Publications by authors named "Mary K Daly"

27 Publications

  • Page 1 of 1

Adult-onset asthma and periocular xanthogranuloma - A rare infiltrative disease of the orbit and eyelid.

Am J Ophthalmol Case Rep 2021 Jun 21;22:101043. Epub 2021 Mar 21.

Veterans Affairs Boston Healthcare System, Department of Ophthalmology, 150 South Huntington Avenue, Boston, MA, 02130, USA.

Purpose: To present a case of adult onset asthma with periocular xanthogranuloma (AAPOX), and discuss existing literature on adult orbital xanthogranulomatous diseases (AOXGDs) and their treatment.

Observations: A 63 year old male presented with progressive bilateral eyelid swelling with overlying yellow plaques associated with asthma. CT scan showed periorbital swelling with enlargement of the superior and lateral rectus muscles bilaterally. Biopsy demonstrated orbital xanthogranulomatous disease with increased IgG4 plasma cells. The patient was treated with intralesional triamcinolone, oral prednisone, and cyclophosphamide without significant improvement. Surgical debulking was eventually performed which improved his external symptoms until he was lost to follow up 15 months later.

Conclusions And Importance: AOXGDs are a group of rare infiltrative diseases of the eyelids and orbit that can be associated with significant systemic morbidities. While they all have similar underlying histopathologic features, appreciating the clinical difference between these diseases is important in understanding patient prognosis and ensuring appropriate clinical monitoring. There is also growing research demonstrating that AAPOX, along with other AOXGDs, may represent part of a continuum of IgG4 related disease, similar to what is seen in this case. There is currently no reliably effective treatment for AOXGDs, and additional research into the management of these diseases is necessary.
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http://dx.doi.org/10.1016/j.ajoc.2021.101043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8044650PMC
June 2021

Anterior uveitis secondary to intraocular fiber from a hair enhancement product.

Am J Ophthalmol Case Rep 2020 Jun 22;18:100622. Epub 2020 Feb 22.

Veterans Affairs Boston Healthcare System, Department of Ophthalmology, 150 South Huntington Avenue, Boston, MA, United States.

Purpose: To report a case of anterior uveitis caused by migration of cosmetic "hair-building fibers" into the anterior chamber and discuss previous literature describing ocular disease caused by small foreign fibers.

Observations: A 73 year old male presented with his first episode of acute anterior uveitis. He was found to have a white fiber penetrating through the cornea into the anterior chamber. This foreign body was removed. The patient identified the material as a being from the cosmetic hair-building fiber product he had been using called Toppik. He was treated with topical steroids and antibiotic drops. The uveitis resolved without recurrence by six weeks after his initial presentation.

Conclusions: Small synthetic and non-synthetic fibers represent sources of both superficial and intraocular injury. Careful examination of the anterior chamber is critical in patients with new acute uveitis to identify possible foreign fibers that can migrate through the cornea. While medical therapy with topical steroids may suffice for treatment in many cases, intraocular persistence of these materials can result in recurrent inflammation, ocular hypertension, or further migration into the posterior chamber which may require surgical intervention.
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http://dx.doi.org/10.1016/j.ajoc.2020.100622DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7114603PMC
June 2020

A 64-year-old man with an unusual conjunctival cyst.

Digit J Ophthalmol 2017;23(1):40-42. Epub 2017 Mar 8.

Department of Ophthalmology, Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts.

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http://dx.doi.org/10.5693/djo.03.2016.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5596953PMC
May 2018

Reply.

Retina 2017 10;37(10):e120

*Department of Ophthalmology, Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts †Department of Ophthalmology, Boston University School of Medicine, Boston, Massachusetts ‡Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1097/IAE.0000000000001838DOI Listing
October 2017

Comparison of training effect on tremor using 2 training modules.

J Cataract Refract Surg 2017 05;43(5):656-661

From the Departments of Ophthalmology, Veterans Affairs Boston Healthcare System (Payal, Kim, Gonzalez Gonzalez, Daly), Jamaica Plain, and Boston University School of Medicine (Kim, Daly) and Harvard Medical School (Payal, Daly), Boston, Massachusetts, USA. Electronic address:

Purpose: To compare training effect of 2 training models-a surgical simulator anti-tremor module and a paper version-on tremor and time-to-task completion.

Setting: Ophthalmology Department, Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts, USA.

Design: Prospective crossover study.

Methods: Trainees completed simulator and paper training modules (baseline test, 3 training sessions, posttraining test, and final test) with their dominant and nondominant hands. The change in tremor, number of paper errors, and time-to-task completion in dominant and nondominant hands were compared. The 2 training modules were compared using nonparametric tests.

Results: The study comprised 19 trainees. There was a moderate correlation between average tremor values (simulator, 3-dimensional module) and paper errors (paper, 2-dimensional module) (Spearman ⍴ = 0.35, P < .0001). Practice on the simulator or paper modules did not reduce tremor significantly from baseline to final tasks for both hands combined (P = .12, simulator; P = .2, paper). Practice on the training modules improved time-to-task completion in the simulator module and paper module (both P < .0001). The improvement in time from baseline to final tasks was greater in the nondominant hands in the simulator module (improvement 64.5% over baseline time) than in the paper module (53.6% over baseline time).

