Publications by authors named "Carolyn Kloek"

35 Publications

Healthcare disparities contribute to missed follow-up visits after cataract surgery in the USA: results from the perioperative care for intraocular lens study.

BMJ Open 2021 03 17;11(3):e038565. Epub 2021 Mar 17.

Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA

Objective: To identify factors that contribute to missed cataract surgery follow-up visits, with an emphasis on socioeconomic and demographic factors.

Methods: In this retrospective cohort study, patients who underwent cataract extraction by phacoemulsification at Massachusetts Eye and Ear between 1 January and 31 December 2014 were reviewed. Second eye cases, remote and international patients, patients with foreign insurance and combined cataract cases were excluded.

Results: A total of 1931 cases were reviewed and 1089 cases, corresponding to 3267 scheduled postoperative visits, were included. Of these visits, 157 (4.8%) were missed. Three (0.3%) postoperative day 1, 40 (3.7%) postoperative week 1 and 114 (10.5%) postoperative month 1 visits were missed. Age<30 years (adjusted OR (aOR)=8.2, 95% CI 1.9 to 35.2) and ≥90 years (aOR=5.7, 95% CI 2.0 to 15.6) compared with patients aged 70-79 years, estimated travel time of >2 hours (aOR=3.2, 95% CI 1.4 to 7.4), smokers (aOR=2.7, 95% CI 1.6 to 4.8) and complications identified up to the postoperative visit (aOR=1.4, 95% CI 1.0 to 2.1) predicted a higher rate of missed visits. Ocular comorbidities (aOR=0.7, 95% CI 0.5 to 1.0) and previous visit best-corrected visual acuity (BCVA) of 20/50-20/80 (aOR=0.4, 95% CI 0.3 to 0.7) and 20/90-20/200 (aOR=0.4, 95% CI 0.2 to 0.9), compared with BCVA at the previous visit of 20/40 or better, predicted a lower rate of missed visits. Gender, race/ethnicity, language, education, income, insurance, alcohol use and season of the year were not associated with missed visits.

Conclusions: Medical factors and demographic characteristics, including patient age and distance from the hospital, are associated with missed follow-up visits in cataract surgery. Additional studies are needed to identify disparities in cataract postoperative care that are population-specific. This information can contribute to the implementation of policies and interventions for addressing them.
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http://dx.doi.org/10.1136/bmjopen-2020-038565DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7978071PMC
March 2021

Surgical Curriculum for Presbyopia-Correcting Intraocular Lenses: Resident Experiences and Surgical Outcomes.

Clin Ophthalmol 2020 24;14:2441-2451. Epub 2020 Aug 24.

Dean McGee Eye Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA.

Objective: To describe a stepwise surgical curriculum that was implemented to teach novice surgeons about currently available advanced technology intraocular lenses (ATIOLs) for correction of presbyopia and to report the experiences and surgical results of ATIOL surgery performed by residents who engaged in the curriculum.

Design Setting And Participants: Third-year ophthalmology residents participated in a curriculum incorporating didactic lectures (with objective assessment and wet-lab practice) and observation of attending-performed ATIOL surgeries prior to performing ATIOL surgery as primary surgeon under direct supervision. Post-operative outcomes studied were best corrected distance visual acuity (BCDVA) and uncorrected distance (UDVA), intermediate (UIVA) near (UNVA) visual acuity and correction of astigmatism with at least 3 months of follow-up (POM3+). Residents were also given a survey to assess experiences with the surgical curriculum, preparedness for use of ATIOLs post-residency, and ATIOL practice pattern post-residency.

Results: A total of 12 residents from four consecutive classes completed the curriculum. Residents overall had a favorable opinion of the curriculum and felt well prepared to use ATIOLs after training. Graduates who currently perform cataract surgery felt comfortable using all available ATIOLs. A total of 100 eyes from 72 patients met the inclusion criteria for analysis in the study. At the POM3+ timepoint, 88% of eyes had UDVA of 20/30 or better, 93% had UIVA of 20/30 or better, and 71.2% had UNVA of 20/30 (J2) or better. Among eyes that received an astigmatism-correcting ATIOL, 91% had <1 diopter of astigmatism after surgery.

Conclusion: Resident surgeons learned to perform ATIOL surgery (medical knowledge) and achieve strong surgical outcomes (patient care) with all currently available ATIOLs after completion of a stepwise curriculum. Educators may be encouraged to incorporate an ATIOL curriculum based on the results of this study. The curriculum presented is a prototype and may be further improved with future experiences and studies.
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http://dx.doi.org/10.2147/OPTH.S263249DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457827PMC
August 2020

Quantifying the educational benefit of additional cataract surgery cases in ophthalmology residency.

J Cataract Refract Surg 2020 Nov;46(11):1495-1500

From the Department of Ophthalmology, Massachusetts Eye and Ear (Liebman, McKay, Moustafa, Kloek), Boston, Department of Medicine, Cambridge Health Alliance (Liebman), Cambridge, Massachusetts, Department of Ophthalmology, University of Washington (McKay), Seattle, Washington, Department of Epidemiology, Boston University (Haviland), Boston, Massachusetts, Department of Ophthalmology, Duke University Eye Center (Borkar), Durham, North Carolina, Dean McGee Eye Institute, University of Oklahoma (Kloek), Oklahoma City, Oklahoma, USA.

Purpose: To quantify the resident learning curve for cataract surgery using operative time as an indicator of surgical competency, to identify the case threshold at which marginal additional educational benefit became equivocal, and to characterize heterogeneity in residents' pathways to surgical competency.

