Publications by authors named "Ayman Naseri"

40 Publications

Comparative Effectiveness of Carotid Endarterectomy vs Initial Medical Therapy in Patients With Asymptomatic Carotid Stenosis.

JAMA Neurol 2020 09;77(9):1110-1121

Department of Medicine, Indiana University School of Medicine, Indianapolis.

Importance: Carotid endarterectomy (CEA) among asymptomatic patients involves a trade-off between a higher short-term perioperative risk in exchange for a lower long-term risk of stroke. The clinical benefit observed in randomized clinical trials (RCTs) may not extend to real-world practice.

Objective: To examine whether early intervention (CEA) was superior to initial medical therapy in real-world practice in preventing fatal and nonfatal strokes among patients with asymptomatic carotid stenosis.

Design, Setting, And Participants: This comparative effectiveness study was conducted from August 28, 2018, to March 2, 2020, using the Corporate Data Warehouse, Suicide Data Repository, and other databases of the US Department of Veterans Affairs. Data analyzed were those of veterans of the US Armed Forces aged 65 years or older who received carotid imaging between January 1, 2005, and December 31, 2009. Patients without a carotid imaging report, those with carotid stenosis of less than 50% or hemodynamically insignificant stenosis, and those with a history of stroke or transient ischemic attack in the 6 months before index imaging were excluded. A cohort of patients who received initial medical therapy and a cohort of similar patients who received CEA were constructed and followed up for 5 years. The target trial method was used to compute weighted Kaplan-Meier curves and estimate the risk of fatal and nonfatal strokes in each cohort in the pragmatic sample across 5 years of follow-up. This analysis was repeated after restricting the sample to patients who met RCT inclusion criteria. Cumulative incidence functions for fatal and nonfatal strokes were estimated, accounting for nonstroke deaths as competing risks in both the pragmatic and RCT-like samples.

Exposures: Receipt of CEA vs initial medical therapy.

Main Outcomes And Measures: Fatal and nonfatal strokes.

Results: Of the total 5221 patients, 2712 (51.9%; mean [SD] age, 73.6 [6.0] years; 2678 men [98.8%]) received CEA and 2509 (48.1%; mean [SD] age, 73.6 [6.0] years; 2479 men [98.8%]) received initial medical therapy within 1 year after the index carotid imaging. The observed rate of stroke or death (perioperative complications) within 30 days in the CEA cohort was 2.5% (95% CI, 2.0%-3.1%). The 5-year risk of fatal and nonfatal strokes was lower among patients randomized to CEA compared with patients randomized to initial medical therapy (5.6% vs 7.8%; risk difference, -2.3%; 95% CI, -4.0% to -0.3%). In an analysis that incorporated the competing risk of death, the risk difference between the 2 cohorts was lower and not statistically significant (risk difference, -0.8%; 95% CI, -2.1% to 0.5%). Among patients who met RCT inclusion criteria, the 5-year risk of fatal and nonfatal strokes was 5.5% (95% CI, 4.5%-6.5%) among patients randomized to CEA and was 7.6% (95% CI, 5.7%-9.5%) among those randomized to initial medical therapy (risk difference, -2.1%; 95% CI, -4.4% to -0.2%). Accounting for competing risks resulted in a risk difference of -0.9% (95% CI, -2.9% to 0.7%) that was not statistically significant.

Conclusions And Relevance: This study found that the absolute reduction in the risk of fatal and nonfatal strokes associated with early CEA was less than half the risk difference in trials from 20 years ago and was no longer statistically significant when the competing risk of nonstroke deaths was accounted for in the analysis. Given the nonnegligible perioperative 30-day risks and the improvements in stroke prevention, medical therapy may be an acceptable therapeutic strategy.
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http://dx.doi.org/10.1001/jamaneurol.2020.1427DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7265126PMC
September 2020

Gender Differences in Case Volume Among Ophthalmology Residents.

JAMA Ophthalmol 2019 Sep;137(9):1015-1020

Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, New York.

Importance: Although almost equal numbers of male and female medical students enter into ophthalmology residency programs, whether they have similar surgical experiences during training is unclear.

Objective: To determine differences for cataract surgery and total procedural volume between male and female residents during ophthalmology residency.

Design, Setting, Participants: This retrospective, longitudinal analysis of resident case logs from 24 US ophthalmology residency programs spanned July 2005 to June 2017. A total of 1271 residents were included. Data were analyzed from August 12, 2017, through April 4, 2018.

Main Outcomes And Measures: Variables analyzed included mean volumes of cataract surgery and total procedures, resident gender, and maternity or paternity leave status.