Conclusion: Practice might not reduce tremor but improved the outcome measure of time, and results suggest that trainees can learn to compensate for tremor in both hands, which is important in bimanual microsurgery.
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http://dx.doi.org/10.1016/j.jcrs.2017.01.021DOI Listing
May 2017

Impact of First Eye versus Second Eye Cataract Surgery on Visual Function and Quality of Life.

Ophthalmology 2017 10 16;124(10):1496-1503. Epub 2017 May 16.

VA Tennessee Valley Healthcare System, Nashville, Tennessee; Vanderbilt University School of Medicine, Nashville, Tennessee.

Purpose: To compare the impact of first eye versus second eye cataract surgery on visual function and quality of life.

Design: Cohort study.

Participants: A total of 328 patients undergoing separate first eye and second eye phacoemulsification cataract surgeries at 5 veterans affairs centers in the United States. Patients with previous ocular surgery, postoperative endophthalmitis, postoperative retinal detachment, reoperation within 30 days, dementia, anxiety disorder, hearing difficulty, or history of drug abuse were excluded.

Methods: Patients received complete preoperative and postoperative ophthalmic examinations for first eye and second eye cataract surgeries. Best-corrected visual acuity (BCVA) was measured 30 to 90 days preoperatively and postoperatively. Patients completed the National Eye Institute Visual Functioning Questionnaire (NEI-VFQ) 30 to 90 days preoperatively and postoperatively. The NEI-VFQ scores were calculated using a traditional subscale scoring algorithm and a Rasch-refined approach producing visual function and socioemotional subscale scores.

Main Outcome Measures: Postoperative NEI-VFQ scores and improvement in NEI-VFQ scores comparing first eye versus second eye cataract surgery.

Results: Mean age was 70.4 years (±9.6 standard deviation [SD]). Compared with second eyes, first eyes had worse mean preoperative BCVA (0.55 vs. 0.36 logarithm of the minimum angle of resolution (logMAR), P < 0.001), greater mean BCVA improvement after surgery (-0.50 vs. -0.32 logMAR, P < 0.001), and slightly worse postoperative BCVA (0.06 vs. 0.03 logMAR, P = 0.039). Compared with first eye surgery, second eye surgery resulted in higher postoperative NEI-VFQ scores for nearly all traditional subscales (P < 0.001), visual function subscale (-3.85 vs. -2.91 logits, P < 0.001), and socioemotional subscale (-2.63 vs. -2.10 logits, P < 0.001). First eye surgery improved visual function scores more than second eye surgery (-2.99 vs. -2.67 logits, P = 0.021), but both first and second eye surgeries resulted in similar improvements in socioemotional scores (-1.62 vs. -1.51 logits, P = 0.255).

Conclusions: Second eye cataract surgery improves visual function and quality of life well beyond levels achieved after first eye cataract surgery alone. For certain socioemotional aspects of quality of life, second eye cataract surgery results in comparable improvement to first eye cataract surgery.
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http://dx.doi.org/10.1016/j.ophtha.2017.04.014DOI Listing
October 2017

Outcomes after cataract surgery in eyes with pseudoexfoliation: Results from the Veterans Affairs Ophthalmic Surgery Outcomes Data Project.

Can J Ophthalmol 2017 Feb 7;52(1):61-68. Epub 2016 Dec 7.

Veterans Affairs Boston Healthcare System, Ophthalmology Department, Jamaica Plain, MA; Harvard Medical School, Department of Ophthalmology, Boston, MA; Boston University School of Medicine, Department of Ophthalmology, Boston, MA.. Electronic address:

Objective: To compare clinical outcomes of cataract surgery in eyes with and without pseudoexfoliation (PXF).

Design: Retrospective deidentified data analysis.

Participants: A total of 123 PXF and 4776 non-PXF eyes of patients who underwent cataract surgery.

Methods: We compared data on visual acuity, Visual Function Questionnaire (VFQ)-based quality of life, and complications in PXF and non-PXF eyes from the Veterans Affairs (VA) Ophthalmic Surgery Outcomes Data Project across 5 VA medical centres.

Results: Pupillary expansion devices were used in 31 (25.2%) PXF cases and 398 (8.4%) non-PXF cases (p < 0.0001). Capsular tension rings were used in 6 (4.9%) PXF cases and 55 (1.2%) non-PXF cases (p < 0.004). The following complications occurred more frequently in PXF cases: zonular dehiscence without vitrectomy (4 [3.3%] PXF cases vs 40 [0.8%] non-PXF cases p = 0.02), persistent inflammation (28 [24.1%] vs 668 [14.5%]; p = 0.007), and persistent intraocular pressure elevation (5 [4.3%] vs 68 [1.5%]; p = 0.03). Best corrected visual acuity (BCVA) improved in both groups after 1 month, but 87 (83.7%) PXF cases achieved postoperative BCVA better than or equal to 20/40 compared to 3991 (93.8%) non-PXF cases (p = 0.0003). There was no significant difference in the postoperative composite VFQ scores between PXF (82.1 ± 16.9) and non-PXF cases (84.2 ± 16.8, p = 0.09).

