Greetings OAS Members!

2022 is an exciting time to be a member. Our growing organization has over 100 members and we are proud to be the only organization where anesthesiologists, ophthalmologists, registered nurse anesthetists and other clinicians can come together to improve the quality of care for our patients.

This year we are hosting the 36th Annual OAS Scientific Meeting in Baltimore Maryland – and offering online access for those who cannot travel. It’s a vibrant, new city for OAS members with a wealth of academic support from our partners on the East coast. Can’t wait to see you there!

Michael Morley, MD, ScM ¹, Anne M. Menke, RN, PhD², Karen C. Nanji, MD, MPH³

¹ Ophthalmic Consultants of Boston, Harvard Medical School, Boston, MA
² Ophthalmic Mutual Insurance Company, San Francisco, CA 
³ Massachusetts General Hospital, Harvard Medical School, Boston, MA

DOI: https://doi.org/10.1016/j.ophtha.2019.12.019

Publication date: December 25, 2019
Ophthalmology Journal - a publication of the American Academy of Ophthalmology

PurposeTo evaluate the types of anesthesia-related closed claims and their contributing factors, using data from the Ophthalmic Mutual Insurance Company (OMIC).

Design
Retrospective analysis of preexisting data.

Participants
Plaintiffs who filed a professional liability claim or suit (written demand for money) against OMIC-insured ophthalmologists, ophthalmic practices, or surgicenters in which the surgical case occurred.

Methods
Plaintiff claims were collected from the OMIC database from 2008 to 2018 using search queries for terms associated with known complications of ophthalmic anesthesia.

Main Outcome Measures
Number and types of anesthesia-related injuries and claims, who administered the anesthesia, the outcomes of the claim or suit, cost to defend, and payments made to plaintiffs.

Results
Sixty-three anesthesia-related claims or suits were filed by 50 plaintiffs. Anesthesia-related injuries included globe perforation (n = 17), death (n = 13), retrobulbar hemorrhage (n = 7), optic nerve damage (n = 4), vascular occlusions (n = 2), pain (n = 2), eye or head movement resulting in injury (n = 2), and 1 case each for numbness, diplopia, and tooth loss during intubation. All but 1 patient who died had preexisting, significant comorbidities. Two deaths were related to brainstem anesthesia. Regarding the type of anesthesia in the closed claims, retrobulbar and peribulbar anesthesia were the most common types (n = 16 each), followed by local infiltration around the lids and facial nerve (n = 6), topical anesthesia (n = 5), and general anesthesia (n = 5). In 2 cases, the exact type of anesthesia was unknown but not general. The 5 topical with sedation anesthesia-related claims were due to inadequate pain control (n = 2), ocular movement resulting in capsular rupture (n = 2), or death (n = 1) allegedly related to excessive or inadequate monitoring of sedation. There were 5 claims related to general anesthesia including 4 deaths and 1 tooth loss during intubation. Sedation was alleged to be a factor in 5 cases resulting in death. Anticoagulants were a factor in 3 retrobulbar hemorrhage cases.

Conclusions
Although claims and suits were infrequent given the large number of insured ophthalmologists and the large number of surgical cases requiring various types of anesthesia performed over the 10.5-year study period, severe injuries can occur

A Single-Center, Retrospective Records Review of 130,775 Patients, 1999-2015

Vinodkumar Singh, MD¹,Ayesha S. Bryant, MSPH, MD¹, Matthew Hull, MD¹, Jason Skelley, MD¹, Robin Walters, MD² , R. Clark Cross, MD¹, Marc A. Rozner, MD³ , and Gwendolyn L. Boyd, MD¹

¹ Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
² Department of Anesthesiology, University of Kansas Medical Center, Kansas City, MO, USA
³ Baylor College of Medicine Education at The University of Texas MD Anderson Cancer Center, Houston, TX, USA 