Results: Among the 1271 residents included in the analysis (815 men [64.1%]), being female was associated with performing fewer cataract operations and total procedures. Male residents performed a mean (SD) of 176.7 (66.2) cataract operations, and female residents performed a mean (SD) of 161.7 (56.2) (mean difference, -15.0 [95% CI, -22.2 to -7.8]; P < .001); men performed a mean (SD) of 509.4 (208.6) total procedures and women performed a mean (SD) of 451.3 (158.8) (mean difference, -58.1 [95% CI, -80.2 to -36.0]; P < .001). Eighty-five of 815 male residents (10.4%) and 71 of 456 female residents (15.6%) took parental leave. Male residents who took paternity leave performed a mean of 27.5 (95% CI, 13.3 to 41.6; P < .001) more cataract operations compared with men who did not take leave, but female residents who took maternity leave performed similar numbers of operations as women who did not take leave (mean difference, -2.0 [95% CI, -18.0 to 14.0]; P = .81). From 2005 to 2017, each additional year was associated with a 5.5 (95% CI, 4.4 to 6.7; P < .001) increase in cataract volume and 24.4 (95% CI, 20.9 to 27.8; P < .001) increase in total procedural volume. This increase was not different between genders for cataract procedure volume (β = -1.6 [95% CI, -3.7 to 0.4]; P = .11) but was different for total procedural volume such that the increase in total procedural volume over time for men was greater than that for women (β = -8.0 [95% CI, -14.0 to -2.1]; P = .008).

Conclusions And Relevance: Female residents performed 7.8 to 22.2 fewer cataract operations and 36.0 to 80.2 fewer total procedures compared with their male counterparts from 2005 to 2017, a finding that warrants further exploration to ensure that residents have equivalent surgical training experiences during residency regardless of gender. However, this study included a limited number of programs (24 of 119 [20.2%]). Future research including all ophthalmology residency programs may minimize the selection bias issues present in this study.
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http://dx.doi.org/10.1001/jamaophthalmol.2019.2427DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6646997PMC
September 2019

A Painful Red Eye.

JAMA Ophthalmol 2018 Mar;136(3):299-300

Department of Ophthalmology, University of California, San Francisco.

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http://dx.doi.org/10.1001/jamaophthalmol.2017.4167DOI Listing
March 2018

Early Reoperation Rate, Complication, and Outcomes in Resident-performed Glaucoma Surgery.

J Glaucoma 2017 Feb;26(2):87-92

Department of Ophthalmology, San Francisco School of Medicine, University of California, San Francisco, CA.

Purpose Of The Study: The purpose of the study was to examine reoperation rate and complications of resident-performed glaucoma surgeries within the first 90 postoperative days.

Materials And Methods: A retrospective study of resident-performed glaucoma filtering surgeries at the San Francisco Veterans Affairs Medical Center between 2002 and 2014 was performed. Patients requiring reoperation within 90 days of the initial surgery were included in our study. Combined surgeries were excluded. Complications and the rates of reoperation within the first 90 days were evaluated. Clinical outcomes for those who needed reoperations were evaluated at the 1-year follow-up.

Results: Total of 180 cases were reviewed [34 trabeculectomy, 85 Ex-PRESS shunt, and 61 Ahmed glaucoma valve (AGV)]. One hundred and four eyes developed complications, most commonly choroidal effusion (65.3%), followed by hypotony (45.2%) and wound leak (32.7%). Complications were comparable among the 3 groups, except that filtering surgery had significantly more wound leak than AGV (P<0.001). Seven (3.9%) cases required reoperation within first 90 days. There was no reoperation for trabeculectomy group. Reoperation rate was 4.7% for Ex-PRESS and 4.9% for AGV (P=0.74). Indications for reoperation were persistent wound leak (4 cases) and tube occlusion/revision (3 cases). For the 7 patients who required reoperations, their intraocular pressure at 1-year postreoperation was significantly decreased compared with intraocular pressure before the initial glaucoma surgery (P<0.001) with similar number of glaucoma medications and stable visual acuity.

Conclusions: Glaucoma incisional surgeries performed by third-year ophthalmology residents had acceptable and comparable reoperation rates and complication rates for patients with trabeculectomy, Ex-PRESS, and AGV. Clinical outcomes for the patients requiring reoperation were favorable.
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http://dx.doi.org/10.1097/IJG.0000000000000533DOI Listing
February 2017

Risk Factors for Return to the Operating Room after Resident-Performed Cataract Surgery.

Semin Ophthalmol 2018 29;33(2):210-214. Epub 2016 Sep 29.

a Department of Ophthalmology , University of California, San Francisco , San Francisco , CA , USA.

Objective: Investigate risk factors for unplanned return to the operating room after resident-performed cataract surgery.

Design: Retrospective case-control study.

Setting: Institutional.

Methods: Study population: All patients with reoperation within 90 days of resident-performed phacoemulsification were matched to four control eyes which had surgery within 30 days of the reoperation at the same institution.

Observation Procedure: Billing codes were used to identify all patients who underwent resident-performed intended phacoemulsification with intraocular lens placement from January 2005 to December 2010.

Main Outcome Measures: Investigated risk factors for reoperation included cataract characteristics and preexisting ocular co-morbidities, including diabetic retinopathy, retinal detachment history, glaucoma, corneal pathology, and uveitis. Additional preoperative risk factors studied included resident training year, history of tamsulosin use, phacodonesis, pupillary dilation, presence of pseudoexfoliation, myopia, history of trauma, visual acuity, and monocular status. Intraoperative variables were the use of iris expansion devices, use of capsular stain, attending type, incision type, use of sutures, vitreous loss, anesthesia type, and phacoemulsification technique.