Conclusions: Several complications occurred more frequently in the PXF group compared to the non-PXF group, and fewer PXF cases achieved BCVA better than or equal to 20/40. Despite this, both groups experienced similar improvement in vision-related quality of life after cataract surgery.
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http://dx.doi.org/10.1016/j.jcjo.2016.07.019DOI Listing
February 2017

CONSTRUCT AND FACE VALIDITY OF THE EYESI INDIRECT OPHTHALMOSCOPE SIMULATOR.

Retina 2017 Oct;37(10):1967-1976

*Department of Ophthalmology, Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts; †Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; and ‡Department of Ophthalmology, Boston University School of Medicine, Boston, Massachusetts.

Purpose: To evaluate construct and face validity of the Eyesi Binocular Indirect Ophthalmoscope Simulator.

Methods: The performance of 25 medical students (Group A) was compared with that of 17 ophthalmology and optometry trainees (Group B) on the Eyesi Binocular Indirect Ophthalmoscope Simulator. During the course of a single session, each participant viewed an orientation module followed by an instruction session and a demonstration case, and performed 6 cases of progressively increasing difficulty (4 levels) and a 10-question face validity questionnaire. Outcomes included total score, total examination time, percent retina examined, and duration of eye exposure to light.

Results: Group B achieved significantly better total scores than Group A on all difficulty levels (P = 0.02, P = 0.001, P = 0.001, and P = 0.0001, for Levels 1-4, respectively) and had a significantly faster mean duration of examination (8 minutes 58 seconds vs. 5 minutes 21 seconds, P < 0.0001). Medical students reported higher scores in the face validity questionnaire for the simulator experience being helpful at orienting them to true indirect ophthalmology, and that further training on the simulator would improve their skills in the clinic (P = 0.03 for all).

Conclusion: The Eyesi Binocular Indirect Ophthalmoscope Simulator has significant construct and face validity and shows promise for medical education.
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http://dx.doi.org/10.1097/IAE.0000000000001438DOI Listing
October 2017

A rare case of keratitis.

Am J Ophthalmol Case Rep 2017 Apr 7;5:81-84. Epub 2016 Dec 7.

Department of Ophthalmology, VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA, USA.

Purpose: We report a rare case of fungal keratitis in a patient sustaining a corneal laceration from impact with a piece of moldy plaster.

Observations: The patient was treated with topical voriconazole with resolution of active keratitis and formation of a stromal scar. The patient's final visual acuity was 20/20 in the affected eye.

Conclusions And Importance: There is only one other case of keratitis reported in the literature. The patient in the previous case required amniotic membrane transplantation for persistent stromal melting with resultant visual acuity of hand motions only. The present case demonstrates that the early use of topical antifungal medication with close follow-up can prevent corneal perforation and result in excellent visual acuity.
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http://dx.doi.org/10.1016/j.ajoc.2016.12.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5758013PMC
April 2017

American Society of Anesthesiologists classification in cataract surgery: Results from the Ophthalmic Surgery Outcomes Data Project.

J Cataract Refract Surg 2016 07;42(7):972-82

From the Ophthalmology Department (Payal, Sola-Del Valle, Gonzalez-Gonzalez, Cakiner-Egilmez, Daly), Veterans Affairs Boston Healthcare System, Jamaica Plain, Department of Ophthalmology (Daly), Boston University School of Medicine, and Department of Ophthalmology (Sola-Del Valle), Harvard Medical School (Payal, Daly), Boston, Massachusetts; Veteran Affairs Tennessee Valley Healthcare System Center (Chomsky) and Vanderbilt Eye Institute (Chomsky), Vanderbilt University Medical, Nashville, Tennessee; the Ophthalmology Department (Vollman), St. Louis Veteran Affairs Medical Center, and Department of Ophthalmology and Visual Sciences (Vollman), Washington University School of Medicine, St. Louis, Missouri; Michael E. DeBakey Veteran Affairs Medical Center (Baze) and Cullen Eye Institute (Baze), Baylor College of Medicine, Houston, Texas; and the Department of Defense/Veterans Affairs Vision Center of Excellence (Lawrence), Bethesda, Maryland, USA. Electronic address:

Purpose: To explore the association of American Society of Anesthesiologists (ASA) classification with cataract surgery outcomes.

Setting: Five Veterans Affairs Medical Centers, United States.

Design: Retrospective observational cohort study.

Methods: The study analyzed the outcomes of cataract surgery cases. Corrected distance visual acuity (CDVA), unanticipated events, and vision-related quality of life (VRQL) were assessed using the National Eye Institute Visual Function Questionnaire (NEI-VFQ), comparing ASA classes I through IV. For some analyses, ASA classes I and II were designated as Group A and ASA classes III and IV were designated Group B.

Results: Of the 4923 cases, 875 (17.8%) were in Group A, 4032 (81.9%) were in Group B, and 16 (0.3%) had missing data. The mean CDVA and mean composite NEI-VFQ score improved after cataract surgery in both groups (P < .0001); however, Group A had a better mean postoperative CDVA and postoperative VFQ composite scores than Group B (P < .0001, both outcomes). A higher ASA class was associated with an increased risk for 2 unanticipated events; that is, clinically significant macular edema (CSME) (Group A: 4 [0.47%] versus Group B: 50 [1.28%]; adjusted odds ratio [OR], 3.02; 95% confidence interval [CI], 1.02-13.05; P = 0.04) and readmission to the hospital within 30 days (2 [0.23%] versus 56 [1.41%]; OR, 8.26; 95% CI, 1.71-148.62; P = .004) CONCLUSIONS: Among United States veterans, the ASA classification could be an important predictor of VRQL and visual outcomes. In this cohort, it was associated with an increased risk for 2 serious unanticipated events-CSME and readmission to the hospital-both costly, unwanted outcomes.