Abstract 

Purpose: The most recent study of ophthalmic surgery morbidity and mortality was published in 1995, with a patient study population from 1977 to 1988. The present study reports surgical outcomes from a single-center, retrospective analysis of patient records from 1999 to 2015. Methods: Three International Classification of Diseases–9-CM codes for cardiorespiratory events were searched in the discharge diagnoses in an eye hospital over a 16-year period. The overall mortality and preoperative risk factors were analyzed, including the type of anesthetic, type of surgery, medical comorbidities, and bradycardia preceding the cardiac events. Results: Between February 1, 1999 and October 1, 2015, a total of 130 775 patients presented for ophthalmic surgery. Fifty-nine patients (0.45 per 1000) experienced a cardiorespiratory event. Of the 59 patients, 14 patients had a cardiorespiratory arrest, 9 of whom died during the perioperative period. Of the remaining 45 patients, 29 had significant adverse events needing some form of advanced monitoring, evaluation, and/or intervention. There was a significantly greater prevalence of diabetes among patients who had a cardiorespiratory event (P < .001). Conclusions: The major risk factor associated with ophthalmic surgery morbidity and mortality was diabetes with its associated complications of autonomic neuropathy, nephropathy, and retinopathy. Of the 9 patients who died, 8 were diabetic with proliferative diabetic retinopathy and renal  insufficiency/failure. The ninth mortality was secondary to a venous air embolism during ocular air infusion. The adage that “the eye is the window to our overall health” seems to be correct.

Click here to read the full paper. 

Howard Palte, MBChB
University of Miami System of Health 

Ocular trauma is common arising secondary to sports injury, road accidents, assault and leisure. The quoted incidence is imprecise because estimates are retrospective and drawn from hospital records and population surveys. However, the World Health Organization (WHO) estimates there are 55 million injuries globally with more than 2.5 million occurring in the United States, alone. The majority (90%) occur in males, particularly those in the 15-24-year age group.

The Ocular Trauma Study Group divides eye trauma into open and closed globe injury with further classification according to type, grade, pupil response and zone of injury (Table 1). Moreover, the area affected is divided into three zones, viz. zone I (limited to the cornea and limbus), zone II (< 5mm posterior to limbus) and zone III ( > 5mm posterior to limbus).

The primary considerations in the management of eye trauma are control of intraocular pressure (IOP) and preservation of ocular integrity by preventing extrusion of ocular contents. In brief, the primary factors affecting IOP are changes in intraocular volume (blood and aqueous humor), orbit compliance and external compressive forces. Intraoperative coughing, straining and retching result in massive increases in IOP and pose significant threat to visual outcome.

Anesthesia management of ocular trauma extends beyond the eye., The preoperative evaluation is important because there may be additional factors that modify the anesthesia plan. The provider should determine the mechanism of injury and examine for associated injuries, especially head trauma. In certain instances, additional investigations  such as, CT scan orbit and head and metabolic panel may be warranted.

For decades, general anesthesia (GA) has been preferred for repair of open globe injuries (OGI) because it provides ocular akinesia, lowered IOP, airway control and eliminates the peril of unexpected patient movement. Anecdotal reports, dating back to the 1950s, stressed avoidance of succinylcholine because of elevations in IOP and extrusion of ocular contents. However, succinylcholine  may be considered in select OGI when airway control or aspiration is of concern because it produces moderate and transient increases in IOP (9mmHg), and not an implicated precursor of vitreous expulsion. The drawbacks of GA  include risk of regurgitation, increased nausea and vomiting and significant increases in IOP with coughing and bucking.

Regional anesthesia (RA) with monitored anesthesia care (MAC) is an alternative option in select open globe injuries. A retrospective review at a leading eye institute examined outcomes of eye injuries managed under RA + MAC in terms of  long-term visual acuity. It found that anterior (Zone I & II) injuries and intraocular foreign bodies (IOFB) managed under RA & MAC resulted in reduced operative times, and no statistical difference in visual acuity at 2-month follow-up.

The regional anesthesia technique used in open globe injuries requires modification in order to prevent fluctuations in IOP. Eyelid squeezing causes massive increases in IOP and is attenuated by performance of a facial nerve (VII) block, commonly adopting a modified van Lint approach. The subsequent extraconal (peribulbar) block is performed using a restricted volume (5-6 ml) of LA injected in small aliquots over 2-3 minutes (limiting external compressive forces on the globe).

Eye injuries in children require operative repair under GA. It is estimated that 90% of these injuries are preventable because the majority occur at home when there is no parental supervision.  The mechanism varies with age with cleaning products injuring toddlers and older children more likely to sustain sports and projectile insults.