Results: There were 67 returns to the operating room (i.e., cases) over five years that were assigned to 268 control eyes. In preoperative multivariate analysis, phacoemulsification done by a first- or second-year resident (OR 3.2, 95% CI: 1.7-6.0, p < 0.001) was associated with an increased risk of reoperation. In postoperative multivariate analysis, only the use of the divide-and-conquer technique (OR 4.0, 95% CI:1.7-9.2, p = 0.001) was associated with an increased risk of reoperation.

Conclusions: Phacoemulsification done by a junior resident or using the divide-and-conquer technique had the highest risk of reoperation.
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http://dx.doi.org/10.1080/08820538.2016.1208760DOI Listing
April 2018

Effect of mitomycin c and 5-flurouracil adjuvant therapy on the outcomes of Ahmed glaucoma valve implantation.

Clin Exp Ophthalmol 2017 Mar 1;45(2):128-134. Epub 2016 Sep 1.

Department of Ophthalmology, University of California, San Francisco, California, USA.

Background: To examine the effect of mitomycin c and 5-flurouracil on treatment outcomes following Ahmed glaucoma valve implantation.

Design: Retrospective consecutive case series.

Participants: Fifty patients who received Ahmed glaucoma valve implantation from 1999 to 2013 in the San Francisco Veterans Administration Hospital.

Methods: The +INJECTION group received intraoperative mitomycin c followed by postoperative mitomycin c and/or 5-flurouracil, whereas the -INJECTION group did not.

Main Outcome Measures: Primary outcome was treatment success at 1 year post-implantation. Intraocular pressure, hypertensive phase, and the number of glaucoma medications were also examined.

Results: Twenty-six patients/eyes in the +INJECTION group and 24 patients/eyes in the -INJECTION group were included. Treatment success was higher in the +INJECTION compared with the -INJECTION group (86 vs. 58%; P = 0.04). Intraocular pressure was lower in the +INJECTION compared with the -INJECTION group at 1, 3, 6 and 12 months (P ≪ 0.00001, P = 0.00003, 0.0008 and 0.024). Hypertensive phase occurred less often in the +INJECTION compared with the -INJECTION group (3.8 vs. 54%; P = 0.021). The +INJECTION group required fewer medications compared with the -INJECTION group (P = 0.02, 0.002, 0.003 and 0.008 at 1, 3, 6 and 12 months). Complication rates were comparable between groups (46.2 and 54.2%; P = 0.63).

Conclusions: Adjuvant treatment with antifibrotics following Ahmed glaucoma valve implantation decreased the hypertensive phase and improved surgical outcomes without impacting complication rates at 1 year. This study postulates a role for antifibrotics in the postoperative management of Ahmed glaucoma valves.
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http://dx.doi.org/10.1111/ceo.12811DOI Listing
March 2017

Common Reasons That Asymptomatic Patients Who Are 65 Years and Older Receive Carotid Imaging.

JAMA Intern Med 2016 05;176(5):626-33

Veterans Health Administration Health Services Research and Development Service Center of Excellence on Implementing Evidence-Based Practice, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana8Department of Internal Medicine, Indi.

Importance: National guidelines do not agree on the role of carotid screening in asymptomatic patients (ie, patients who have not had a stroke or transient ischemic attack). Recently, several physician organizations participating in the Choosing Wisely campaign have identified carotid imaging in selected asymptomatic populations as being of low value. However, the majority of patients who are evaluated for carotid stenosis and subsequently revascularized are asymptomatic.

Objective: To better understand why asymptomatic patients who undergo revascularization receive initial carotid imaging.

Design, Setting, And Participants: Retrospective cohort study of 4127 Veterans Health Administration patients 65 years and older undergoing carotid revascularization for asymptomatic carotid stenosis between 2005 and 2009.

Main Outcomes And Measures: Indications for carotid ultrasounds were extracted using trained abstractors. Frequency of indications and appropriateness of initial carotid ultrasound imaging for patients within each rating category after the intervention were reported.

Results: The mean (SD) age of this cohort of 4127 patients was 73.6 (5.9) years; 4014 (98.8%) were male. Overall, there were 5226 indications for 4063 carotid ultrasounds. The most common indications listed were carotid bruit (1578 [30.2% of indications]) and follow-up for carotid disease (stenosis/history of carotid disease) in patients who had previously documented carotid stenosis (1087 [20.8% of indications]). Multiple vascular risk factors were the next most common indication listed. Rates of appropriate, uncertain, and inappropriate imaging were 5.4% (227 indications), 83.4% (3387 indications), and 11.3% (458 indications), respectively. Among the most common inappropriate indications were dizziness/vertigo and syncope. Among the 4063 patients, 3373 (83.0%) received a carotid endarterectomy. Overall, 663 procedures were performed in patients 80 years and older.

Conclusions And Relevance: Carotid bruit and follow-up for carotid disease accounted for approximately half of all indications provided by physicians for carotid testing. Strong consideration should be given to improving the evidence base around carotid testing, especially around monitoring stenosis over long periods and evaluating carotid bruits. Targeting carotid ultrasound ordering with decision support tools may also be an important step in reducing use of low-value imaging.
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http://dx.doi.org/10.1001/jamainternmed.2016.0678DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5156480PMC
May 2016

A Comparison of Resident-performed Argon and Selective Laser Trabeculoplasty in Patients With Open-angle Glaucoma.