Financial Disclosure: Dr. Vollman is a consultant to Forsight Vision5. None of the authors has a financial or proprietary interest in any material or method mentioned.
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http://dx.doi.org/10.1016/j.jcrs.2016.04.032DOI Listing
July 2016

Outcomes of cataract surgery with residents as primary surgeons in the Veterans Affairs Healthcare System.

J Cataract Refract Surg 2016 Mar;42(3):370-84

From the Ophthalmology Department (Payal, Gonzalez-Gonzalez, Chen, Cakiner-Egilmez, Daly), Veterans Affairs Boston Healthcare System, Jamaica Plain, the Department of Ophthalmology (Daly), Boston University School of Medicine, and the Department of Ophthalmology (Payal, Chen, Daly), Harvard Medical School, Boston, Massachusetts; the Veteran Affairs Tennessee Valley Healthcare System Center and Vanderbilt Eye Institute (Chomsky), Vanderbilt University Medical, Nashville, Tennessee; the Michael E. DeBakey Veteran Affairs Medical Center and the Cullen Eye Institute (Baze), Baylor College of Medicine, Houston, Texas; the Ophthalmology Department, St. Louis Veteran Affairs Medical Center and the Department of Ophthalmology and Visual Sciences (Vollman), Washington University School of Medicine, St. Louis, Missouri; the Department of Defense/Veterans Affairs Vision Center of Excellence (Lawrence), Bethesda, Maryland, USA. Electronic address:

Purpose: To explore visual outcomes, functional visual improvement, and events in resident-operated cataract surgery cases.

Setting: Veterans Affairs Ophthalmic Surgery Outcomes Database Project across 5 Veterans Affairs Medical Centers.

Design: Retrospective data analysis of deidentified data.

Methods: Cataract surgery cases with residents as primary surgeons were analyzed for logMAR corrected distance visual acuity (CDVA) and vision-related quality of life (VRQL) measured by the modified National Eye Institute Vision Function Questionnaire and 30 intraoperative and postoperative events. In some analyses, cases without events (Group A) were compared with cases with events (Group B).

Results: The study included 4221 cataract surgery cases. Preoperative to postoperative CDVA improved significantly in both groups (P < .0001), although the level of improvement was less in Group B (P = .03). A CDVA of 20/40 or better was achieved in 96.64% in Group A and 88.25% in Group B (P < .0001); however, Group B had a higher prevalence of preoperative ocular comorbidities (P < .0001). Cases with 1 or more events were associated with a higher likelihood of a postoperative CDVA worse than 20/40 (odds ratio, 3.82; 95% confidence interval, 2.92-5.05; P < .0001) than those who did not experience an event. Both groups had a significant increase in VRQL from preoperative levels (both P < .0001); however, the level of preoperative to postoperative VRQL improvement was significantly less in Group B (P < .0001).

Conclusion: Resident-operated cases with and without events had an overall significant improvement in visual acuity and visual function compared with preoperatively, although this improvement was less marked in those that had an event.

Financial Disclosure: None of the authors has a financial or proprietary interest in any material or method mentioned.
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http://dx.doi.org/10.1016/j.jcrs.2015.11.041DOI Listing
March 2016

Ophthalmic Surgical Simulation in Training Dexterity in Dominant and Nondominant Hands: Results From a Pilot Study.

J Surg Educ 2016 Jul-Aug;73(4):699-708. Epub 2016 Mar 24.

Department of Ophthalmology, Veterans Affairs Boston Healthcare System; Department of Ophthalmology, Boston University School of Medicine; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts. Electronic address:

Purpose: To determine whether a structured training program using the validated EYESI surgical simulator improves dexterity in nondominant (ND) hands.

Setting: Academic tertiary referral center.

Design: Nonrandomized, prospective study.

Methods: Subjects who chose to participate and provided informed consent completed a structured simulation training program, which included a baseline test, 3 sessions of repeated tasks, and a final test on capsulorhexis in dominant (D) and ND hands. Participants completed demographic and satisfaction questionnaires. Performances at each session were recorded. We compared overall scores at baseline and at the end of the study, and analyzed trends over time. Statistical analysis was performed using JMP by SAS.

Results: Overall, 14 subjects completed the training program. In all, 3 (21.4%) were attending physicians and 11 (78.6%) were trainees. There was a significant improvement in the average overall scores (baseline vs. final) in both the D hand (33.4 vs. 46.5; p < 0.05) and the ND hand (28.9 vs. 47.7; p < 0.001). The structured training program demonstrated significantly faster performance times in both hands at the end of the study (D p< 0.001, ND p < 0.02). However, the learning curve was significantly steeper in the ND hand (p < 0.01). Participants agreed that simulation training improved the ND hand dexterity.