Setting: Academic medical center.

Design: Large-scale retrospective consecutive case series.

Methods: All cataract surgery cases performed by resident physicians as primary surgeon at Massachusetts Eye and Ear from July 1, 2010, through June 30, 2015, were reviewed. Data were abstracted from Accreditation Council for Graduate Medical Education case logs and operative time measurements. A linear mixed-methods analysis was conducted to model changes in residents' cataract surgery operative times as a function of sequential case number, with resident identity included as a random effect in the model to normalize between-resident variability.

Results: A total of 2096 cases were analyzed. A marked progressive decrease in operative time was noted for resident cases 1 to 39 (mean change -0.17 minutes per additional case, 95% CI, -0.21 to -0.12; P < .001). A modest, steady reduction in operative time was subsequently noted for case numbers 40 to 149 (mean change -0.05 minutes per additional case, 95% CI, -0.07 to -0.04; P < .001). No statistically significant improvement was found in operative times beyond the 150th case.

Conclusions: Residents derived educational benefit from performing a greater number of cataract procedures than current minimum requirements. However, cases far in excess of this threshold might have diminishing educational return in residency. Educational resources currently used for these cases might be more appropriately devoted to other training priorities.
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http://dx.doi.org/10.1097/j.jcrs.0000000000000298DOI Listing
November 2020

Clinical factors affecting operating room utilization in cataract surgery: Results from the PCIOL study.

J Cataract Refract Surg 2020 01;46(1):14-19

From the Department of Ophthalmology, Massachusetts Eye and Ear Infirmary (McKay, Borkar, Moustafa, Kloek), Department of Epidemiology, Boston University School of Public Health (Haviland), Boston, Massachusetts, and Wills Eye Hospital Retina Service (Borkar), Philadelphia, Pennsylvania, USA.

Purpose: To identify preoperative clinical characteristics affecting cataract surgery operative time.

Setting: Academic center.

Design: Large-scale retrospective cohort study.

Methods: All cases of cataract extraction by phacoemulsification and intraocular lens insertion performed by Comprehensive Ophthalmology at Massachusetts Eye and Ear between January 1, 2014, and December 31, 2014, were reviewed. Clinically relevant predictors of operative time were identified a priori, and a multivariate analysis was used to identify which predictors were associated with operative time. To quantify the surgeon effect, 2 regression models were built, one inclusive of surgeon identity and the other with years of experience and the training level of the supervised resident instead of identity.

Results: Overall, 1349 cataract surgeries in 1072 patients were included. The mean operative time was 22.1 ± 7.8 minutes. Multiple clinical factors were significantly associated with operative time, with attending surgeon identity being the most important. In the multivariate model with surgeon identity, longer operative time was associated with male sex, increased body mass index, first-eye surgery, left operative eye, advanced cataract, use of iris hooks, use of Malyugin ring, use of trypan blue, history of diabetic retinopathy, short axial length, and shallow anterior chamber depth. The R value for the model inclusive of attending identity was 0.42, significantly higher than the R value of 0.23 for the model exclusive of identity.

Conclusion: Preoperative clinical characteristics, such as patient demographics, biometry data, and cataract severity, significantly correlate with operative time. Surgeon identity is highly correlated with operative time. Incorporating these results into predictive algorithms may allow for more predictable surgical scheduling and more efficient use of operative resources.
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http://dx.doi.org/10.1016/j.jcrs.2019.08.004DOI Listing
January 2020

Optimization of cataract surgery follow-up: A standard set of questions can predict unexpected management changes at postoperative week one.

PLoS One 2019 19;14(9):e0221243. Epub 2019 Sep 19.

Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, United States of America.

Purpose: There is limited evidence to inform the optimal follow-up schedule after cataract surgery. This study aims to determine whether a standardized question set can predict unexpected management changes (UMCs) at the postoperative week one (POW1) timepoint.

Setting: Massachusetts Eye and Ear, Harvard Medical School.

Design: Prospective cohort study.

Methods: Two-hundred-and-fifty-four consecutive phacoemulsification cases having attended an examination between postoperative days 5-14. A set of 7 'Yes' or 'No' questions were administered to all participants by a technician at the POW1 visit. Patient answers along with perioperative patient information were recorded and analyzed. Outcomes were the incidence of UMCs at POW1.

Results: The incidence of UMCs was zero in uneventful cataract cases with unremarkable history and normal postoperative day one exam if no positive answers were given with the question set demonstrating 100% sensitivity (p<0.0001). A test version with 5 questions was equally sensitive in detecting UMCs at POW1 after cataract surgery.

Conclusion: In routine cataract cases with no positive answers to the current set of clinical questions, a POW1 visit is unlikely to result in a management change. This result offers the opportunity for eye care providers to risk-stratify patients who have had cataract surgery and individualize follow-up.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0221243PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6752806PMC
March 2020

Reply.

Am J Ophthalmol 2019 12 26;208:443-444. Epub 2019 Jul 26.

Boston, Massachusetts; Oklahoma City, Oklahoma.

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http://dx.doi.org/10.1016/j.ajo.2019.04.005DOI Listing
December 2019

Evaluation of computer-based retinopathy of prematurity (ROP) education for ophthalmology residents: a randomized, controlled, multicenter study.

J AAPOS 2019 04 16;23(2):86.e1-86.e7. Epub 2019 Mar 16.

Massachusetts Eye and Ear, Harvard Medical School, Department of Ophthalmology, Boston, Massachusetts. Electronic address:

Purpose: To evaluate the effect of a computer-based training program-Massachusetts Eye & Ear ROP Trainer-on residents' knowledge of retinopathy of prematurity (ROP) management.