Primary closure of open globe injuries is optimally achieved within 24 hours. Long-term visual outcomes are determined by initial visual acuity . The US Eye Injury Register indicates that long-term visual acuity is determined by presenting light perception. Ultimately, 3 /4 patients retain a degree of vision and 20% regain normal light perception. 

First off, I would like to sincerely thank the Board of Directors and all the members of the Ophthalmic Anesthesia Society for your trust and support in nominating me as this year’s president. I will do my best to fulfill my duties and responsibilities, but I will need your help - I want to hear your ideas, feedback, and suggestions to help our society develop a strong voice for patient care, patient safety, and operating room business in ophthalmic surgery and anesthesia.

Membership is very crucial for the survival of any organization, and I believe that the value of the membership is a very important factor in retaining existing members and attracting new members. Therefore, improving the value of our membership will continue to be my main focus of the OAS business in the upcoming year.

The OAS annual scientific meeting has been a great platform for all our members to come together face to face to exchange updated information, discuss new founded theories, and practice ophthalmic surgery and anesthesia. I want to enhance the educational value of the 34th Annual Scientific Meeting and start the planning of the 34th annual scientific meeting early in order to invite valuable speakers, to advertise the benefits of the meeting, and attract new members to our society while gaining new attendees.

Many of our members are already experts in the practice of ophthalmic surgery and anesthesia. Their publications, including papers, articles, abstracts, practice protocols, institutional policies, and letters to editors are very valuable to showcase to our members and the international ophthalmic society as well. Four years ago, during my first term of presidency, I wanted to create an online repository to host all the publications from our members, however, the project was delayed due to technical difficulty so I would like to try to implement this one again in the upcoming year. In addition to post your work, the repository will also house guidelines from centers across the country to help in building consensus statements on key issues in the specialty. I will need each of you to send all of your publications to Lori and Melissa as the first step of this exciting project.

The OAS newsletter has been getting better and better in the last several years thanks to the hard work of the OAS Scientific Advisory Panel, but we need help from every member to participate and make a contribution to the newsletter to make it more meaningful and educational. Please send your suggestions to Lori, Melissa, the board members, and myself included.

The online discussion forum has also been a great success in the last several years by being more simple, effective, and accessible. If you have questions or have answers to the questions other members posted, we encourage you to participate as this is can be a great learning experience for you and your peers. Our small society is advantageous for us to get to know each other, so I hope the improvement of the online discussion forum can further develop the communication between our members.

In addition to improving the value of membership, I am also asking every member to help our society grow by reaching out to our surgical and anesthesia colleagues and encouraging them to become new members and participate in this wonderful community that we have built.

If you have any questions, comments, or concerns, please don’t hesitate to reach out to me. I am very excited for the new business year of the Ophthalmic Anesthesia Society and am looking forward to working with every member closely for the bright future of our society.

Respectfully submitted, 

Zhuang T. Fang, M.D., MSPH, FASA
Clinical Professor
David Geffen School of Medicine at UCLA
Department of Anesthesiology and Perioperative Medicine
Associate Director, Wasserman Stein Operating Service

This fall, TLC presented data at the American Society of Anesthesiologists annual meeting from a Phase I/II clinical trial which showed TLC590 to yield more immediate and long-lasting pain reduction than ropivacaine.

The multilamellar vesicles ropivacaine (MVR) demonstrates a sustained-release profile in an in vitro serum environment model after 24 hrs of incubation which translates in the in vivo rat pharmacokinetic profile of ropivacaine as a prolonged half-life that is 10-fold longer in duration than plain ropivacaine solution. The anesthetic effect of single-dose MVR is apparent by providing a prolonged analgesia effect compared to plain ropivacaine solution in an in vivo guinea pig pin-prick wheal model after a single intracutaneous injection.

From a safety evaluation, MVR is well tolerated after a subcutaneously injection at a dose level of 20 mg/kg in rats, with no observable changes in clinical observation, body weight, organ weight, hematology and serum chemistry analysis In addition, in vivo findings in which TLC590 showed no dose-related toxicity and other preclinical data were recently published in the International Journal of Nanomedicine.

OAS members have long expressed interest in non-opioid solutions for pain management following surgery, so we’ll stay tuned for more advances – including advances in nanoscience and bioengineering.

Read the journal article online.

This month, the Centers for Medicare and Medicaid Services (CMS) has released the 2020 Medicare Physician Fee Schedule final rule, which includes the proposed drop in payments for cataract surgery.