Conclusions: We found a significantly greater trend for improvement in the ND compared with the D hand. These results suggest that an elaborate, structured curriculum targeting teaching dexterity results in better simulated performance.
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http://dx.doi.org/10.1016/j.jsurg.2016.01.014DOI Listing
March 2017

Effects of tear gases on the eye.

Surv Ophthalmol 2016 Jul-Aug;61(4):434-42. Epub 2016 Jan 22.

Department of Ophthalmology, Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts, USA; Department of Ophthalmology, Boston University School of Medicine, Boston, Massachusetts, USA; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Chemical agents that target the eyes have been a popular choice for law enforcement during riots and for military training for nearly a century. The most commonly used agents are chloroacetophenone (formerly sold as Mace), o-chlorobenzylidene malononitrile, and oleoresin capsicum (OC or pepper spray, current ingredient for Mace). Initially, most severe ocular injuries were caused by the explosive force rather than the chemical itself. The development of sprays reduced the mechanical severity of ocular injuries, but resulted in a variety of chemical injuries. The effects on eyes include conjunctival injection, complete corneal epithelial defects, pseudopterygium, corneal neovascularization, persistent conjunctivalization, corneal opacities, and reduced visual acuity. Current management, based on limited human studies, emphasizes decontamination and symptomatic treatment. We review the literature related to clinical and histopathologic effects of tear gas agents on the eye and their management.
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http://dx.doi.org/10.1016/j.survophthal.2016.01.002DOI Listing
May 2017

Cataract Surgery Outcomes in Glaucomatous Eyes: Results From the Veterans Affairs Ophthalmic Surgery Outcomes Data Project.

Am J Ophthalmol 2015 Oct 22;160(4):693-701.e1. Epub 2015 Jul 22.

Ophthalmology Department, Veterans Affairs Boston Healthcare System, Jamaica Plains, Massachusetts; Department of Ophthalmology, Boston University School of Medicine, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts. Electronic address:

Purpose: To compare visual acuity outcomes, vision-related quality of life, and complications related to cataract surgery in eyes with and without glaucoma.

Design: Retrospective cohort study.

Methods: Cataract surgery outcomes in cases with and without glaucoma from the Veterans Affairs Ophthalmic Surgical Outcomes Data Project were compared.

Results: We identified 608 glaucoma cases and 4306 controls undergoing planned cataract surgery alone. After adjusting for age, pseudoexfoliation, small pupil, prior ocular surgery, and anterior chamber depth, we found that glaucoma cases were more likely to have posterior capsular tear with vitrectomy (odds ratio [OR] 1.8, P = .03) and sulcus intraocular lens placement (OR 1.65, P = .03) during cataract surgery. Glaucoma cases were more likely to have postoperative inflammation (OR 1.73, P < .0001), prolonged elevated intraocular pressure (OR 2.96, P = .0003), and additional surgery within 30 days (OR 1.92, P = .03). Mean best-corrected visual acuity (BCVA) and Visual Function Questionnaire (VFQ) scores significantly improved after cataract surgery in both groups (P < .0001), but there were larger improvements in BCVA (P = .01) and VFQ composite scores (P < .0001) in the nonglaucoma vs the glaucoma group. A total of 3621 nonglaucoma cases (94.1%) had postoperative BCVA 20/40 or better, compared to 466 glaucoma cases (89.6%) (P = .0003).

Conclusions: Eyes with glaucoma are at increased risk for complications and have more modest visual outcomes after cataract surgery compared to eyes without glaucoma. Despite this, glaucoma patients still experience significant improvement in vision-related outcomes after cataract extraction. Further study is needed to explore potential factors that influence cataract surgery outcomes in glaucomatous eyes.
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http://dx.doi.org/10.1016/j.ajo.2015.07.020DOI Listing
October 2015

Management of Corneal Bee Sting Injuries.

Semin Ophthalmol 2017 ;32(2):177-181

a Veterans Affairs Boston Healthcare System , Boston , MA , USA.

Purpose: To review the management of keratitis after corneal bee stings and to report a case of deep stromal corneal infiltrate secondary to a retained bee stinger managed conservatively in a patient who presented three days after unsanitary manipulation of the stinger apparatus.

Methods: Case report and review of literature.

Results: A 57-year-old male beekeeper was evaluated for pain, blurry vision, and photosensitivity after a corneal bee sting. Of note, the venom sac had been removed with dirty tweezers three days prior to his visit. On exam, a focal infiltrate with diffuse edema was seen surrounding a retained bee stinger in the peripheral cornea. Trace cells in the anterior chamber were also noted. Based on a high suspicion for infectious keratitis, a conservative treatment strategy was elected. Administration of broad-spectrum topical antibiotics with concomitant abstention of corticosteroids led to rapid resolution of the symptoms. Over 16 months of follow-up, the stinger has remained in situ without migration and the patient has maintained 20/20 visual acuity without complications. There is debate on the preferred method for the management of corneal injury secondary to bee stings, especially when it is associated with a retained stinger. We herein present our findings in our appraisal of reported cases.