J Glaucoma 2016 Mar;25(3):e157-61

*Department of Ophthalmology ‡Francis I. Proctor Foundation §Department of Epidemiology and Biostatistics, Division of Preventive Medicine and Public Health, University of California San Francisco ∥Department of Ophthalmology, San Francisco Veterans Affairs Medical Center, San Francisco, CA †Department of Ophthalmology, Oregon Health and Science University, Portland, OR.

Purpose: To compare intraocular pressure (IOP) reduction and complications of resident-performed argon laser trabeculoplasty (ALT) and selective laser trabeculoplasty (SLT).

Patients And Methods: This was a retrospective, interventional, comparative case series performed at the San Francisco Veterans Affairs Hospital. The study included 77 patients each undergoing 1 resident-performed ALT procedure from April 2006 through November 2009, and 81 patients each undergoing 1 resident-performed SLT procedure from November 2009 through December 2011. Reduction in IOP at 12 months and a longitudinal analysis across 24 months was determined. Secondary outcomes investigated included additional interventions of either repeat trabeculoplasty or trabeculectomy as well as change in eye drop medications.

Results: There was no evidence of a difference between IOP reductions in patients undergoing ALT compared with SLT at 12 months (P=0.41, linear modeling) or across all follow-up appointments (P=0.62, linear-mixed effects regression). Patients undergoing ALT had a significantly increased number of eye drops (+0.6 vs. -0.1 drops, P<0.001, Wilcoxon rank-sum test) and trend toward increased rates of additional interventions (P=0.06, Weibull regression). There was no difference in immediate postprocedure IOP rise between the 2 groups (P=0.75, Wilcoxon rank-sum test) or any evidence of change in visual acuity.

Conclusions: We found no difference in IOP reduction between patients undergoing resident-performed ALT compared with SLT. However, patients undergoing ALT had a significant increase in eye drop medications and trend toward additional interventions compared with patients undergoing SLT.
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http://dx.doi.org/10.1097/IJG.0000000000000207DOI Listing
March 2016

Benefits of and barriers to immediate sequential cataract surgery.

JAMA Ophthalmol 2014 Nov;132(11):1362-3

Department of Ophthalmology, University of California, San Francisco.

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http://dx.doi.org/10.1001/jamaophthalmol.2014.3637DOI Listing
November 2014

Resident-performed selective laser trabeculoplasty in patients with open-angle glaucoma.

JAMA Ophthalmol 2014 Apr;132(4):403-8

Department of Ophthalmology, University of California, San Francisco4Francis I. Proctor Foundation, University of California, San Francisco5Department of Ophthalmology, San Francisco VA Medical Center, San Francisco, California.

IMPORTANCE To our knowledge, this is the first study to investigate effectiveness and complication rates of resident-performed selective laser trabeculoplasty (SLT). OBJECTIVES To evaluate the effectiveness and complications of SLT performed by resident ophthalmologists and to identify predictors for success. DESIGN, SETTING, AND PARTICIPANTS Retrospective case series of 81 patients with open-angle glaucoma undergoing 110 SLT procedures from November 17, 2009, through December 16, 2011, at the San Francisco Veterans Affairs Medical Center. INTERVENTION Resident-performed SLT. MAIN OUTCOMES AND MEASURES Intraocular pressure (IOP) reduction. Secondary outcomes included change in eyedrop medications, complication rates, and predictors of SLT success defined as a 20% reduction in IOP. RESULTS The mean IOP at baseline, defined as the average IOP of the 2 appointments prior to the SLT procedure, was 18.7 mm Hg. The mean decrease in postoperative IOP compared with baseline was 2.2 mm Hg (12%; 95% CI, 5%-19%) at 12 months and 3.3 mm Hg (18%; 95% CI, 13%-23%), 2.8 mm Hg (15%; 95% CI, 10%-21%), and 3.6 mm Hg (19%; 95% CI, 11%-27%) at 3, 6, and 24 months, respectively (all P < .001, linear mixed-effects regression). Success rates were 36% (95% CI, 27%-47%) at 12 months and 41% (95% CI, 31%-53%), 50% (95% CI, 40%-60%), and 39% (95% CI, 26%-53%) at 3, 6, and 24 months, respectively. The most common complication was a temporary IOP spike, with increases of at least 6 mm Hg occurring in 7% (95% CI, 4%-14%) of the population. The largest IOP spike was 11 mm Hg. Increased number of laser shots performed was not associated with better IOP control but was associated with a reduction in number of eyedrop medications (P = .02). Increased baseline IOP was associated with an odds ratio for success of 1.24 (95% CI, 1.08-1.44) at 3 months, 1.20 (95% CI, 1.05-1.37) at 6 months, and 1.31 (95% CI, 1.13-1.53) at 12 months of follow-up (P = .003, P = .006, and P < .001, respectively, logistic regression). In a multivariate analysis, baseline IOP remained the greatest predictor of effectiveness. CONCLUSIONS AND RELEVANCE Resident-performed SLT obtains outcomes similar to the IOP reduction reported in the literature for attending-performed SLT with low levels of complications. Increasing the number of shots in a treatment session may lead to less long-term need for eyedrop medications. In this patient group, higher baseline IOP was the strongest predictor of treatment effectiveness.
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http://dx.doi.org/10.1001/jamaophthalmol.2013.7651DOI Listing
April 2014

Predictors of matching in ophthalmology residency for international medical graduates.

