Quick Hits

Silence reduces risk of infection from IVI

Wills Eye implements a “no-talking” policy.

A policy of prohibiting talking during intravitreal injections implemented by Wills Eye Hospital has paid off in a significantly reduced incidence of post-injection endophthalmitis. A study, led by Michael Dollin, MD, reviewed more than 126,000 injections over four years. A large-scale study was necessary to validate the concept of a no-talking policy because post-injection endophthalmitis is a relatively rare occurrence.

Before this study, others had put forward ideas to reduce the incidence of post-injection infection, including wearing masks and not talking, but the Wills researchers believe their study, presented at the recent ARVO meeting, is the first real-world effort on a large-enough scale to confirm the value of a no-talking policy.

The study was based on a retrospective, comparative case series of all patients at Wills diagnosed with endophthalmitis following intravitreal injection (IVI) of an anti-VEGF agent between January 1, 2009 and December 31, 2012. Researchers compared a 24-month period when a no-talking policy was implemented during IVI to the previous 24 months without a no-talking policy.

During the study period, a total of 126,587 IVIs were performed (47,773 before the no-talking period and 78,814 during the no-talking period) with a total of 48 cases of endophthalmitis (0.038%; 1:2,637 injections), 17 of which were culture-positive (0.013%; 1:7,446).

During the 24 months before the no-talking policy started, Wills had 27 cases of reported endophthalmitis (0.057%; 1: 1,769), nine of which were culture-positive (0.019%; 1:5,308).

During the 24-month no-talking period, Wills physicians diagnosed 21 cases of endophthalmitis (0.027%; 1:3,753), eight of which were culture-positive (0.010%; 1:9,852). Among culture-positive cases, oral pathogens were seen in greater frequency before the no-talking policy took effect.

The study found the no-talking policy during IVI was strongly associated with decreased risk of endophthalmitis, culture-positive endophthalmitis and oral pathogen-associated endophthalmitis.

The researchers concluded that implementing a no-talking policy during IVI appears to be effective in helping reduce the risk of post-injection endophthalmitis, including oral pathogen-associated cases that could be linked to talking.

REFERENCE

Neuro-imaging expands understanding of glaucoma

The disease goes beyond just the optic nerve.

By Bill Kekevian, Senior Associate Editor

While neuro-imaging devices are crucial to diagnosing neuropathic emergencies, they can also be used to change the perception of disease altogether. One such example is a shake-up in understanding the far-reaching pathology of glaucoma damage. “Understanding glaucoma as a disease with damage not exclusive to the eye certainly opens up other avenues of inquiry,” says Ian Conner, MD, PhD, a clinician-researcher at the University of Pittsburgh.

He believes through neuro-imaging, that glaucoma patients may someday be able to receive more than just IOP-lowering treatment. “I think when we learn to better understand glaucoma as a disease affecting the central nervous system rather than as a disease of the optic nerve alone, it may open the box a little bit in terms of coming up with ways to treat the disease,” he says.

He says imaging the visual system back to the visual cortex can better help ophthalmologists understand which factors play a role in the development of glaucoma. In his research, he says, “we image the optic nerve, the optic chiasm and the optic tracts. We look at measures such as the gross dimensions of those structures as well as diffusion tensor imaging of the white matter tracts to look at the organization within them, all the way to the geniculate nucleus and then back through the optic radiation into the striate and even extrastriate cortex.”

Though it may be years away, these technologies promise a practical use to look at subtle changes in the visual system and identify patients with either very early-stage disease or who are otherwise unable to help their doctors by participating in a visual field testing.

“For a long time in glaucoma, we’ve been looking for something that’s been relatively non-invasive, but also not really rely upon the patient for much input that could help determine progression,” says Dr. Conner. “Some of the imaging technologies we currently use, such as OCT, really help us along that direction, but these are still limited to providing information about the eye and optic nerve head.”

“If we can better understand what other CNS markers play a role in the development of glaucoma, perhaps we can better identify patients who are destined to develop more aggressive forms of the disease and target them for early and more aggressive treatment,” he speculates.

First Advanced Cornea Conference has impact

Participants cite learning they can put into practice.

By Jerry Helzner, Senior Editor

The purpose of the first Advanced Cornea Conference (ACC) was to provide cornea specialists and comprehensive ophthalmologists with three days of intense instruction and interaction on a full range of cornea-related topics from a 19-member faculty led by Course Director Thomas John, MD, of Loyola University, Chicago. The goal was what the ACC program described as “a comprehensive cornea learning experience, both in medical and surgical corneal areas, that also encompasses the ocular surface and anterior segment of the eye.”