Conclusion: In the aftermath of an ocular bee sting, close surveillance for inflammation and infection is essential. Individual manifestations of these injuries vary in timing, type, and severity; therefore, the accessibility of the stinger and the evolving clinical picture should guide therapeutic decisions.
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http://dx.doi.org/10.3109/08820538.2015.1045301DOI Listing
March 2017

Functional Visual Improvement After Cataract Surgery in Eyes With Age-Related Macular Degeneration: Results of the Ophthalmic Surgical Outcomes Data Project.

Invest Ophthalmol Vis Sci 2015 Apr;56(4):2536-40

DoD/VA Vision Center of Excellence, Crystal City, Virginia, United States.

Purpose: To determine if cataract surgery on eyes with AMD confers as much functional visual improvement as surgery on eyes without retinal pathology.

Methods: This is a retrospective analysis of 4924 cataract surgeries from the Veterans Healthcare Administration Ophthalmic Surgical Outcomes Data Project (OSOD). We included cases of eyes with AMD that had both preoperative and postoperative NEI-VFQ-25 questionnaires submitted and compared their outcomes with controls without retinal pathology. We excluded patients with other retinal pathologies (740 patients). The analyses compared changes in visual acuity and overall functional visual improvement and its subscales using t-tests, multivariate logistic regressions, and linear regression modeling.

Results: Preoperative and postoperative questionnaires were submitted by 58.3% of AMD and 63.8% of no retinal pathology cases (controls). Analysis of overall score showed that cataract surgery on eyes with AMD led to increased visual function (13.8 ± 2.4 NEI-VFQ units, P < 0.0001); however, increases were significantly less when compared with controls (-6.4 ± 2.9 NEI-VFQ units, P < 0.0001). Preoperative best-corrected visual acuity (preBCVA) in AMD was predictive of postoperative visual function (r = -0.38, P < 0.0001). In controls, postoperative visual function was only weakly associated with preBCVA (r = -0.075, P = 0.0002). Patients with AMD with vision of 20/40 or better had overall outcomes similar to controls (-2.2 ± 4.7 NEI-VFQ units, P = 0.37).

Conclusions: Cataract surgery on eyes with AMD offers an increase in functional visual improvement; however, the amount of benefit is associated with the eye's preBCVA. For eyes with preBCVA of 20/40 or greater, the improvement is similar to that of patients without retinal pathology. However, if preBCVA is less than 20/40, the amount of improvement was shown to be significantly less and decreased with decreasing preBCVA.
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http://dx.doi.org/10.1167/iovs.14-16069DOI Listing
April 2015

Reply: To PMID 24593958.

Am J Ophthalmol 2014 Oct;158(4):848-9

Bethesda, Maryland.

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http://dx.doi.org/10.1016/j.ajo.2014.07.019DOI Listing
October 2014

Reply: To PMID 24593958.

Am J Ophthalmol 2014 Oct;158(4):847-8

Bethesda, Maryland.

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http://dx.doi.org/10.1016/j.ajo.2014.06.027DOI Listing
October 2014

Management of mydriasis and pain in cataract and intraocular lens surgery: review of current medications and future directions.

Clin Ophthalmol 2014 3;8:1281-9. Epub 2014 Jul 3.

Department of Ophthalmology, Veterans Administration Boston Healthcare System, Boston, MA, USA ; Department of Ophthalmology, Harvard Medical School, Boston, MA, USA ; Department of Ophthalmology, Boston University School of Medicine, Boston, MA, USA.

The maintenance of mydriasis and the control of postoperative pain and inflammation are critical to the safety and success of cataract and intraocular lens replacement surgery. Appropriate mydriasis is usually achieved by topical and/or intracameral administration of anticholinergic agents, sympathomimetic agents, or both, with the most commonly used being cyclopentolate, tropicamide, and phenylephrine. Ocular inflammation is common after cataract surgery. Topical steroids and nonsteroidal anti-inflammatory drugs are widely used because they have been proved effective to control postsurgical inflammation and decrease pain. Topical nonsteroidal anti-inflammatory drugs have also been shown to help maintain dilation. However, use of multiple preoperative drops for pupil dilation, inflammation, and pain control have been shown to be time consuming, resulting in delays to the operating room, and they cause dissatisfaction among perioperative personnel; their use can also be associated with systemic side effects. Therefore, ophthalmologists have been in search of new options to streamline this process. This article will review the current medications commonly used for intraoperative mydriasis, as well as pain and inflammation control. In addition, a new combination of ketorolac, an anti-inflammatory agent, and phenylephrine, a mydriatic agent has recently been designed to maintain intraoperative mydriasis and to reduce postoperative pain and irritation from intraocular lens replacement surgery. Two Phase III clinical trials evaluating this combination have demonstrated statistically significant differences when compared to placebo in maintaining intraoperative mydriasis (P<0.00001) and in reducing pain in the early postoperative period (P=0.0002). This medication may be of benefit for use in cataract and lens replacement surgery in the near future.
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http://dx.doi.org/10.2147/OPTH.S47569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4086849PMC
July 2014

Intraoperative floppy iris and prevalence of intraoperative complications: results from ophthalmic surgery outcomes database.

Am J Ophthalmol 2014 Jun 1;157(6):1130-1135.e1. Epub 2014 Mar 1.

Department of Defense/Veterans Affairs Vision Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland.

