (62.6) 11 (8.9) 10 (8.1) 12 (9.8) 5 (4.1) 8 (6.5) 544 G 32
0.39 G 0.38 20/50
0.28 G 0.32 20/40
0.31 G 0.33 20/40
16.0 G 4.6 8, 28
17.5 G 4.8 10, 32
17.1 G 4.8 8, 32
2.0 G 1.0 2.0 6.8 G 6.6 74.6 G 12.5
1.9 G 1.1 2.0 6.8 G 4.6 72.6 G 12.2
1.9 G 1.1 2.0 6.8 G 5.2 73.3 G 12.3
P Value .37 !.001*
.55
!.001*
.11 .13
.13
.50
.98 .46
CDVA Z corrected distance visual acuity; IOP Z intraocular pressure; logMAR Z logarithm of the minimum angle of resolution; OCT Z optical coherence tomography; PXF Z pseudoexfoliation *Statistically significant
glaucoma medications in the resident group and attending group at each follow-up visit. The number of glaucoma medications at baseline and the final follow-up visit was similar between the 2 groups.
Figure 3 shows the Kaplan-Meier survival plot of the primary outcome (IOP reduction at least 20% from baseline without use of glaucoma medications); there was no statistically significant difference between resident cases
Figure 1. Mean intraocular pressure by group.
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Figure 2. Mean number of glaucoma medications by group (* Z P ! .05).
and attending cases (P Z .12). Figure 4 shows a similar analysis for the secondary outcome (IOP 21.0 mm Hg or less without medications) and Figure 5 for the other efficacy outcome (IOP 21.0 mm Hg or less with medications). The percentages of patients achieving an IOP reduction of 20% or more without medications, a reduction of 20% or more with medications, and an IOP of than 21.0 mm Hg or less at the most recent follow-up visit was similar between the resident group and attending group (Table 2). There were no intraoperative complications in the attending group. In the resident group, there was 1 case of 5 clock hours of iridodialysis during microbypass stent implantation that occurred when the patient suddenly moved her head while the injector was in the eye. An intraoperative decision was made to not implant
Figure 3. Kaplan-Meier survival plot showing percentage of patients with intraocular pressure reduction of at least 20% from baseline with no ocular hypertensive medications. Censored refers to the exclusion at a given timepoint of patients not seen in the relevant time window.
the microbypass stent. At the most recent follow-up 17 months after surgery, the patient had an IOP of 14.0 mm Hg with 2 glaucoma medications. She did not have prolonged postoperative inflammation, hemorrhage, or long-term complications other than the appearance of the eye. The patient was offered repair of the iridodialysis for cosmetic purposes but declined. Two cases of layered hyphema in the attending group and 1 case in the resident group were noted 1 day postoperatively. All cases of hyphema resolved by 1 month without complications. DISCUSSION As trabecular microbypass surgery has become increasingly popular over the past few years, teaching residents how to implant the stent and how to perform other MIGS surgery will gradually become more widespread. To our knowledge, this is the first study assessing resident outcomes after iStent implantation. Our analysis showed that resident-performed and attending-performed microbypass stent surgery had similar efficacy and safety. There was no statistically significant difference in visual acuity outcomes between the resident group and attending group. After surgery, 94% of eyes in the resident group had a CDVA of 20/40 or better and 42% of eyes of 20/20; these results are comparable to findings in other studies. A metaanalysis of 19 studies3 found that 87% of resident surgeries result in a CDVA of least 20/40, with 56% having 20/20 or better. The postoperative IOP was similar between the 2 groups at all follow-up timepoints. The mean IOP was approximately 14.0 to 15.0 mm Hg at the most recent follow-up in both groups, which is similar to findings in other studies, including a large meta-analysis by Le and Saheb.19 In a study by Fea,17 the mean IOP in the iStent group was 17.9 G 2.6 mm Hg at the 1-year follow-up. Another study20 found similar results, with a mean IOP of 17.0 G 2.8 mm Hg at the 1-year follow-up. Volume 45 Issue 12 December 2019
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Figure 4. Kaplan-Meier survival plot showing percentage of patients with intraocular pressure reduction to 21 mm Hg or less without ocular hypertensive medications.
Figure 5. Kaplan-Meier survival plot showing percentage of patients with intraocular pressure reduction to 21 mm Hg or less with ocular hypertensive medications.
