Fellowship: Massachusetts Eye and Ear Infirmary Ophthalmic Training (1997) MA
Fellowship: Armed Forces Institute of Pathology (1996) DC
Board Certification: American Board of Ophthalmology, Ophthalmology (1991)
Residency: Walter Reed Army Medical Center (1990) DC
Internship: Malcolm Grow Medical Clinic (1980) MD
Medical Education: University of Mississippi (1979) MS
Comparing cataract surgery complication rates in veterans receiving VA and community care.
Health services research
OBJECTIVES: To compare 90-day postoperative complication rates between Veterans receiving cataract surgery in VA vs Community Care (CC) during the first year of implementation of the Veterans Choice Act.DATA SOURCES: Fiscal Year (FY) 2015 VA and CC outpatient data from VA's Corporate Data Warehouse (CDW) 10/01/14-9/30/15). FY14 data were used to obtain baseline clinical information prior to surgery.STUDY DESIGN: Retrospective one-year study using secondary data to compare 90-day complication rates following cataract surgery (measured using National Quality Forum (NQF) criteria) in VA vs CC. NQF defines major complications from a specified list of Current Procedural Terminology (CPT) codes. We ran a series of logistic regression models to predict 90-day complication rates, adjusting for Veterans' sociodemographic characteristics, comorbidities, preoperative ocular conditions, eye risk group, and type of cataract surgery (classified as routine vs complex).DATA COLLECTION: We linked VA and CC users through patient identifiers obtained from the CDW files. Our sample included all enrolled Veterans who received outpatient cataract surgery either in the VA or through CC during FY15. Cataract surgeries were identified through CPT codes 66984 (routine) and 66982 (complex).PRINCIPAL FINDINGS: Of the 83,879 cataract surgeries performed in FY15, 31 percent occurred through CC. Undergoing complex surgery and having a high-risk eye (based on preoperative ocular conditions) were the strongest clinical predictors of 90-day postoperative complications. Overall, we found low complication rates, ranging from 1.1 percent in low-risk eyes to 3.6 percent in high-risk eyes. After adjustment for important confounders (eg, race, rurality, and preoperative ocular conditions), there were no statistically significant differences in 90-day complication rates between Veterans receiving cataract surgery in VA vs CC.CONCLUSIONS: As more Veterans seek care through CC, future studies should continue to monitor quality of care across the two care settings to help inform VA's "make vs buy decisions."
View details for DOI 10.1111/1475-6773.13320
View details for PubMedID 32715468
A Survey of Glaucoma Surgery Practice Patterns in the Veterans Health Administration.
Glaucoma surgical practice patterns are not well described in the United States (US). This study aims to evaluate the indications for and potential barriers to glaucoma surgery in the Veterans Health Administration (VHA).An anonymous 10-question survey using REDCap (Nashville, TN) software was sent by mail (with web link) and email to ophthalmology chiefs at the 86 academically affiliated Veterans Affairs Medical Centers (VAMCs). Academic-affiliated VAMCs were selected because of their patient range and role in ophthalmic education. Non-responders received two reminder e-mails and two phone calls; the survey was closed after 6 weeks. The data were analyzed using descriptive statistics.The response rate was 45% (39/86). Most respondents (92%) worked in an integrated eye clinic with both ophthalmology and optometry services. Almost half of the respondents (49%; 19/39) believed that laser trabeculoplasty (LTP) was an option for initial glaucoma therapy. Noncompliance was a commonly reported indication for LTP (95%), tube shunt procedures (65%), micro-invasive glaucoma surgery (59%), and trabeculectomy (48.7%). One third of the respondents believed that there were delays in glaucoma care. The respondents noted that significant barriers in access to surgery included lack of transportation (69%), scheduling challenges (62%), and delayed referral (62%).This survey of glaucoma surgery practice patterns highlights the growing role of LTP and suggests that non-compliance and access remain significant barriers to glaucoma surgical care within the VHA.
View details for DOI 10.1093/milmed/usaa033
View details for PubMedID 32412083
Cataract surgery practices in the United States Veterans Health Administration
ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2017
View details for Web of Science ID 000432170301362
Emerging Cataract Surgery Practice Patterns in the Veterans Health Administration.
Federal practitioner : for the health care professionals of the VA, DoD, and PHS
2016; 33 (9): 10–13
A survey finds low rates for femtosecond laser-assisted cataract surgery, intracameral antibiotics, and immediate sequential bilateral cataract surgery in cataract surgery practice.