Purpose: To estimate the prevalence of untoward events during cataract surgery with the use of pupillary expansion devices and intraoperative floppy iris (IFIS).

Design: Retrospective analysis of 4923 cataract surgery cases from the Veterans Affairs Ophthalmic Surgical Outcomes Data Project.

Methods: Outcomes from 5 Veterans Affairs medical centers were analyzed, including use of alpha-blockers (both selective and nonselective), IFIS, intraoperative iris trauma, intraoperative iris prolapse, posterior capsular tear, anterior capsule tear, intraoperative vitreous prolapse, and use of pupillary expansion devices. P values were calculated using the χ(2) test.

Results: A total of 1254 patients (25.5%) took alpha-blockers preoperatively (selective, 587; nonselective, 627; both, 40). Of these 1254 patients, 428 patients (34.1%) had documented IFIS. However, 75.2% of patients with IFIS (428/569) had taken alpha-blockers preoperatively (P < .00001). A total of 430 patients (8.7%) had a pupillary expansion device used during their cataract surgery, of which 186 patients (43.4%) had IFIS (P < .0001). Eighty-six patients with IFIS had at least 1 intraoperative complication and 39 patients with IFIS had more than 1 intraoperative complication (P < .001).

Conclusions: The use of either selective or nonselective alpha-antagonists preoperatively demonstrated a significant risk of IFIS. Nonselective alpha-antagonists caused IFIS at a higher prevalence than previously reported. This study did demonstrate statistically significant increased odds of surgical complications in patients with IFIS vs those without IFIS in all groups (those taking selective and nonselective alpha-antagonists and also those not taking medications).
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http://dx.doi.org/10.1016/j.ajo.2014.02.052DOI Listing
June 2014

Efficacy of surgical simulator training versus traditional wet-lab training on operating room performance of ophthalmology residents during the capsulorhexis in cataract surgery.

J Cataract Refract Surg 2013 Nov;39(11):1734-41

From the Veterans Affairs Boston Healthcare System (Daly, Gonzalez, Siracuse-Lee) and the Departments of Ophthalmology, Boston University School of Medicine (Daly, Siracuse-Lee) and Harvard Medical School (Daly, Gonzalez), Boston, Massachusetts, USA. Electronic address:

Purpose: To compare the operating room performance of ophthalmology residents trained by traditional wet-lab versus surgical simulation on the continuous curvilinear capsulorhexis (CCC) portion of cataract surgery.

Setting: Academic tertiary referral center.

Design: Prospective randomized study.

Methods: Residents who chose to participate and provided informed consent were randomized to preoperative CCC training in the wet lab or on a simulator. Residents completed pre-practice demographic questionnaires including habits of daily living. After completion of their preoperative training (wet lab versus simulator), residents performed their first CCC of the clinical rotation under the direct supervision of an attending physician as part of their standard training at the facility. Residents then completed satisfaction questionnaires regarding their preoperative training. Two attending surgeons reviewed and graded each video of operating room performance. The mean score between the 2 attending physicians was used as the individual performance score for each of the 12 performance criteria. The overall score was calculated as the sum of these 12 individual performance scores (standardized).

Results: Ten residents trained in the wet lab and 11 on the simulator. There was no significant difference in overall score between the 2 groups (P=.608). There was no significant difference in any individual score except time (wet-lab group faster than simulator group) (P=.038).

Conclusions: Preoperative simulator training prepared residents for the operating room as effectively as the wet lab. The time to pass the simulator curriculum was predictive of the time and overall performance in the operating room.

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.2013.05.044DOI Listing
November 2013

Informed consent for cataract surgery: patient understanding of verbal, written, and videotaped information.

J Cataract Refract Surg 2012 Jan 6;38(1):80-4. Epub 2011 Nov 6.

Department of Ophthalmology, Veterans Affairs Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts, USA.

Purpose: To determine the effectiveness of verbal, written, and videotaped descriptions of cataract surgery on patients' understanding of the risks, benefits, and treatment alternatives.

Setting: Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.

Design: Randomized prospective study.

Methods: Patients eligible for cataract surgery were randomized into 1 of 4 arms of the informed consent process as follows: Group 1, conventional verbal information; Group 2, conventional verbal information plus second-grade reading level brochure; Group 3, conventional verbal information plus eighth-grade reading level brochure; Group 4, conventional verbal information plus American Academy of Ophthalmology DVD Understanding Cataract Surgery: Patient Education DVD Featuring an Aid to Informed Consent. After the informed consent process, patients in each group completed a 12-question questionnaire discussing the surgical procedure, its benefits, its foreseeable and unforeseeable risks, and the alternatives to cataract surgery. Scores in each group were calculated as the number of correct responses out of 12 questions.

Results: Patients in Group 2 (mean score 10.8 ± 1.29 [SD]) and Group 4 (mean score 10.56 ± 1.44) scored significantly higher than patients in Group 1 (mean score 7.68 ± 2.80) or Group 3 (mean score 9.08 ± 1.60). Previous cataract surgery and education level had no significant influence on recall of the informed-consent process.