Methods: In this prospective, randomized study, ophthalmology residents from nine different training programs consented to participate. Those who completed the study were randomly assigned to either the Trainer or the control group. The ROP Trainer was created using clinical cases encompassing the stages of ROP in digital pictures and videos. It includes sections on screening decisions, examination techniques, and diagnosis, and a reference section with the expert video clips and a searchable image library. Subjects in the control group were asked to study standard print material on ROP. A pre- and post-test, consisting of theoretical and practical (diagnosis) questions, and a post-intervention satisfaction test were administered. Accuracy of ROP diagnosis was assessed.

Results: A total of 180 residents agreed to participate, of whom 60 completed the study. Residents in the Trainer group had statistically significant improvements (P = 0.003) in ROP knowledge and diagnostic ability (P = 0.005). Residents randomized to the Trainer group were more satisfied with the training materials than were those in the control group. There was no significant difference in improving knowledge by year of training, sex, or country. Considering all training levels, a statistically significant increase was observed in sensitivity for the diagnosis of preplus or worse, zone I or II, ROP stage, category, and aggressive posterior ROP in the Trainer group.

Conclusions: In this study, the Trainer was shown to significantly improve ROP knowledge and diagnostic skills of residents, regardless of sex, year, of training, or country.
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http://dx.doi.org/10.1016/j.jaapos.2018.11.008DOI Listing
April 2019

Reply.

J Cataract Refract Surg 2019 01;45(1):113-114

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http://dx.doi.org/10.1016/j.jcrs.2018.11.007DOI Listing
January 2019

Outcomes in resident-performed cataract surgeries with iris challenges: Results from the Perioperative Care for Intraocular Lens study.

J Cataract Refract Surg 2018 Dec 1;44(12):1469-1477. Epub 2018 Nov 1.

From the Department of Ophthalmology (Moustafa, Borkar, McKay, Lorch, Kloek), Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, Retina Service (Borkar), Wills Eye Hospital, Philadelphia, Pennsylvania, Harvard Medical School (Eton), Boston, Massachusetts, and University of Southern California Roski Eye Institute (Koulisis), Keck School of Medicine, Los Angeles, California, USA.

Purpose: To assess the outcomes of resident-performed cataract surgeries with iris challenges and to compare these outcomes with similar surgeries performed by attending surgeons.

Setting: Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.

Design: Retrospective chart review.

Methods: All cases of cataract extraction by phacoemulsification with intraocular lens implantation, performed by comprehensive ophthalmologists between January 1 and December 31, 2014, were reviewed. Cases with preoperative or intraoperative miosis, iris prolapse, and intraoperative floppy iris syndrome, were included for analysis. Visual outcomes and the rate of perioperative adverse events were compared between resident and attending surgeon cases. Factors predicting adverse events were also assessed.

Results: In total, 1931 eye cases of 1434 patients were reviewed, and 65 resident cases and 168 attending surgeon cases were included. The mean logarithm of the minimum angle of resolution corrected distance visual acuity was better in the resident group 1 month after surgery (0.051 ± 0.10 [SD] versus 0.132 ± 0.30, P = .03); however, the difference was eliminated when controlling for macular disease. The mean operative time was 43.8 ± 26.5 minutes and 30.9 ± 12.6 minutes for cases performed by resident surgeons and attending surgeons, respectively (P  .0001). Residents utilized supplemental pharmacologic dilation or retraction more frequently than attending surgeons (98% versus 87% of cases, P = .008). The overall rate of adverse events was no different between residents and attending surgeons (P = 0.16). Dense nuclear sclerosis predicted adverse events in cataract cases with iris challenges (adjusted odds ratio, 1.86; 95% confidence interval, 1.17-2.94; P = .001).

Conclusion: Although requiring longer operative times and more surgical manipulation, residents who performed cataract surgeries with iris challenges achieved outcomes comparable to those performed by attending surgeons, and residents should be given the opportunity to operate on these eyes.
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http://dx.doi.org/10.1016/j.jcrs.2018.08.019DOI Listing
December 2018

Incidence of Management Changes at the Postoperative Week 1 Visit after Cataract Surgery: Results from the Perioperative Care for IntraOcular Lens Study.

Am J Ophthalmol 2019 03 17;199:94-100. Epub 2018 Oct 17.

Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Purpose: To ascertain the incidence of unexpected management changes at the postoperative week 1 visit in asymptomatic patients who have had an uncomplicated cataract surgery and a routine postoperative day 1 examination.

Design: Retrospective observational study.

Methods: A retrospective chart review was conducted of all cases of cataract extraction by phacoemulsification with intraocular lens insertion performed by the Comprehensive Ophthalmology Service at Massachusetts Eye and Ear between January 1, 2014 and December 31, 2014. The preoperative consultation, operative report, and postoperative day 1 and week 1 (postoperative days 5-14) visits were reviewed. Cases with intraoperative complications, as well as clinical findings at postoperative day 1 requiring close follow-up, were excluded. The main outcome measure was incidence of unexpected management changes at the postoperative week 1 visit after cataract surgery, defined as an unanticipated change in postoperative drops, additional procedures, or urgent referral to a specialty service.