Ophthalmology 2014 Apr 13;121(4):974-975.e2. Epub 2014 Jan 13.

Department of Ophthalmology, University of California, San Francisco, San Francisco, California; Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California; Department of Ophthalmology, San Francisco Veterans Administration Medical Center, San Francisco, California.

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http://dx.doi.org/10.1016/j.ophtha.2013.11.024DOI Listing
April 2014

Return to the operating room after resident-performed cataract surgery.

JAMA Ophthalmol 2014 Feb;132(2):223-4

Department of Ophthalmology, University of California, San Francisco2Department of Ophthalmology, San Francisco General Hospital, San Francisco, California.

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http://dx.doi.org/10.1001/jamaophthalmol.2013.5675DOI Listing
February 2014

Cost comparison of scleral buckle versus vitrectomy for rhegmatogenous retinal detachment repair.

Am J Ophthalmol 2013 Oct 20;156(4):661-6. Epub 2013 Jul 20.

Department of Ophthalmology, University of California, San Francisco, San Francisco, California.

Purpose: To estimate and compare the costs of scleral buckle (SB) and pars plana vitrectomy (PPV) for treatment of rhegmatogenous retinal detachment (RRD).

Design: Cost analysis based on published prospective data comparing SB and PPV for RRD repair.

Methods: The costs of initial surgery, postoperative retina-affecting procedures, and eventual cataract extraction resulting from SB and PPV for RRD repair were estimated for both phakic and pseudophakic or aphakic patients and then were compared. A univariate sensitivity analysis also was performed to examine the sensitivity of our estimations.

Results: When considering all costs, SB was 10.7% less expensive than PPV for RRD repair in phakic patients, whereas PPV was 12% less expensive than SB for RRD repair in pseudophakic or aphakic patients. These conclusions were robust in the sensitivity analysis.

Conclusions: SB seems to offer a modest cost savings over PPV for repair of RRD in phakic patients. However, in pseudophakic and aphakic patients, PPV seems to be less expensive than SB.
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http://dx.doi.org/10.1016/j.ajo.2013.05.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6141238PMC
October 2013

Predictors of matching in an ophthalmology residency program.

Ophthalmology 2013 Apr 20;120(4):865-70. Epub 2012 Dec 20.

Department of Ophthalmology, University of California San Francisco, San Francisco, California 94121, USA.

Purpose: To examine the characteristics of US medical students applying for ophthalmology residency and to determine the predictors of matching.

Design: A retrospective case series.

Participants: A total of 3435 medical students from the United States who applied to an ophthalmology residency program from 2003 to 2008 were included.

Methods: Matched and unmatched applicants were compared and stratified by predictor variables, including United States Medical Licensing Examination (USMLE) Step 1 score, Alpha Omega Alpha (AOA) status, medical school reputation, and medical school geographic region. Differences in proportions were analyzed using the Fisher exact test. Logistic regression was used to determine the predictors of successful matching.

Main Outcome Measures: Successful matching to an ophthalmology program.

Results: The majority of applicants (72%, 2486/3435) matched in ophthalmology. In multivariate analysis, AOA membership (odds ratio [OR], 2.6, P<0.0001), USMLE score (OR, 1.6; P<0.0001), presence of an ophthalmology residency at medical school (OR, 1.4; P = 0.01), top 25 medical school (OR, 1.4; P<0.03), top 10 medical school (OR, 1.6; P<0.02), and allopathic degree (OR, 4.0; P<0.0001) were statistically significant predictors of matching. Approximately 60% (1442/2486) of applicants matched to the same geographic region as their medical school. Applicants were more likely to match at a program in the same geographic region as their medical school than would be predicted by chance alone (P<0.0001). In multivariate analysis, higher USMLE score (OR, 0.9; P<0.0001) and top 10 medical school (OR, 0.7; P = 0.027) were statistically significant predictors of matching to outside the geographic region as one's medical school.

Conclusions: The majority of applicants applying for an ophthalmology residency position match successfully. Higher performance on quantitative metrics seems to confer an advantage for matching. The majority of applicants match at a residency program within the same geographic region as one's medical school.
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http://dx.doi.org/10.1016/j.ophtha.2012.09.028DOI Listing
April 2013

Technique for shortening a long clear corneal incision.