Conclusions: Concise informed consent information sheets at lower reading grade levels and videotape presentation optimized patient understanding of the risks, benefits, and treatment alternatives to cataract surgery. The cost-benefit of these results is important because better patient understanding has the potential to decrease the risk for indemnity payments awarded because of inadequate informed consent.
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http://dx.doi.org/10.1016/j.jcrs.2011.07.030DOI Listing
January 2012

Intraocular ophthalmic ointment following anterior segment surgery.

J Cataract Refract Surg 2011 Dec 17;37(12):2218-21. Epub 2011 Oct 17.

Veterans Affairs Boston Healthcare System, Boston, Massachusetts, USA.

A 79-year-old man had uneventful phacoemulsification at an outside facility. During the postoperative period, his vision worsened secondary to chronic cystoid macular edema (CME). The patient was referred to the Veteran Affairs Boston Healthcare System for review 2 years and 4 months after the initial cataract procedure. The CME was confirmed, and a large pearly white globule that moved with changes in head position was noted. Surgical removal was performed, and nuclear magnetic resonance spectroscopy identified the unknown substance as petroleum jelly. The patient was treated with topical ketorolac tromethamine and prednisolone acetate with subsequent resolution of inflammation and CME, resulting in a corrected distance visual acuity of 20/25. The visual acuity was maintained 5 years after surgery. This case highlights the importance of ensuring the integrity of clear corneal incisions and suggests that use of topical ointment at the conclusion of a clear corneal case should be avoided.
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http://dx.doi.org/10.1016/j.jcrs.2011.09.015DOI Listing
December 2011

Indications and care of keratoprosthesis patients.

Insight 2010 Apr-Jun;35(2):10-3

VA Boston Healthcare System, Ophthalmology Section, Boston, MA, USA.

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December 2010

Effect of trypan blue staining on the elastic modulus of anterior lens capsules of diabetic and nondiabetic patients.

J Cataract Refract Surg 2009 Feb;35(2):318-23

Department of Ophthalmology, Veterans Affairs Boston Healthcare System Jamaica Plain, Boston, Massachusetts 02130-4893, USA.

Purpose: To determine whether trypan blue causes a significant difference in the biomechanical properties (stiffness) of diabetic and nondiabetic anterior lens capsules and to determine whether diabetes significantly alters the stiffness of anterior lens capsules.

Setting: Veterans Administration Boston Healthcare Center System, Jamaica Plain, Massachusetts, USA.

Methods: In this unmasked prospective randomized controlled experimental study, anterior lens capsules were obtained from diabetic and nondiabetic patients approved for cataract surgery. Four treatment groups were created: (1) capsules of nondiabetic patients without trypan blue; capsules of nondiabetic patients with trypan blue; (3) capsules of diabetic patients without trypan blue; (4) capsules of diabetic patients with trypan blue. Anterior lens capsule stiffness as a function of elastic (Young's) modulus (kilopascals) was measured with the Hysitron TriboIndenter.

Results: The use of trypan blue led to significantly stiffer anterior lens capsules (P= .036). Trypan blue had the greatest effect on the stiffness of diabetic lens capsules (P= .046).

Conclusion: Trypan blue contributed to increased capsule stiffness during capsulorhexis, especially in diabetic patients.
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http://dx.doi.org/10.1016/j.jcrs.2008.10.040DOI Listing
February 2009

Effects of topical nonsteroidal antiinflammatory drugs on the expression of matrix metalloproteinases in the cornea.

J Cataract Refract Surg 2003 May;29(5):989-97

Ocular Microbiology and Immunology Laboratory, Refractive Surgery Research Laboratory, The Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD 21093, USA.

Purpose: To assess the effects of nonsteroidal antiinflammatory drug (NSAID) eyedrops on the expression of matrix metalloproteinases in corneal tissue.

Setting: Ocular Microbiology and Immunology Laboratory, Refractive Surgery Research Laboratory, The Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA.

Methods: Seventy rats were divided into 2 groups: intact and debrided epithelium. Uniform central corneal epithelial defects were created in the right eye of the debrided corneal group. Each group was divided into 4 subgroups, each receiving 1 of the following eyedrops or artificial tears: The 3 NSAIDs were diclofenac sodium 0.1% (Falcon or Voltaren) and preservative-free ketorolac 0.5% (Acular PF). The artificial tears were carboxymethylcellulose sodium 0.5% (Refresh Plus PF). The eyedrops were administered 4 times a day for 1 week. The rats were killed on days 2 and 7. The corneas were excised and processed for immunohistochemical staining, Western blot assay, and zymography studies to determine the localization of the production of the following matrix metalloproteinases (MMPs): MMP-1, MMP-2, MMP-8, and MMP-9.

Results: Matrix metalloproteinase-1, MMP-8, and MMP-2 were detected in rat corneas at 48 hours in the debrided and intact epithelium groups treated with NSAID eyedrops. The MMP-1 and MMP-8 expression levels were higher in intact corneas in the diclofenac sodium groups than in the ketorolac and artificial tears groups. The expression was localized mostly in the epithelial cells and occasionally in keratocytes.

Conclusion: This study provides preliminary evidence that topical application of some NSAIDs can induce the early expression of MMP-1, MMP-2, and MMP-8 in the cornea, suggesting that MMPs play a role in the corneal cytotoxicity of certain NSAIDs.
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http://dx.doi.org/10.1016/s0886-3350(02)01737-6DOI Listing
May 2003