Results: Overall, 1938 surgical cases of 1471 patients were reviewed, and 1510 cases (77.9%) underwent uncomplicated phacoemulsification with intraocular lens implantation with a routine postoperative day 1 examination. Of these 1510 cases, 238 (15.8%) reported symptoms at the postoperative week 1 visit, including flashes, floaters, redness, pain, or decreased vision, which warranted an examination. In total, 1272 cases were asymptomatic, and only 11 of these cases (0.9%) had an unexpected management change at postoperative week 1. Eight of 11 patients were asymptomatic steroid responders requiring alteration of their postoperative drops. Two of these patients had an intraocular pressure >30 mm Hg.

Conclusions: Unexpected management changes at the postoperative week 1 timepoint after cataract surgery are rare in asymptomatic patients who have had uncomplicated cataract surgery and a routine postoperative day 1 examination. Limited data are available to outline an optimal postoperative regimen after cataract surgery. The results of this study suggest that postoperative week 1 examinations could potentially be performed on an as-needed basis in the appropriate subgroup of patients after cataract surgery.
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http://dx.doi.org/10.1016/j.ajo.2018.10.013DOI Listing
March 2019

A Comprehensive Surgical Curriculum Reduced Intra-operative Complication Rates of Resident-performed Cataract Surgeries.

J Surg Educ 2019 Jan - Feb;76(1):150-157. Epub 2018 Aug 19.

Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts. Electronic address:

Objectives: To evaluate the impact of a comprehensive cataract surgery curriculum on the incidence of intraoperative complications.

Design: We retrospectively compared the total number of cataract surgeries that the residents performed in all of the teaching sites, and the incidences of intraoperative complications (anterior capsule tear, posterior capsule rent, vitreous loss, anterior vitrectomy, zonular dialysis, iris trauma, hemorrhage, dropped lens fragment, corneal wound burn, incorrect intraocular lens) for the surgeries performed at Massachusetts Eye & Ear by residents in the pre-intervention group (residents graduating in 2004 and 2005), before the implementation of a surgical curriculum, and the residents in the post-intervention group (residents graduating in 2014 and 2015).

Setting: Ophthalmology residency program at a major academic institution.

Participants: Residents graduating in 2004, 2005, 2014, and 2015.

Results: We reviewed 4373 charts. 2086 of those surgeries were performed at Massachusetts Eye & Ear. The incidence of posterior capsule rent/vitreous loss/anterior vitrectomy was lower in the post-intervention group (1.4% versus 7.7%, p < 0.0001). Other complications were also lower in the post-intervention group.

Conclusions: Implementation of a comprehensive cataract surgery curriculum focusing on pre-operative, intra-operative and post-operative interventions, with an emphasis on patient outcomes resulted in a decrease in the rate of intraoperative complications.
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http://dx.doi.org/10.1016/j.jsurg.2018.07.009DOI Listing
June 2020

Diabetic Retinopathy Assessment Variability Among Eye Care Providers in an Urban Teleophthalmology Program.

Telemed J E Health 2019 04 24;25(4):301-308. Epub 2018 Jul 24.

4 Massachusetts Eye and Ear Infirmary, Harvard Medical School , Boston, Massachusetts.

Background: Teleophthalmology is an evidence-based method for diabetic eye screening. It is unclear whether the type of eye care provider performing teleophthalmology interpretation produces significant variability.

Introduction: We assessed grading variability between an optometrist, general ophthalmologist, and retinal specialist using images from an urban, diabetic retinopathy teleophthalmology program.

Methods: Three readers evaluated digital retinal images in 100 cases (178 eyes from 90 patients with type 2 diabetes). Fisher's exact test, percent agreement, and the observed proportion of positive (P) or negative agreement (P) were used to assess variability.

Results: Among cases deemed gradable by all three readers (n = 65), there was substantial agreement on absence of any retinopathy (88% ± 4.6%, P = 0.91-0.95), presence of moderate nonproliferative or worse retinopathy (87% ± 3.9%, P = 0.67-1.00), and presence of macular edema (99% ± 0.9%, P = 0.67-1.00). There was limited agreement regarding presence of referable nondiabetic eye pathology (61% ± 11%, P = 0.21-0.59) and early, nonroutine referral for a follow-up clinical eye exam (66% ± 8.1%, P = 0.19-0.54). Among all cases (n = 100), there was acceptable agreement regarding which had gradable images (77% ± 5.0%, P = 0.50-0.90).

Discussion: Inclusion of multiple types of eye care providers as teleophthalmology readers is unlikely to produce significant variability in the assessment of diabetic retinopathy among high-quality images. Greater variability was found regarding image gradability, nondiabetic eye pathology, and recommended clinical referral times.

Conclusions: Our results suggest that more extensive training and uniform referral standards are needed to improve consensus on image gradability, referable nondiabetic eye pathology, and recommended clinical referral times.
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http://dx.doi.org/10.1089/tmj.2018.0019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6482899PMC
April 2019

Prosthetic Replacement of the Ocular Surface Ecosystem Treatment of Ocular Surface Disease After Skull Base Tumor Resection.

World Neurosurg 2018 Feb 28;110:e124-e128. Epub 2017 Oct 28.

Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.

Background: Prosthetic replacement of the ocular surface ecosystem (PROSE) treatment is an effective, nonsurgical therapeutic option for patients with ocular surface disease related to cranial nerve deficits secondary to skull base tumor resection.

Methods: This case series describes the impact of PROSE treatment in patients with symptomatic exposure keratopathy or neurotrophic keratitis after skull base tumor surgery.

Results: All patients improved symptomatically and functionally with PROSE treatment, and have had sustained improvement for as long as 3 years.