Arch Ophthalmol 2012 Dec;130(12):1589-90

An optimal clear corneal incision creates a self-sealing intrastomal tunnel. Variability in incision length may pose surgical difficulties for subsequent phacoemulsification. An incision that is too long may lead to challenges including decreased instrument mobility, decreased visibility due to corneal striae, stromal hydration, and a difficult angle of approach to the cataract. These sequelae may lead to surgical complications or abandonment of the original incision. We describe a technique for shortening a long clear corneal incision with the intentional creation of a flap of corneal tissue at the posterior internal wound edge. This technique is a simple and quick modification that may avoid the pitfalls of an incision that is too long.
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http://dx.doi.org/10.1001/archophthalmol.2012.2536DOI Listing
December 2012

Surgeon cataract volume and endophthalmitis.

Authors:
Ayman Naseri

Ophthalmology 2012 Nov;119(11):2415; author reply 2416

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http://dx.doi.org/10.1016/j.ophtha.2012.07.013DOI Listing
November 2012

A multicenter analysis of the ophthalmic knowledge assessment program and American Board of Ophthalmology written qualifying examination performance.

Ophthalmology 2012 Oct 28;119(10):1949-53. Epub 2012 Jul 28.

Department of Ophthalmology, The Methodist Hospital, Houston, Texas, USA.

Objective: To compare the performance on the American Board of Ophthalmology Written Qualifying Examination (WQE) with the performance on step 1 of the United States Medical Licensing Examination (USMLE) and the Ophthalmic Knowledge Assessment Program (OKAP) examination for residents in multiple residency programs.

Design: Comparative case series.

Participants: Fifteen residency programs with 339 total residents participated in this study. The data were extracted from the 5-year American Board of Ophthalmology report to each participating program in 2009 and included residency graduating classes from 2003 through 2007. Residents were included if data were available for the USMLE, OKAP examination in ophthalmology years 1 through 3, and the WQE score. Residents were excluded if one or more of the test scores were not available.

Methods: Two-sample t tests, logistic regression analysis, and receiver operating characteristic (ROC) curves were used to examine the association of the various tests (USMLE, OKAP examination year 1, OKAP examination year 2, OKAP examination year 3, and maximum OKAP examination score) as a predictor for a passing or failing grade on the WQE.

Main Outcome Measures: The primary outcome measure of this study was first time pass rate for the WQE.

Results: Using ROC analysis, the OKAP examination taken at the third year of ophthalmology residency best predicted performance on the WQE. For the OKAP examination taken during the third year of residency, the probability of passing the WQE was at least 80% for a score of 35 or higher and at least 95% for a score of 72 or higher.

Conclusions: The OKAP examination, especially in the third year of residency, can be useful to residents to predict the likelihood of success on the high-stakes WQE examination.
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http://dx.doi.org/10.1016/j.ophtha.2012.06.010DOI Listing
October 2012

Patient consent for resident involvement in surgical care.

Authors:
Ayman Naseri

Arch Ophthalmol 2012 Jul;130(7):917-8

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http://dx.doi.org/10.1001/archophthalmol.2012.98DOI Listing
July 2012

Rabbit models for continuous curvilinear capsulorhexis instruction.

J Cataract Refract Surg 2012 Jul;38(7):1266-70

Department of Ophthalmology, University of California San Francisco, San Francisco, California 94143, USA.

Purpose: To develop a rabbit model for continuous curvilinear capsulorhexis (CCC) instruction.

Setting: University of California San Francisco, San Francisco, California, USA.

Design: Experimental study.

Methods: Isolated rabbit lenses were immersed in 2% to 8% paraformaldehyde (PFA) fixative from 15 minutes to 6 hours. Rabbit eyes were treated by substituting aqueous with 2% to 4% PFA for 30 minutes to 6 hours, followed by washes with a balanced salt solution. Treated lenses and eyes were held in purpose-designed holders using vacuum. A panel of 6 cataract surgeons with 5 to 15 years of experience performed CCC on treated lenses and eyes and responded to a questionnaire regarding the utility of these models for resident teaching using a 5-item Likert scale.

Results: The expert panel found that rabbit lenses treated with increasing amounts of fixative simulated CCC on human lens capsules from the third to the seventh decade of life. The panel also found fixative-treated rabbit eyes to simulate some of the experience of CCC within the human anterior chamber but noted a shallower anterior chamber depth, variation in pupil size, and corneal clouding under some treatment conditions.

Conclusions: Experienced cataract surgeons who performed CCC on these rabbit models strongly agreed that isolated rabbit lenses treated with fixative provide a realistic simulation of CCC in human patients and that both models were useful tools for capsulorhexis instruction. Results indicate that rabbit lenses treated with 8% PFA for 15 minutes is a model with good fidelity for CCC training.

Financial Disclosure: No author has a financial or proprietary interest in any material or method mentioned.
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http://dx.doi.org/10.1016/j.jcrs.2012.01.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3383622PMC
July 2012

Assessing the value of simulator training on residency performance.

J Cataract Refract Surg 2012 Jan;38(1):188-9; author reply 189

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http://dx.doi.org/10.1016/j.jcrs.2011.11.014DOI Listing
January 2012

Effect of timing and duration of tamsulosin exposure on complications in resident-performed phacoemulsification.

Ophthalmic Surg Lasers Imaging 2011 Sep-Oct;42(5):416-22. Epub 2011 Jun 9.

Department of Ophthalmology, University of California San Francisco, San Francisco, California 94143, USA.