Our study found no difference in the reduction in IOP between the resident group and attending group. The primary and secondary endpoint results were similar between the 2 groups. However, the percentage of patients who met the primary and secondary endpoints was lower in our study than in other studies. A randomized controlled trial by Samuelson et al.16 found that the percentage of patients with an IOP reduction of 20% or more without medications was 66% and the percentage with an IOP of 21.0 mm Hg or less without medications was 72%. Craven et al.20 reported 20% and 61%, respectively. Although the percentage of patients who met the primary and secondary outcomes was lower in both groups in our study, these results were expected. The previous randomized control trials included a washout period requiring the unmedicated IOP to be at least 22.0 mm Hg with an average post-washout IOP of 25.4 G 3.6 mm Hg. Because we did not have a washout period before surgery, the patients’ baseline IOP was lower; thus, the patients were less likely to reach a 20% IOP reduction after surgery. Furthermore, the lack of a standardized protocol regarding medication re-initiation after surgery and the unknown equivalence in glaucoma severity and IOP goals between these study groups further limit conclusions based on medication use. The number of postoperative medications was slightly higher in the resident group than in the attending group
at the 1-month and 6-month follow-up visits; however, the number was similar between groups at the 1-year follow-up. For attending surgeons included in this study (J.S.M., M.R.R., D.L.), general practice patterns included a trial of no drops after postoperatively. The resident group had less long-term experience with implanting the iStent and might have been more hesitant to perform such a trial. The overall number of medications in both groups was slightly higher than in other studies. Craven et al.20 found a mean IOP of 17.0 G 2.8 mm Hg with a mean of 0.2 G 0.6 medications at 1 year. Fea17 found that a mean of 0.4 G 0.7 medications at 15 months. Our mean IOP was lower (14.8 G 3.2 mm Hg attending group; 14.0 G 3.1 mm Hg resident group) at 1 year; however, more medications were required. We speculate that our tertiary referral center might have a higher proportion of patients with more advanced glaucoma. As a result, our cohort might have included a greater proportion of patients with more progression of glaucoma requiring a lower target IOP and more medications to reach that IOP. Other studies12,14 have directly compared resident outcomes with attending outcomes for trabeculectomy and tube shunt surgery and found them to be similar between the groups. In a study of trabeculectomies performed at Birmingham and Midland Eye Hospital in the United Kingdom, Morell et al.12 reported surgical success (IOP
Table 2. Number of patients achieving IOP reduction endpoints at most recent follow-up visit. Patients, n (%) Parameter IOP reduction R20% without medications IOP %21 mm Hg without medications IOP %21 mm Hg with medications IOP Z intraocular pressure
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Resident Surgeons
Attending Surgeons
P Value
3 (10) 11 (35) 30 (97)
14 (15) 37 (40) 85 (92)
.17 .44 .66
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!21.0 mm Hg without progression) in 85% of resident cases and 92% of attending cases (P Z .96). Similarly, Kwong et al.11 found no statistical difference in the success rates of trabeculectomies performed by residents and casematched control trabeculectomies performed by attending surgeons at Jules Stein Eye Institute in Los Angeles, California, USA. A study by Thangamathesvaran et al.14 compared tube shunt surgery performed by residents with surgeries on case-matched controls performed by attendings. The attending group had a significantly lower IOP and number of medications at 3 months; however, there was no significant difference between the 2 groups at the 1-year follow-up visit. The baseline characteristics in our study, except for race, were similar between the attending group and resident group. The resident group had significantly more black patients, which might have confounded our results. Our resident clinic aims to help serve uninsured patients in Philadelphia, Pennsylvania, USA. Previous studies21,22 have shown variability in health insurance coverage between racial and ethnic groups, with black patients being less likely to have health insurance. Other studies have also shown that patients of resident physicians were more likely to be black.21 Regarding intraoperative complications, the resident group had 1 case of iridodialysis during microbypass stent implantation. This was caused when the patient suddenly moved her head during surgery. Because residents take longer to perform ophthalmic surgery and have less experience with patient movement, it is possible that the additional time required for surgery might result in more opportunity for additional complications secondary to patient movement. This patient had no major long-term complications. She did not have bothersome symptoms and declined cosmetic repair of the iridodialysis. The number of postoperative hyphema cases was similar between the 2 groups. The single case later requiring trabeculectomy for high IOP was in the attending group. This study did not address the learning curve of the iStent use after residency with regard to early cases in the absence of an attending surgeon. The literature on glaucoma surgery by recently graduated residents compared with that of established or older surgeons is lacking. A recent study of Canadian cataract surgeons23 found a higher rate of complications in the first year of independent practice. Further research is needed to determine the outcomes and complication rates of ophthalmologists performing microbypass stent implantation immediately after residency. Given the increasing popularity of microbypass stent implantation, residency is the optimum time to gain experience in performing angle surgery. Resident-performed iStent surgery resulted in to a decrease in the mean IOP and mean number of hypotensive medications compared with baseline. In our study, the efficacy and safety of microbypass stent were similar between cases
performed by resident trainees and those performed by attending surgeons.