Conclusions: In postneurosurgical cases in which neurologic function may recover, PROSE treatment offers a safe, nonsurgical treatment option to support the ocular surface during the period of observation awaiting neurologic recovery.
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http://dx.doi.org/10.1016/j.wneu.2017.10.111DOI Listing
February 2018

Communication Skills Training in Ophthalmology: Results of a Needs Assessment and Pilot Training Program.

J Surg Educ 2018 Mar - Apr;75(2):417-426. Epub 2017 Sep 1.

Department of Ophthalmology, Mass Eye and Ear, Boston, Massachusetts. Electronic address:

Objective: To conduct a needs assessment to identify gaps in communication skills training in ophthalmology residency programs and to use these results to pilot a communication workshop that prepares residents for difficult conversations.

Design: A mixed-methods design was used to perform the needs assessment. A pre-and postsurvey was administered to workshop participants.

Setting: Mass Eye and Ear Infirmary, Harvard Medical School (HMS), Department of Ophthalmology.

Participants: HMS ophthalmology residents from postgraduate years 2-4 participated in the needs assessment and the workshop. Ophthalmology residency program directors in the United States participated in national needs assessment.

Methods: Ophthalmology program directors across the United States were queried on their perception of resident communication skills training through an online survey. A targeted needs assessment in the form of a narrative exercise captured resident perspectives on communication in ophthalmology from HMS residents. A group of HMS residents participated in the pilot workshop and a pre- and postsurvey was administered to participants to assess its effectiveness.

Results: The survey of program directors yielded a response rate of 40%. Ninety percent of respondents agreed that the communication skills training in their programs could be improved. Fifteen of 24 residents (62%) completed the needs assessment. Qualitative analysis of the narrative material revealed four themes; (1) differing expectations, (2) work role and environment, (3) challenges specific to ophthalmology, and (4) successful strategies adopted. Nine residents participated in the workshop. There was a significant improvement post-workshop in resident reported scores on their ability to manage their emotions during difficult conversations (p = 0.03).

Conclusions: There is an opportunity to improve communication skills training in ophthalmology residency through formalized curriculum.
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http://dx.doi.org/10.1016/j.jsurg.2017.08.011DOI Listing
December 2018

Early Performance on an Eye Surgery Simulator Predicts Subsequent Resident Surgical Performance.

J Surg Educ 2017 Nov - Dec;74(6):1105-1115. Epub 2017 Apr 21.

Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts. Electronic address:

Objective: To examine early performance on an eye surgery simulator and its relationship to subsequent live surgical performance in a single large residency program.

Design: Retrospective study.

Setting: Massachusetts Eye and Ear, Harvard Medical School, Department of Ophthalmology.

Methods: In a retrospective study, we compared performance of 30 first-year ophthalmology residents on an eye surgery simulator to their surgical skills as third-year residents. Variables collected from the eye surgery simulator included scores on the following modules of the simulator (Eyesi, VRmagic, Mannheim, Germany): antitremor training level 1, bimanual training level 1, capsulorhexis level 1 (configured), forceps training level 1, and navigation training level 1. Subsequent surgical performance was assessed using the total number of phacoemulsification cataract surgery cases for each resident, as well as the number performed as surgeon during residency and scores on global rating assessment of skills in intraocular surgery (GRASIS) scales during the third year of residency. Spearman correlation coefficients were calculated between each of the simulator performance and subsequent surgical performance variables. We also compared variables in a small group of residents who needed extra help in learning cataract surgery to the other residents in the study.

Main Outcome Measures: Relationships between Eyesi scores early in residency and surgical performance measures in the final year of residency.

Results: A total of 30 residents had Eyesi data from their first year of residency and had already graduated so that all subsequent surgical performance data were available. There was a significant correlation between capsulorhexis task score on the simulator and total surgeries (r = 0.745, p = 0.008). There was a significant correlation between antitremor training level 1 (r = 0.554, p = 0.040), and forceps training level 1 (r = 0.622, p = 0.023) with primary surgery numbers. There was a significant correlation between forceps training level 1 (r = 0.811, p = 0.002), and navigation training level 1 (r = 0.692, p = 0.013) with total GRASIS score. There was a significant inverse correlation between total GRASIS score and residents in need of extra help (r = -0.358, p = 0.003).

Conclusion: Module scores on an eye surgery simulator early in residency may predict a resident׳s future performance in the operating room. These scores may allow early identification of residents in need of supplemental training in cataract surgery.
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http://dx.doi.org/10.1016/j.jsurg.2017.04.002DOI Listing
August 2018

An evidence-based approach to surgical teaching in ophthalmology.

Surv Ophthalmol 2017 May - Jun;62(3):371-377. Epub 2017 Jan 17.

Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA.

An apprenticeship model has traditionally been used in procedural and surgical teaching. As the pressures of work hours and patient outcome monitoring increase, surgical teachers need a more flexible plan for teaching procedural skills. We attempt to delineate a program of preprocedural, intraprocedural, and postprocedural teaching that can be used in the field of ophthalmology to maximize a resident's skill acquisition in a constructive learning environment. We review the literature on surgical teaching from within ophthalmology as well as other surgical fields and combine this with teaching experience in an ophthalmic surgical training program to produce a collection of procedural teaching guidelines. These guidelines are structured to serve in both individual teaching settings and in curriculum design.
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http://dx.doi.org/10.1016/j.survophthal.2017.01.003DOI Listing
September 2017

Assessing Resident Cataract Surgery Outcomes Using Medicare Physician Quality Reporting System Measures.

J Surg Educ 2016 Sep-Oct;73(5):774-9. Epub 2016 May 17.

Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; Glaucoma Service, Massachusetts Eye & Ear Infirmary, Boston, Massachusetts. Electronic address:

Objectives: To assess resident cataract surgery outcomes at an academic teaching institution using 2 Physician Quality Reporting System (PQRS) cataract measures, which are intended to serve as a proxy for quality of surgical care.

Design: A retrospective review comparing cataract surgery outcomes of resident and attending surgeries using 2 PQRS measures: (1) 20/40 or better best-corrected visual acuity following cataract surgery and (2) complications within 30 days following cataract surgery requiring additional surgical procedures.

Setting: An academic ophthalmology center.

Participants: A total of 2487 surgeries performed at the Massachusetts Eye and Ear Infirmary from January 1, 2011 to December 31, 2012 were included in this study.

Results: Of all 2487 cataract surgeries, 98.95% achieved a vision of at least 20/40 at or before 90 days, and only 0.64% required a return to the operating room for postoperative complications. Of resident surgeries, 98.9% (1370 of 1385) achieved 20/40 vision at or before 90 days follow-up. Of attending surgeries, 99.0% (1091 of 1102) achieved 20/40 vision at or before 90 days (p = 1.00). There were no statistically significant differences between resident and attending cases regarding postoperative complications needing a return to the operating room (i.e., 0.65%, or 9 of 1385 resident cases vs 0.64%, or 7 of 1102 attending cases; p = 1.00).

Conclusions: Using PQRS Medicare cataract surgery criteria, this study establishes new benchmarks for cataract surgery outcomes at a teaching institution and supplemental measure for assessing resident surgical performance. Excellent cataract outcomes were achieved at an academic teaching institution, with results exceeding Medicare thresholds of 50%. There appears to be no significant difference in supervised trainee and attending cataract surgeon outcomes using 2 PQRS measures currently used by Medicare to determine physician reimbursement and quality of care.
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http://dx.doi.org/10.1016/j.jsurg.2016.04.007DOI Listing
March 2017

Introducing a New Surgical Technology: Controversies in Femtosecond Laser-assisted Cataract Surgery and Impact on Resident Surgical Training.

Int Ophthalmol Clin 2015 ;55(4):23-35

Femtosecond laser-assisted cataract surgery is becoming more widely available as an option for patients considering cataract surgery. Controversies exist around determining the best platform for LCS, the potential global role and cost to the health care system of LCS, as well as the future of LCS in resident surgical training.
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http://dx.doi.org/10.1097/IIO.0000000000000093DOI Listing
May 2016

Assessing the Effect of a Glaucoma Surgical Curriculum in Resident Physicians.

JAMA Ophthalmol 2015 Sep;133(9):1077-80

Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston.

Importance: Subspecialty surgical training is an important part of resident education. We changed the glaucoma rotation in which postgraduate year 4 residents worked with multiple attending physicians with varying teaching styles to a structured surgical curriculum led by 2 dedicated preceptors, and we evaluated the effect on residents' surgical performance prospectively.

Observations: A curriculum consisting of preoperative training, intraoperative teaching, postoperative feedback, and repetition was implemented for postgraduate year 4 residents between July 2, 2012, and June 30, 2014. In a class of 8 residents per year, the mean (SD) glaucoma surgical volume increased from 8.9 (0.8) cases in the prior year to 13.6 (2.5) in 2013 (mean difference, 4.8 cases; 95% CI, 2.4-7.1; P = .001) and 14.8 (4.2) in 2014 (mean difference, 5.9 cases; 95% CI, 2.1-9.6; P = .007). A self-assessment survey showed improvement in suturing (scores for each section range from 1 [worst] to 5 [best]; mean rating, 3.9 in the prior year vs 4.4 in 2013 [P = .04] and 4.5 in 2014 [P = .02]). A validated survey assessing overall surgical competency revealed improvement in handling adverse events (mean rating, 4.1 in the prior year vs 5.0 for both 2013 and 2014; both P < .001).

Conclusions And Relevance: Despite the small sample size and nonrandomized study design, these data suggest that a structured surgical curriculum has advantages in teaching subspecialty surgery and might be considered by other ophthalmology training programs.
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http://dx.doi.org/10.1001/jamaophthalmol.2015.1846DOI Listing
September 2015

Improving the Teaching Skills of Residents in a Surgical Training Program: Results of the Pilot Year of a Curricular Initiative in an Ophthalmology Residency Program.

J Surg Educ 2015 Sep-Oct;72(5):890-7. Epub 2015 Apr 23.

Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA.

Objective: To design and implement a teaching skills curriculum that addressed the needs of an ophthalmology residency training program, to assess the effect of the curriculum, and to present important lessons learned.

Design: A teaching skills curriculum was designed for the Harvard Medical School (HMS) Residency Training Program in Ophthalmology. Results of a needs assessment survey were used to guide curriculum objectives. Overall, 3 teaching workshops were conducted between October 2012 and March 2013 that addressed areas of need, including procedural teaching. A postcurriculum survey was used to assess the effect of the curriculum.

Setting: Massachusetts Eye and Ear Infirmary, a tertiary care institution in Boston, MA.

Participants: Overall, 24 residents in the HMS Residency Training Program in Ophthalmology were included.

Results: The needs assessment survey demonstrated that although most residents anticipated that teaching would be important in their future career, only one-third had prior formal training in teaching. All residents reported they found the teaching workshops to be either very or extremely useful. All residents reported they would like further training in teaching, with most residents requesting additional training in best procedural teaching practices for future sessions.