Background And Objectives: Tamsulosin can cause intraoperative floppy iris syndrome and increase the risk of phacoemulsification complications. This study evaluated whether the risk of complications was associated with the timing or duration of preoperative tamsulosin exposure.

Patients And Methods: The current study was a retrospective review of electronic medical records of resident-performed phacoemulsification surgeries from 1998 to 2008 at a Veterans Administration Hospital. There were 73 eyes with recent tamsulosin exposure (within 30 days preoperatively) and 28 eyes with remote exposure (> 30 days preoperatively but within 3 years of surgery).

Results: There was a trend toward more total complications in recent compared with remote tamsulosin exposure cases (31.5% vs 14.3%, P = .09). A longer duration of tamsulosin use was not statistically associated with an increased risk of total complications.

Conclusion: The authors were unable to detect a statistically significant effect of duration of tamsulosin use on the risk of intraoperative complications in phacoemulsification surgery.
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http://dx.doi.org/10.3928/15428877-20110602-01DOI Listing
November 2011

Resident-performed phacoemulsification surgery in tamsulosin-treated patients.

Arch Ophthalmol 2010 Aug;128(8):967-72

Department of Ophthalmology, University of California, USA.

Objectives: To compare intraoperative complication rates and visual outcomes for patients treated and not treated with tamsulosin hydrochloride who underwent resident-performed phacoemulsification, and to determine whether the recognition of intraoperative floppy iris syndrome in 2005 affected the subsequent complication rates for tamsulosin-treated patients.

Methods: This comparative retrospective cohort study included 101 tamsulosin-treated eyes and 404 non-tamsulosin-treated eyes from January 1, 1998, to August 31, 2008. Main outcome measures were major and minor complication rates and postoperative best-corrected visual acuity. Complication rates were compared between August 11, 1999, to December 31, 2005, and January 1, 2006, to September 3, 2008, for both tamsulosin-treated and non-tamsulosin-treated eyes.

Results: The major complication rates were 3.0% for tamsulosin-treated eyes and 8.9% for non-tamsulosin-treated eyes (P = .08), while the minor complication rates were 24.8% and 12.1%, respectively (P = .002). Both groups had an equal likelihood of attaining better than 20/40 postoperative visual acuities (82.2% vs 82.9%, respectively; P = .85). Frequency of major complications between tamsulosin-treated and non-tamsulosin-treated eyes was 6.0% vs 15.8%, respectively (P = .09), from August 11, 1999, to December 31, 2005, compared with 0.0% vs 2.0%, respectively (P > .99), from January 1, 2006, to September 3, 2008.

Conclusions: Differences in the major complication rates for tamsulosin-treated and non-tamsulosin-treated eyes were not significant, whereas tamsulosin exposure was associated with a significant increase in minor complications. Both groups had similar, good postoperative visual outcomes. After 2005, a reduction in major complications was seen in both groups, attributed to programmatic changes in surgical education. Recognition of intraoperative floppy iris syndrome did not impart a significant additional protective effect in preventing major complications.
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http://dx.doi.org/10.1001/archophthalmol.2010.154DOI Listing
August 2010

Nepafenac-assisted mydriasis in a rabbit model.

J Cataract Refract Surg 2010 Oct 31;36(10):1779-82. Epub 2010 Jul 31.

Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.

Purpose: To compare the effectiveness of nepafenac 0.10% in achieving and maintaining pupil dilation with the effectiveness of flurbiprofen 0.03% and a placebo in a rabbit model.

Setting: Department of Ophthalmology, University of California, San Francisco, California, USA.

Design: Laboratory study.

Methods: Adult pigmented rabbits were randomized to 3 equal-sized groups: placebo, flurbiprofen, and nepafenac. Cataract surgery was performed in randomized order by a surgeon who was masked to group assignment. The treatment or placebo was administered starting 1 day before surgery. Phenylephrine 10.0% was administered starting 30 minutes before surgery. Phacoemulsification was performed in standard fashion. Pupil measurements were recorded before and after surgery. A linear mixed model with a random effect for the rabbits and a fixed effect for the treatment groups was used to compare mean pupil diameters between groups.

Results: Baseline pupil measurements were similar between the placebo, flurbiprofen, and nepafenac groups. Preoperative pupil dilation was statistically significantly greater in the nepafenac group (mean 11.5 mm ± 0.5 [SD]) than in the placebo group (mean 10.2 ± 1.1 mm) and the flurbiprofen group (mean 9.9 ± 1.1 mm) (P<.005 and P<.001, respectively). The greater dilation was maintained at the end of surgery, at which time the nepafenac group had statistically significantly larger pupils (mean 9.4 ± 1.2 mm) than the placebo group (mean 7.9 ± 0.6 mm) and the flurbiprofen group (mean 8.5 ± 0.9 mm) (P<.001 and P<.05, respectively).

Conclusion: Nepafenac was more effective than a placebo and flurbiprofen in achieving maximum preoperative and postoperative pupil mydriasis in rabbits.
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http://dx.doi.org/10.1016/j.jcrs.2010.04.033DOI Listing
October 2010

Prophylaxis of postoperative endophthalmitis following cataract surgery: current status and future directions.