The final work relative value unit (RVU) for complex cataracts 66982 is 10.25, compared to the current Work RVU of 11.08, a $47 reduction. For non-complicated cataracts 66984, the proposed Work RVU is 7.35, compared to the current 8.52, a $97 reduction.

Improved technology in hands of a skilled ophthalmic surgery care team have created efficiencies and, ultimately, a reduction in time. The decrease in valuation is directly connected to the decreasing time ophthalmologists spend in the surgery room and the decreased time spent on post-operative visits (especially the less frequent, fourth post-operative visit).

The American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS), meanwhile, have lobbied for a less dramatic decrease in reimbursements by highlighting on the other part of the RVU’s formula: intensity and complexity.

Cataract surgery is a complex procedure with irrefutable, life-changing outcomes.

So, what advice are the experts giving to blunt the decrease in Medicare/Medicaid reimbursements?

• Ophthalmic surgery teams should pay their dues and become more active with their professional societies. Ongoing collaboration with OAS, AAO, ASCRS, and the American Society of Ophthalmic Administrators will empower these organizations to ensure we are represented whenever RVUs are considered. RVUs are determined by a special committee formed by the American Medical Association (AMA), known as the AMA/Specialty Society RVS Update Committee. We need seats at their table!
• Reevaluate your cases. It may be prudent to audit charts more judiciously, confirm that visual criteria are clearly defined and each patient truly needs cataract surgery.
• Streamline services and diversify, where appropriate. Some patients may benefit by undergoing other procedures in conjunction with cataract surgery: glaucoma techniques, femto-LASIK surgery, multifocal lens implants, etc.  
• Continue developing relationships with your patients and delivering quality care. The reason ophthalmic surgery procedures weren’t cut as dramatically as we feared is because there is tremendous value to the care we provide. Our skills, the quality of our care and our outcomes are a factor when considering the intensity and complexity in valuation discussions.

Learn more:

https://www.federalregister.gov/documents/2019/11/15/2019-24086/medicare-program-cy-2020-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other

http://ascrs.org/2020-medicare-physician-fee-schedule-mpfs-proposed-rule

https://www.aao.org/eyenet/article/cataract-surgery-payment-in-medicare?september-2019

https://asoa.org/news/ascrs-special-report-key-information-about-2020-medicare-physician-fee-schedule-proposed-rule

https://www.reviewofophthalmology.com/article/medicare-proposes-another-cut-in-cataract-reimbursement

By Ric Rivers, MD, and Tina Tran, MD

OAS is happy to roll out a new series, designed to connect members from across the United States and showcase our communities. Ophthalmic anesthesia is a very niche field so we're working hard to give member every opportunity to connect, discuss and discover. 

The first in the series spotlights the Wilmer Eye Institute. We hope you enjoy it! 

This summer marks the 10-year anniversary of the opening of Wilmer Eye Institute’s Robert H. & Clarice Smith Building and Maurice Bendann Surgical Pavilion.

The first of its kind, this landmark building united ophthalmology research and care delivery to a degree not seen before in the field of ophthalmology. The building supports engineers, scientists, clinicians and their teams in working together and sharing ideas in an open, interactive, and collaborative environment. 

In light of this anniversary, here is a quick introduction to the Wilmer Eye Institute written by OAS members Ric Rivers, MD, and Tina Tran, MD.

About William Holland Wilmer & Wilmer Eye Institute 

William Holland Wilmer began to practice ophthalmology in 1889 and over the next 35 years became one of the most renowned practitioners in his field. In 1924, the Wilmer Foundation was started to raise funds to allow him to carry on his own research work and to train young doctors. An endowment of nearly $4 million was raised, and one year later, the foundation established the Wilmer Institute of Ophthalmology at The Johns Hopkins Hospital. The institute was the nation's first university eye clinic to combine patient care, research and teaching under one roof, and Wilmer was chosen, at age 61, to become its inaugural director. He remained in that position until his retirement in 1934.

At the beginning there was an ophthalmology emergency room, two ophthalmology operating rooms, and eight ophthalmology inpatient beds in a single same Wilmer building, spread over 2 floors. About 15 years ago we finally grew out of that space. Now Wilmer shares space in the Johns Hopkins adult emergency department, has seven ophthalmology operating rooms in the new Smith building, and admits patients to the main hospital. Wilmer currently performs almost 7000 cases per year and all subspecialties are represented.