Conclusions: The pilot year of the resident-as-teacher curriculum for the HMS Residency Training Program in Ophthalmology demonstrated a need for this curriculum and was perceived as beneficial by the residents, who reported increased comfort in their teaching skills after attending the workshops.
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http://dx.doi.org/10.1016/j.jsurg.2015.03.002DOI Listing
May 2016

A broadly applicable surgical teaching method: evaluation of a stepwise introduction to cataract surgery.

J Surg Educ 2014 Mar-Apr;71(2):169-75. Epub 2013 Sep 14.

Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.

Objective: Although cataract surgery is one of the most commonly performed surgeries in the country, it is a microsurgical procedure that is difficult to learn and to teach. This study aims to assess the effectiveness of a new method for introducing postgraduate year (PGY)-3 ophthalmology residents to cataract surgery.

Setting: Hospital-based ophthalmology residency program.

Design: Retrospective cohort study.

Participants: PGY-3 and PGY-4 residents of the Harvard Medical School Ophthalmology Residency from graduating years 2010 to 2012.

Results: In July 2009, a new method of teaching PGY-3 ophthalmology residents cataract surgery was introduced, which was termed "the stepwise introduction to cataract surgery." This curriculum aimed to train residents to perform steps of cataract surgery by deliberately practicing each of the steps of surgery under a structured curriculum with faculty feedback. Assessment methods included surveys administered to the PGY-4 residents who graduated before the implementation of these measures (n = 7), the residents who participated in the first and second years of the new curriculum (n = 16), faculty who teach PGY-4 residents cataract surgery (n = 8), and review of resident Accreditation Council for Graduate Medical Education surgical logs. Resident survey response rate was 100%. Residents who participated in the new curriculum performed more of each step of cataract surgery in the operating room, spent more time practicing each step of cataract surgery on a cataract surgery simulator during the PGY-3 year, and performed more primary cataract surgeries during the PGY-3 year than those who did not. Faculty survey response rate was 63%. Faculty noted an increase in resident preparedness following implementation of the new curriculum. There was no statistical difference between the precurriculum and postcurriculum groups in the percentage turnover of cataracts for the first 2 cataract surgery rotations of the PGY-4 year of training.

Conclusions: The introduction of cataract surgery to PGY-3 residents in an organized, stepwise manner improved resident preparedness for the PGY-4 year of residency. This surgical teaching method can be easily applied to other surgical specialties.
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http://dx.doi.org/10.1016/j.jsurg.2013.07.007DOI Listing
November 2014

Achieving target refraction after cataract surgery.

Ophthalmology 2014 Feb 26;121(2):440-4. Epub 2013 Nov 26.

Massachusetts Eye and Ear Infirmary, Boston, Massachusetts. Electronic address:

Purpose: To evaluate the difference between target and actual refraction after phacoemulsification and intraocular lens implantation at an academic teaching institution's Comprehensive Ophthalmology Service.

Design: Retrospective study.

Participants: We examined 1275 eye surgeries for this study.

Methods: All consecutive cataract surgeries were included if they were performed by an attending or resident surgeon from January through December 2010. Postoperative refractions were compared with preoperative target refractions. Patients were excluded if they did not have a preoperative target refraction documented or if they did not have a recorded postoperative manifest refraction within 90 days.

Main Outcome Measures: The main outcome measure was percentage of cases achieving a postoperative spherical equivalent ± 1.0 diopter (D) of target spherical equivalent.

Results: We performed 1368 cataract surgeries from January through December of 2010. Of these, 1275 (93%) had sufficient information for analysis. Of the included cases, 94% (1196 of 1275) achieved ± 1.0 D of target refraction by 90 days after cataract surgery.

Conclusions: This paper establishes a new benchmark for a teaching hospital, where 94% of patients achieved within 1.0 D of target refraction after cataract surgery. The refractive outcomes after cataract surgery at this academic teaching institution were higher than average international benchmarks.
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http://dx.doi.org/10.1016/j.ophtha.2013.09.022DOI Listing
February 2014

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

Characteristics of traumatic cataract wound dehiscence.

Am J Ophthalmol 2011 Aug 28;152(2):229-33. Epub 2011 May 28.

Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts 02215, USA.

Purpose: To characterize the clinical course of cataract wound dehiscence.

Design: Retrospective, comparative case series.

Methods: Charts of open globe injuries (848 injuries in 846 patients) treated surgically at the Massachusetts Eye and Ear Infirmary between 2000 and 2009 were retrospectively reviewed. Time from original surgery to wound dehiscence, type of initial surgery, Ocular Trauma Score, age, gender, mechanism of injury, and visual acuity were analyzed.

Results: Of 846 patients with 848 open globe injuries, 63 experienced cataract wound dehiscence. The majority of these cataract wounds (89%) were extracapsular cataract extraction (ECCE), with only 7 (11%) phacoemulsification wounds. The mean patient age in the wound rupture group was 78.2 years. Female patients comprised the majority (67%) of this subpopulation. The most common mechanisms of injury were fall (65%), blunt trauma (23%), and motor vehicle accident (7%). The median raw ocular trauma score was 47 in wound dehiscence patients. Visual acuity at presentation was light perception in the wound dehiscence group. The best postoperative visual acuity was significantly worse in the wound dehiscence group (hand motion) than in the remaining patients (20/40; P=.0002). When considering the phacoemulsification patients alone, these patients fared much better, with a median postoperative vision of 20/60.