View details for PubMedID 30930612
Automated Perimetry and Visual Dysfunction in Blast-Related Traumatic Brain Injury
2016; 123 (2): 415-424
To evaluate feasibility and results of automated perimetry in veterans with combat blast neurotrauma.Prospective, longitudinal, observational case series.Sixty-one patients in a Veterans Affairs Polytrauma Center diagnosed with traumatic brain injury (TBI) from combat blast exposure.Study participants underwent automated perimetry at baseline (median interval, 2 months after injury) (Humphrey Field Analyzer, Carl Zeiss Meditec, Dublin, CA, Swedish Interactive Threshold Algorithm 30-2 Standard or Fast), and 36 of them were followed up (median interval, 10 months after baseline). Presence of significant mean deviation and pattern standard deviation was determined for testing with reliability indices ≤20% for fixation loss, 15% for false-positives, and 33% for false-negatives. Test-retest stability of global visual field indices was assessed for tests with these cutoffs or with elevated fixation loss. Associations between global visual field defects and predictors were examined.Global visual field indices (mean deviation and pattern standard deviation).Among 61 study participants (109 study eyes) with baseline testing, a field that met reliability cutoffs was obtained for 48 participants (79%) and 78 eyes (72%). Fixation loss was found in 29% of eyes in initial testing. Nine study participants (15%) demonstrated hemianopia or quadrantanopia, and an additional 36% had an abnormal global visual field index. Global indices were relatively stable at follow-up testing for tests meeting fixation-loss cutoffs and tests that did not. Visual scotomas due to post-chiasmal lesions were associated with moderate to severe TBI or penetrating head injury, but other visual field deficits were prevalent across the range of mild to severe TBI. Ocular injury to the retina or choroid, poorer visual acuity, and pupillary defect were associated with visual field defects. Participants with depressed visual field sensitivity reported lower visual quality of life.Reliable automated perimetry can be accomplished in most patients with TBI from combat blast exposure and reveals high rates of visual field deficits, indicating that blast forces may significantly affect the eye and visual pathways.
View details for DOI 10.1016/j.ophtha.2015.10.003
View details for Web of Science ID 000368362200036
Closed-Globe Injuries of the Ocular Surface Associated with Combat Blast Exposure
2014; 121 (11): 2165-2172
To describe closed-globe conjunctival and corneal injuries and endothelial cell abnormalities associated with blast exposure and their relationships to other closed-globe injuries and blast-event characteristics.Observational cross-sectional study.Veterans with a history of blast-related traumatic brain injury (TBI).History and ocular examination, including slit-lamp biomicroscopy, gonioscopy, specular microscopy.Type and location of blast injuries to the conjunctiva and cornea.Ocular surface injuries were present in 25% (16 of 65) of blast-exposed veterans with TBI. Injuries included partial-thickness anterior stromal corneal scars (15 eyes), Descemet membrane ruptures (6 eyes), and conjunctival or corneal foreign bodies (7 eyes). Based on normative information from an age-matched comparison group, endothelial cell abnormalities were identified in 37% of participants. Eyes with ocular surface injury were more likely to have lower endothelial cell density, higher coefficient of variation of cell area, and lower percentage of hexagonal cells compared with eyes without injury. Presence of ocular surface injury or endothelial cell abnormalities was associated with elevated rates of other anterior and posterior segment injuries, as well as impairment of visual acuity. We found no relationship between ballistic eyewear use or severity level of TBI and presence of ocular surface injuries from blast.Independent of TBI severity or use of protective eyewear, ocular surface injuries and endothelial cell abnormalities were found in significant numbers of veterans with blast-related brain injury. Descemet membrane ruptures from blast exposure were described. Ocular surface trauma was associated with other ocular injuries throughout the globe. Potential mechanisms for the types and locations of ocular injuries seen were discussed. Any corneal or conjunctival injury in a blast survivor should prompt a thorough ocular trauma examination, including gonioscopy and specular microscopy, with appropriate follow-up for associated injuries. Longitudinal studies are required to determine long-term visual outcomes after blast exposure.
View details for DOI 10.1016/j.ophtha.2014.06.009
View details for Web of Science ID 000344480400021
Afferent visual function in Veterans after combat blast.
ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2014
View details for Web of Science ID 000433199700156
Visual Quality of Life in Veterans With Blast-Induced Traumatic Brain Injury
2013; 131 (12): 1602-1609
Traumatic brain injury (TBI) is an important cause of morbidity worldwide, with increasing awareness of the role of blast exposure in military and civilian casualties. Visual problems have been reported in TBI and may affect functioning and quality of life.To evaluate the 25-item National Eye Institute Visual Functioning Questionnaire and Neuro-Ophthalmic Supplement for utility in assessing the effect of blast exposure on perceived visual functioning among veterans with TBI.Observational cohort study from a tertiary care Veterans Health Administration hospital. Reported visual quality of life was compared with existing norms, and relationships between perceived visual quality and ocular injury, diplopia, visual performance, and blast exposure characteristics were examined. Participants included inpatients with blast-induced TBI who underwent baseline examination between December 7, 2006, and January 11, 2012, at a multiple-trauma rehabilitation center and who had at least 1 intact eye and were able to undergo psychometric testing and ocular examination. Among 64 sequentially eligible patients, 60 completed visual quality testing, 1 declined study participation, and 3 were evaluated prior to inclusion of visual quality testing in the protocol. Thirty-nine patients returned for outpatient follow-up, with a median test-retest interval of 11 months.Combat blast exposure with documented TBI.Composite and subscale scores on the 25-item National Eye Institute Visual Functioning Questionnaire and Neuro-Ophthalmic Supplement.Both tests had high test-retest reliability. Blast-exposed veterans reported significantly poorer visual quality compared with healthy samples and some patient samples with known eye disease. Scores tended to be worse for participants with identified visual performance deficits (poorer visual acuity or spatial contrast sensitivity, visual field depression or defects). Scores were not related to the extent of ocular injury or to blast exposure characteristics such as use of protective eyewear or TBI severity level.Individuals with blast-induced TBI reliably completed both tests and reported significant decrements in their subjective visual experiences. Measures of subjective visual quality may be useful to identify patients needing additional visual or neurologic evaluation and to monitor the effect of visual rehabilitation on patients with blast-related visual disabilities.
View details for DOI 10.1001/jamaophthalmo1.2013.5028
View details for Web of Science ID 000329850600017
View details for PubMedID 24136237
Visual Performance and the Ocular Surface in Traumatic Brain Injury
2013; 11 (1): 25-34
The pathophysiology of neurotrauma is reviewed and an original study investigating the prevalence of dry eye disease in a sample of veterans with traumatic brain injury (TBI) is presented. Fifty-three veterans with TBI were evaluated by history of injury, past ocular history, and medication use. Ocular Disease Surface Index (OSDI), ocular examination, cranial nerve evaluation, tear osmolarity, tear film break-up time (TFBUT), ocular surface staining and tear production testing were performed. A matched comparison group underwent similar testing. TBI causes were blast (44) or non-blast (9). TBI subjects scored significantly worse on the OSDI (P<.001), and ocular surface staining by Oxford scale (P<.001) than non-TBI subjects. Scores for tear film breakup (P=.6), basal tear production less than 3 mm (P=.13), and tear osmolarity greater than 314 mOsm/L (P=.15) were all higher in TBI subjects; significantly more TBI subjects had at least one abnormal dry eye measure than comparisons (P<.001). The OSDI related to presence of dry eye symptoms (P<.01). These effects were present in both blast and non-blast TBI. Seventy percent of TBI subjects were taking at least one medication in the following classes: antidepressant, atypical antipsychotic, anticonvulsant, or h1-antihistamine. There was no association between any medication class and the OSDI or dry eye measures. Reduced corneal sensation in 21 TBI subjects was not associated with OSDI, tear production, or TFBUT, but did correlate with reduced tear osmolarity (P=.05). History of refractive surgery, previous contact lens wear, facial nerve weakness, or meibomian gland dysfunction was not associated with DED. In summary, we found a higher prevalence of DED in subjects with TBI, both subjectively and objectively. This effect is unrelated to medication use, and it may persist for months to years. We recommend that patients with TBI from any cause be evaluated for DED using a battery of standard testing methods described in a protocol presented in this article. Further research into the pathophysiology and outcomes of DED in neurotrauma is needed.
View details for Web of Science ID 000314260300007
View details for PubMedID 23321357
Abiotrophia defectiva causing infectious crystalline keratopathy and corneal ulcer after penetrating keratoplasty: a case report.
Journal of ophthalmic inflammation and infection
2013; 3 (1): 20-?
Infectious crystalline keratopathy is commonly caused by Streptococcus viridans and other gram positive organisms. We present the first case of infectious crystalline keratopathy that developed into a corneal ulcer and grew Abiotrophia defectiva which responded well to topical and systemic antimicrobial therapy and did not require re-grafting. A 78-year-old man underwent penetrating keratoplasty for pseudophakic bullous keratopathy. He presented 1.5 years later with infectious crystalline keratopathy which progressed to a corneal ulcer. The patient received topical fortified vancomycin and moxifloxacin, as well as oral moxifloxacin.The corneal ulcer base was cultured and grew A. defectiva, or nutritionally deficient streptococcus. Complete resolution of the corneal infiltrates was obtained within three months.Nutritionally deficient streptococcus has been implicated in numerous human diseases, including endocarditis, and is increasingly being recognized as an important pathogen. This represents the second reported case of A. defectiva causing infectious crystalline keratopathy in humans and the first case of A. defectiva successfully treated with antibiotics. This case shows that aggressive antibiotic therapy can be effective in A. defectiva-associated infectious crystalline keratopathy.