Though the goal was an ambitious one, participants who offered their feedback at the conclusion of the Conference, held at the Ritz-Carlton Hotel in Fort Lauderdale, Fla., in March, were near-unanimous in their praise for the event, citing the broad scope of new learning that they could put to use in their own practice.

“I rarely take notes on ways to improve my clinical skills and practice efforts but I took 10 pages of notes in three days,” wrote Mitch Jackson, MD, of Lake Villa, Ill. “The information just kept coming and was so useful and practical to my daily job as an ophthalmologist.”

“The meeting provided a unique opportunity for corneal specialists around the country to convene in a more intimate, small-scale, interactive setting as in contrast to our more traditional larger meetings throughout the year,” wrote Kendall Donaldson, MD, MS, of Bascom Palmer Eye Institute.

“This was the most intellectually stimulating conference I have ever attended,” wrote Laura Periman, MD, of Seattle. “I plan to attend next year.”

Allergan, Bausch+Lomb and Biotissue served as Silver Supporters of the Conference, with a total of 16 exhibiting companies.

The 2015 ACC will be held at the Ritz-Carlton in Fort Lauderdale March 13 to 15.

PentaVision Media, publisher of Ophthalmology Management, served as a co-sponsor of this event.

Run a tight ship for a better bottom line

tip of the month

It is easy for money to slip through the cracks in a busy ophthalmology practice. Loose processes and procedures can be almost as costly as an embezzler on your staff. Here, Steven Silverstein, MD, FACS, and writer of our “Efficient Ophthalmologist” column, offers advice on tightening workplace procedures.

1. Don’t be too quick to write off aging receivables. This is one area where persistence can pay off. “In our practice, we re-file claims, call slow pay patients repeatedly to reconcile accounts and sometimes downgrade charges to encourage payment,” says Dr. Silverstein.

2. Stolen merchandise is the same as stolen cash. Secretarial supplies, pharmaceuticals and larger-ticket items from the optical shop are often poorly monitored and have a tendency to walk out the door. Make sure you have effective inventory controls in all areas of the practice.

3. Obtain a police report and background check on all new hires. This may sound unduly cautious but your goal is to protect the practice.

4. Consider a two-person check-signing rule. No one should have absolute authority over dispensing practice funds.

Physicians help spur the US economy

A comprehensive new study commissioned by the AMA and conducted by IMS Health asserts that physicians are major contributors to the health of the overall US economy through both job creation and economic output.

The study, called “The National Economic Impact of Physicians,” found that on the national level physicians supported a total of almost 10 million jobs in 2012, or an average of 13.84 jobs for each physician accounting for more than $1 million in wages and benefits. In terms of economic impact, the study found that US physicians accounted for $1.6 trillion in direct and indirect economic output.

The study also reported that on average each US physician supported more than $90,000 in state and local, tax revenues.

Tennessee ODs win scope-of-practice battle

Legislature approves injections for lid procedures.

By Jerry Helzner, Senior Editor

Despite strong opposition from the Tennessee Academy of Ophthalmology (TNAO) and the Tennessee Medical Association (TMA), optometrists in the state prevailed as legislation was passed and signed into law in April allowing ODs to inject local anesthesia for six types of lid procedures.

“Performing surgical procedures requiring injectable anesthesia requires the highest level of surgical judgment and the ability to ensure patient safety,” said Mark Melson, MD, TNOA president.

“The optometry training model is not focused on providing practitioners with the necessary medical education and surgical skill set to provide safe and quality surgical care. The risks to the patient are too high,” Dr. Melson said. “For these patient safety reasons, the Tennessee medical community opposed this legislation.”

The legislation allows optometrists to surgically remove lesions from the area around the eye using local injectable anesthesia. These lesions are often referred to as “lumps and bumps.” Lesions, cysts and tumors on the eyelid are abnormal growths that could be cancerous or benign, noted Dr. Melson. If cancerous, improper removal of the growths could cause the cancer to spread, he said.

“The TMA and the TNAO feel that (the legislation) does not represent sound health policy for the residents of Tennessee,” said Dr. Melson.

The TMA and TNAO did win one concession in the form of an amendment that specifically limits the use of injectable anesthesia to six lid procedures.

“We are definitely not happy with the outcome but the amendment does help by removing any open-ended interpretation of the legislation that could have occurred without the specific wording that was added,” said Angela Allen, TNOA director of legislative affairs.

The procedures for which ODs can now legally use local injectable anesthesia include needle drainages, excision of small, benign epidermal lesions, incision and curettage of non-recurrent chalazion, repair of small eyelid lacerations and removal of foreign bodies in the eyelid if they do not involve the lid margin, lacrimal drainage structures and extend no deeper than the orbicularis muscle.

A statewide poll showed almost 85% of Tennesseans opposed the legislation.