WHAT WAS KNOWN Ophthalmology resident trainees are required to become proficient in cataract and glaucoma surgery during their training. Studies have shown that residents have similar outcomes to those of attending surgeons for cataract, trabeculectomy, and tube shunt surgery.
WHAT THIS PAPER ADDS Surgical implantation of a microbypass stent by a resident supervised by an attending surgeon improved visual acuity, decreased the mean intraocular pressure, and decreased the mean number of glaucoma medications at final follow-up compared with baseline. Surgical outcomes and safety of microbypass stent implantation by resident trainees were similar to those of attending surgeons.
REFERENCES 1. Menda SA, Driver TH, Neiman AE, Blumberg S, Naseri A, Stewart JM. Risk factors for return to the operating room after resident-performed cataract surgery. Semin Ophthalmol 2018; 33:210–214 2. Finn AP, Borboli-Gerogiannis S, Brauner S, Peggy Chang H-Y, Chen S, Gardiner M, Greenstein SH, Kloek C, Miller JW, Chen TC. Assessing resident cataract surgery outcomes using Medicare physician quality reporting system measures. J Surg Educ 2016; 73:774–779 3. Moustafa GA, Borkar DS, McKay KM, Eton EA, Koulisis N, Lorch AC, Kloek CE, the PCIOL Study Group. Outcomes in resident-performed cataract surgeries with iris challenges: results from the Perioperative Care for Intraocular Lens Study. J Cataract Refract Surg 2018; 44:1469–1477 4. Payal AR, Gonzalez-Gonzalez LA, Chen X, Cakiner-Egilmez T, Chomsky A, Baze E, Vollman D, Lawrence MG, Daly MK. Outcomes of cataract surgery with residents as primary surgeons in the Veterans Affairs Healthcare System. J Cataract Refract Surg 2016; 42:370–384 5. Schmidt CM, Sundararajan M, Biggerstaff KS, Orengo-Nania S, Coffee RE, Khandelwal SS. Indications and outcomes of resident-performed cataract surgery requiring return to the operating room. J Cataract Refract Surg 2016; 42:385–391 6. Puri S, Kiely AE, Wang J, Woodfield AS, Ramanathan S, Sikder S. Comparing resident cataract surgery outcomes under novice versus experienced attending supervision. Clin Ophthalmol 2015; 9:1675–1681 7. Moore DB, Slabaugh MA. Surgical outcomes and cost basis for residentperformed cataract surgery in an uninsured patient population. JAMA Ophthalmol 2013; 131:891–897 8. Hashemi H, Mohammadpour M, Jabbarvand M, Nezamdoost Z, Ghadimi H. Incidence of and risk factors for vitreous loss in residentperformed phacoemulsification surgery. J Cataract Refract Surg 2013; 39:1377–1382 9. Khatibi A, Naseri A, Stewart JM. Rate of rhegmatogenous retinal detachment after resident-performed cataract surgery is similar to that of experienced surgeons [letter]. Br J Ophthalmol 2008; 92:438 10. Chan CK, Lee S, Sangani P, Lin L-W, Lin MS, Lin SC. Primary trabeculectomy surgery performed by residents at a county hospital. J Glaucoma 2007; 16:52–56 11. Kwong A, Law SK, Kule RR, Nouri-Mahdavi K, Coleman AL, Caprioli J, Giaconi JA. Long-term outcomes of resident- versus attendingperformed primary trabeculectomy with mitomycin C in a United States residency program. Am J Ophthalmol 2014; 157:1190–1201 12. Morrell AJ, Searle AET, O’Neill EC. Trabeculectomy as an introduction to intraocular surgery in an ophthalmic training program. Ophthalmic Surg 1989; 20:557–560 13. Connor MA, Knape RM, Oltmanns MH, Smith MF. Trainee glaucoma surgery: experience with trabeculectomy and glaucoma drainage devices. Ophthalmic Surg Lasers Imaging 2010; 41:523–531