View details for DOI 10.1186/1869-5760-3-20
View details for PubMedID 23514629
View details for PubMedCentralID PMC3605112
Eye and visual function in traumatic brain injury
JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT
2009; 46 (6): 811-818
Combat blast is an important cause of traumatic brain injury (TBI) in the Department of Veterans Affairs polytrauma population, whereas common causes of TBI in the civilian sector include motor vehicle accidents and falls. Known visual consequences of civilian TBI include compromised visual acuity, visual fields, and oculomotor function. The visual consequences of TBI related to blast remain largely unknown. Blast injury may include open globe (eye) injury, which is usually detected and managed early in the rehabilitation journey. The incidence, locations, and types of ocular damage in eyes without open globe injury after exposure to powerful blast have not been systematically studied. Initial reports and preliminary data suggest that binocular function, visual fields, and other aspects of visual function may be impaired after blast-related TBI, despite relatively normal visual acuity. Damage to the ocular tissues may occur from blunt trauma without rupture or penetration (closed globe injury). Possible areas for research are development of common taxonomy and assessment tools across services, surgical management, and outcomes for blast-related eye injury; the incidence, locations, and natural history of closed globe injury; binocular and visual function impairment; quality of life in affected service members; pharmacological and visual therapies; and practice patterns for screening, management, and rehabilitation.
View details for DOI 10.1682/JRRD.2008.08.0109
View details for Web of Science ID 000272638100012
View details for PubMedID 20104404
Prospective comparison of topical moxifloxacin in eliminating conjunctival bacterial flora following a one-day or one-hour application
Annual Meeting of the Association-for-Research-in-Vision-and-Ophthalmology
MARY ANN LIEBERT INC. 2008: 427–31
The aim of this study was to compare the efficacy of a 1-hour(h) versus 1-day application of topical moxifloxacin in eliminating conjunctival bacterial flora.In this prospective, nonrandomized, controlled trial, the surgical eyes of 60 patients scheduled for intraocular surgery received topical moxifloxacin four times a day, starting 1 day prior to surgery and three additional applications at 5-minute intervals 1 h before surgery. The nonsurgical eye of each patient only received three applications of the same antibiotic at 5-minute intervals 1 h before surgery. Conjunctival cultures were obtained at baseline and after antibiotic application.Prior to antibiotic application, 80% of surgical eyes and 70% of nonsurgical eyes had positive cultures. Following the 1-day application, significantly fewer eyes (40%) had positive cultures (P < 0.0001), with a further reduction to 32% with three additional doses 1 h prior to surgery. In the nonsurgical eye, the decrease in the percentage of positive cultures, from 55% to 53% following the three applications 1 h prior to surgery, was not significant (P > 0.9999). The 1-day application was associated with significantly fewer positive cultures, compared to the 1-h group (P = 0.0267).The one-day application of moxifloxacin resulted in significantly fewer positive conjunctival cultures, compared with a 1-h application.
View details for DOI 10.1089/jop.2008.0018
View details for PubMedID 18665815
Visual function in patients of a polytrauma rehabilitation center: A descriptive study
JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT
2007; 44 (7): 929-936
Little is known about the visual function deficits associated with polytrauma injury. In this retrospective descriptive study, we examined the records of a clinic established to assess visual function in patients experiencing deployment-related polytrauma. We describe the clinical findings and present a vision examination protocol that may be useful for screening polytrauma patients in other settings. Data from our sample suggested that self-reported vision complaints were common (74%) and confirmed that visual impairment occurred in 38% of all cases. When examining the mechanism of injury, we found that polytrauma due to blast injuries appeared to more than double the risk of visual impairment compared with all other polytrauma causes (i.e., motor vehicle accidents, gunshot and/or shrapnel, assault, falls, or anoxia). The rate of visual impairment in blast-related injury was 52% compared with 20% for all other sources of injury. Visual complaints and impairments were common in the polytrauma patients studied. This finding suggests that comprehensive eye examinations should be routinely administered, particularly when the mechanism of injury involves a blast.
View details for DOI 10.1682/JRRD.2007.01.0003
View details for Web of Science ID 000252524800006
View details for PubMedID 18075950