Drugs 2010 Jul;70(11):1395-409

Department of Ophthalmology, University of California San Francisco, San Francisco, California, USA.

Endophthalmitis is an uncommon but potentially devastating intraocular infection that can occur after routine cataract surgery. Although a broad spectrum of organisms have been shown to cause acute postoperative endophthalmitis, most cases are caused by Gram-positive bacteria, which may be introduced at the time of surgery from colonization of adjacent conjunctiva or eyelid skin. Risk factors for the development of endophthalmitis following cataract surgery include patient age, intraoperative surgical complications and poor wound construction. There are several antibacterial strategies employed to prevent postoperative endophthalmitis, with topical, intracameral and subconjunctival delivery being the most common. Worldwide, there seems to be significant regional variance in the type and method of prophylactic antibacterial regimens; for example, topical fluoroquinolones are commonly used in the US, while intracameral cephalosporins are employed widely in Europe. The optimal antibacterial strategy for the prevention of endophthalmitis should be safe, inexpensive and broad in microbiological activity spectrum, while not requiring patient compliance for its effectiveness.
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http://dx.doi.org/10.2165/11537950-000000000-00000DOI Listing
July 2010

Cataract surgery after refractive surgery.

Curr Opin Ophthalmol 2010 Jan;21(1):35-8

Department of Ophthalmology, University of California San Francisco, California 94143, USA.

Purpose Of Review: To review recent contributions addressing the challenge of intraocular lens (IOL) calculation in patients undergoing cataract extraction following corneal refractive surgery.

Recent Findings: Although several articles have provided excellent summaries of IOL selection in patients wherein prerefractive surgery data are available, numerous authors have recently described approaches to attempt more accurate IOL power calculations for patients who present with no reliable clinical information regarding their refractive history. Additionally, results have been reported using the Scheimpflug camera system to measure corneal power in an attempt to resolve the most important potential source of error for IOL determination in these patients.

Summary: IOL selection in patients undergoing cataract surgery after corneal refractive surgery continues to be a challenging and complex issue despite numerous strategies and formulas described in the literature. Current focus seems to be directed toward approaches that do not require preoperative refractive surgery information. Due to the relative dearth of comparative clinical outcomes data, the optimal solution to this ongoing clinical problem has yet to be determined. Until such data are available, many cataract surgeons compare the results of multiple formulas to assist them in IOL selection for these patients.
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http://dx.doi.org/10.1097/ICU.0b013e328333e9abDOI Listing
January 2010

Cost-effectiveness analysis of intracameral cefuroxime use for prophylaxis of endophthalmitis after cataract surgery.

Ophthalmology 2009 Oct 28;116(10):1887-96.e1. Epub 2009 Jun 28.

Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA.

Objective: To evaluate the cost-effectiveness of intracameral cefuroxime for postoperative endophthalmitis prophylaxis, and to determine the efficacy threshold necessary for alternative antibiotics to attain cost-effective equivalence with intracameral cefuroxime.

Design: Cost-effectiveness analysis.

Participants: We study a hypothetical cohort of 100,000 patients undergoing cataract surgery as a part of the cost analysis.

Methods: A cost-effectiveness model was constructed to analyze different antibiotic prophylactic regimens for postoperative endophthalmitis with intracameral cefuroxime as our base case. Efficacy was defined as the absolute reduction in rate of infection from background rate of infection, which was sourced from the literature. Antibiotic cost data were derived from the Red Book 2007 edition, and salary data were taken from the United States Bureau of Labor Statistics. Multivariate sensitivity analysis assessed the performance of antibiotic options under different scenarios.

Main Outcome Measures: Cost per case of endophthalmitis prevented; theoretical maximal cost-effectiveness; efficacy threshold necessary to achieve cost-effective equivalence with intracameral cefuroxime; ratio indicating how many times more effective or less expensive alternative antibiotics would have to be to achieve cost-effective equivalence with intracameral cefuroxime.

Results: The cost-effectiveness ratio for intracameral cefuroxime is $1403 per case of postoperative endophthalmitis prevented. By comparison, the least expensive topical fluoroquinolone in our study, ciprofloxacin, would have to be >8 times more effective than intracameral cefuroxime to achieve cost-effective equivalence. The most expensive topical fluoroquinolones studied, gatifloxacin and moxifloxacin, would have to be > or =19 times more effective than intracameral cefuroxime to achieve cost-effective equivalence. A sensitivity analysis reveals that even in the worst case scenario for intracameral cefuroxime efficacy and with a 50% reduction in the cost of 4th-generation fluoroquinolones, gatifloxacin and moxifloxacin would have to be > or =9 times more effective than intracameral cefuroxime to achieve cost-effective equivalence.

Conclusions: Administration of intracameral cefuroxime is relatively cost-effective in preventing endophthalmitis after cataract surgery. Owing to their high costs, many commonly used topical antibiotics are not cost-effective compared with intracameral cefuroxime, even under optimistic assumptions about their efficacy.
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http://dx.doi.org/10.1016/j.ophtha.2009.03.014DOI Listing
October 2009
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