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14. Thangamathesvaran L, Crane E, Modi K, Khouri AS. Outcomes of residentversus attending-performed tube shunt surgeries in a United States residency program. J Curr Glaucoma Pract 2018; 12:53–58 15. Desai RU, Pekmezci M, Tam D, Song J, Lin SC. Resident-performed Ahmed glaucoma valve surgery. Ophthalmic Surg Lasers Imaging 2010; 41:222–227 16. Samuelson TW, Katz LJ, Wells JM, Duh Y-J, Giampocaro JE, for the US iStent Study Group. Randomized evaluation of the trabecular micro-bypass stent with phacoemulsification in patients with glaucoma and cataract. Ophthalmology 2011; 118:459–467 17. Fea AM. Phacoemulsification versus phacoemulsification with microbypass stent implantation in primary open-angle glaucoma; randomized double-masked clinical trial. J Cataract Refract Surg 2010; 36:407–412 18. Malvankar-Mehta MS, Iordanous Y, Chen YN, Wang WW, Patel SS, Costella J, Hutnik CML. iStent with phacoemulsification versus phacoemulsification alone for patients with glaucoma and cataract: a meta-analysis. PLoS One 2015; 10 (7):e0131770 19. Le K, Saheb H. iStent trabecular micro-bypass stent for open-angle glaucoma. Clin Ophthalmol 2014; 8:1937–1945 20. Craven ER, Katz LJ, Wells JM, Giamporcaro JE, for the iStent Study Group. Cataract surgery with trabecular micro-bypass stent implantation in patients with mild-to-moderate open-angle glaucoma and cataract: twoyear follow-up. J Cataract Refract Surg 2012; 38:1339–1345 21. Yancy WS Jr, Macpherson DS, Hanusa BH, Switzer GE, Arnold RM, Buranosky RA, Kapoor WN. Patient satisfaction in resident and attending ambulatory care clinics. J Gen Intern Med 2001; 16:755–762 22. Sohn H. Racial and ethnic disparities in health insurance coverage: dynamics of gaining and losing coverage over the life-course. Popul Res Policy Rev 2017; 36:181–201 23. Campbell RJ, El-Defrawy SR, Gill SS, Whitehead M, Campbell EL, Hooper PL, Bell CM, ten Hove M. New surgeon outcomes and the effectiveness of surgical training; a population-based cohort study. Ophthalmology 2017; 124:532–538; erratum, 1879
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OTHER CITED MATERIAL A. Accreditation Council for Graduate Medical Education. Ophthalmology. Case Logs Statistical Reports. National Data Report. 2010-2018. Available at: https://www.acgme.org/Data-Collection-Systems/Case-LogStatistical-Reports. Accessed August 29, 2019 B. Jeffreys’s Amazing Statistics Program. JASP 0.10.2. Available at: https: //jasp-stats.org/download/. Accessed August 29, 2019
Disclosures: Dr. Myers has received grants and personal fees from Aerie Pharmaceuticals, Alcon Laboratories, Inc., Allergan, Inc., and Glaukos Corp. He has received consultation fees from Iridex Corp. and MicroOptx and grant support from Bausch & Lomb, Inc., Diopsys, Inc., Novartis Corp., and Sight Sciences. Dr. Katz has received grants and consultation fees from Aerie Pharmaceuticals, Alcon Laboratories, Inc., Allergan, Inc., Bausch & Lomb, Inc., Diopsys, Inc. and Mati Therapeutics, Inc. He has received consultation fees from Aerpio Therapeutics, Inc., Alimera Sciences, and Glaukos Corp. and grant support from Heidelberg Engineering, Inc. He has ownership interest in Aerie Pharmaceuticals, Glaukos Corp., Mati Therapeutics, Inc., and Olleyes, Inc. None of the other authors has a financial or proprietary interest in any material or methods mentioned.
First author: Cindy X. Zheng, MD Wills Eye Hospital, Philadelphia, Pennsylvania, USA