Conclusions: Despite recent advances in cataract surgery, wound dehiscence remains a significant source of visual disability, mainly in the geriatric population. Rupture ECCE wound patients have a poor visual prognosis. Fortunately, patients with phacoemulsification site dehiscence appear to regain the majority of their vision after open globe repair.
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http://dx.doi.org/10.1016/j.ajo.2011.01.044DOI Listing
August 2011

Low rate of endophthalmitis in a large series of open globe injuries.

Am J Ophthalmol 2009 Apr 1;147(4):601-608.e2. Epub 2009 Feb 1.

Department of Ophthalmology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, Massachusetts, USA.

Purpose: To determine the percentage of patients in whom endophthalmitis developed after open globe injury.

Design: Retrospective, noncomparative, consecutive case series.

Methods: Charts of all patients (675 in total) treated surgically for open globe injury at the Massachusetts Eye and Ear Infirmary (MEEI) between January 1, 2000 and July 31, 2007 were reviewed. Cases with at least 30 days of follow-up were included in statistical analyses (558 in total). A standardized treatment protocol was used in all cases. Intravenous vancomycin and ceftazidime were started on admission and were stopped after 48 hours. Patients were discharged on topical antibiotics, corticosteroids, and cycloplegia. Surgical repairs were performed by the chief of trauma, a full-time position rotating yearly, who is on call for all open globe trauma. Data collection variables included timing of injury and repair, mechanism of injury, details of surgical repair, and details of follow-up such as duration, presence of complications, and vision. A primary outcome measure of endophthalmitis and secondary outcome measure of risk factors for endophthalmitis were studied.

Results: During 7.5 years, 675 open globe injuries were treated at MEEI. Of these, 558 had at least 30 days of follow-up (mean, 11 months) and were used in statistical analyses. The overall percentage of endophthalmitis was 0.9% (3 culture-positive cases and 2 culture-negative cases). Four of the 5 cases achieved final acuity of 20/80 or better. Risk factors for endophthalmitis included intraocular foreign body (P = .03; odds ratio, 7.52) and primary intraocular lens placement (P = .05).

Conclusions: A standardized protocol including surgical repair by a dedicated eye trauma service and 48 hours of intravenous antibiotics was associated with a posttraumatic endophthalmitis percentage of less than 1%.
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http://dx.doi.org/10.1016/j.ajo.2008.10.023DOI Listing
April 2009

Enucleation for open globe injury.

Am J Ophthalmol 2009 Apr 1;147(4):595-600.e1. Epub 2009 Feb 1.

Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA.

Purpose: To report the experience of enucleation after open globe at an ophthalmic trauma referral center.

Design: Retrospective, observational study.

Methods: In an ophthalmic trauma referral center the charts of all patients having suffered an open globe injury between January 1, 2000 and June 30, 2007 were reviewed. Variables assessed were age, gender, type of injury (rupture or laceration [penetrating, intraocular foreign body, or perforating]), ocular trauma score, visual acuity, subsequent enucleation, indication for and timing of enucleation, presence of sympathetic ophthalmia, and length of follow-up.

Results: Among 660 open globe injuries, 55 have undergone enucleation (including 4 eviscerations), 11 primarily and 44 secondarily. Eyes with ruptures were significantly more likely to be enucleated than those with injuries attributable to lacerations (P < .001). The most common reason for secondary enucleation was a blind, painful eye. Two patients (0.3%) developed sympathetic ophthalmia and have maintained good vision in the sympathizing eye.

Conclusions: The vast majority of open globes can be repaired without requiring primary enucleation. Secondary enucleation is most commonly carried out for pain. Eyes with no light perception can be closely observed if the patient chooses.
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http://dx.doi.org/10.1016/j.ajo.2008.10.017DOI Listing
April 2009

Visual outcomes of vitreoretinal surgery in eyes with severe open-globe injury presenting with no-light-perception vision.

Graefes Arch Clin Exp Ophthalmol 2009 Apr 27;247(4):477-83. Epub 2009 Jan 27.

Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.

Background: Severe ocular trauma causing no light perception (NLP) typically carries a dismal prognosis, and implies no further therapeutic intervention. We have identified a cohort of patients with verified NLP following open-globe injury who have recovered vision of light perception (LP) or better. We evaluated the outcomes of vitreoretinal surgery performed on eyes that were NLP post open-globe injury.

Methods: Retrospective review of outcomes of secondary vitreoretinal surgery performed at Massachusetts Eye and Ear Infirmary from 1 January 2001 to 31 December 2006 on all cases of open-globe repair (OGR) that had NLP prior to OGR or on the first post-operative day.

Results: A total of 648 cases of OGR were performed in the study period. Eighty-eight patients had NLP prior to OGR or on the first post-operative day after OGR. Twenty-three patients from the above group (26.1%) spontaneously recovered a vision of light perception (LP) or better. Eight of the 23 patients had a secondary vitreoretinal surgery. All eyes that did not undergo vitreoretinal surgery returned to NLP or became phthisical within 7 months. Among the eight eyes that underwent surgery, five had improvement, with vision ranging from hand motion to 20/70. Prognostic indicators for successful surgical outcome were hand motion or better vision prior to vitreoretinal surgery, recovery of vision within 5 days of OGR, and vitreoretinal intervention within 5 weeks of the initial open-globe injury.

Conclusion: Patients with severe open-globe injury and NLP occasionally recover LP or better vision. These patients may regain useful vision after vitreoretinal surgery if prompt referral and intervention is attempted and if the spontaneous visual recovery occurs within the first week after OGR.
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http://dx.doi.org/10.1007/s00417-009-1035-4DOI Listing
April 2009
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