The operating room operates with a team model that relies a couple of monthly meetings where nursing, surgery, anesthesia, materials management, and administration all participate to make an efficient operation. Patient care is optimized through the use of an electronic medical record that is shared by all members of the team. Daily routine includes morning debriefing sessions where nursing and anesthesia discuss the issues of the day whether it is related to equipment, personnel, or patients.

The seven dedicated operating rooms are separated from the main hospital in a separate building, across the street. All ophthalmology surgical cases except the smallest peds patients, and the critically ill, are performed in this facility. Ninety-five percent of the patients are outpatients and about five percent are planned post-op admissions (transferred by hospital-owned ambulance). 

A recent study, published by MBJ Open Ophthalmology, set out to determine if automated OCT aids in the management of patients in a high-volume after-hours clinic.

OCT has become the standard of care for diagnosing plenty of ocular pathologies, but is generally not available at most institutions after-hours -- when many patients present with acute complaints. Richard I. Kaplan, MD, New York Eye and Ear Infirmary of Mount Sinai, and his team, obtained images over a period of 15 months (202 patients, 359 eyes), reviewed electronic patient records, and surveyed staff to measure the advantages of having an automated OCT for diagnosis and management of acute complaints and ocular emergencies.

Chief complaint, image type, image findings and diagnosis were analyzed. Ultimately, patient complaints included flashes/floaters, metamorphopsia, decreased vision and scotomas. Diagnoses comprised of vascular occlusion, retinal detachment, macular hole, cystoid macular edema and central serous retinopathy.

Twenty-five residents and fellows participated in the voluntary survey. All residents (n=18) and fellows (n=7) found the OCT to be helpful; 15 residents (83%) and 4 fellows (57%) felt that it changed management. Most participants, (21 or 83%), felt that the OCT improved patient satisfaction and reduced delayed or misdiagnosis. Most participants (19 or 76%) also reported reduced physician stress.

Kaplan et al noted OCT aids in the quickly-needed diagnosis of central retinal artery occlusion (CRAO) – data showed six patients with CRAO, and OCT successfully confirmed five.

They also highlighted OCT’s use in differentiating macular-involving versus macular-sparing retinal detachment, leading urgent retinal detachment repair or surgical planning and patient couselling. “In cases of macula-off retinal detachments, the OCT provides objective documentation. As most ophthalmic lawsuits in the USA relate to RD, such documentation substantiates the appropriateness of care in the after-hours setting,” Kaplan explained.

OCT was also found helpful in ruling-out emergent pathology, thus refining triage of patients to subspecialty clinics in hospital and reducing the need for after-hours subspecialty consults. The study included 14 patients with central serous retinopathy who, in general, with OCT verification, follow-up appointments could be extended to 3 weeks.

Although trauma cases were not well represented in the sample, OCT appears to aid in the identification of globe perforation and may aid in ruling out such injuries in the emergency setting.

Finally, one limitation of automatic OCT is the minimum vision requirement necessary for patients to find fixation cues without operator redirection. Some attempted scans had insufficient signal strength, all in patients with visual acuity 20/400 or worse.

“In the after-hours or acute-care setting, the most important goal of care is the timely diagnosis and treatment of vision threatening pathology while efficiently using ancillary testing and consultants. We found OCT accessibility in the after-hours setting improved the diagnosis and disposition of patients. Additional studies will be helpful to further appreciate the benefits of including OCT alongside clinical examination in both eye-only and general emergency settings.”

Summer greetings! Its late July and our 33^rd Annual Scientific Meeting (September 13-15, 2019) is almost upon us.

I am excited at the variety and depth of topics to be covered and am confident that the program will offer special value to attendees whether they are anesthesiologists, ophthalmologists, CRNAs or allied professionals. We are indeed fortunate to host top local experts as well as a number of esteemed international guests. Their combined experience has not been paralleled at prior meetings. In fact, this assembly will offer attendees a rare opportunity to glean valuable theoretic and practical knowledge in a condensed 2-day span.

Many of our local faculty is well known to you. They offer attendees the benefit of invaluable knowledge and years of experience gained from practice at their academic institution or private practice. I am confident that each lecture will leave you with at least one ‘pearl of wisdom’.