Dr. Pershing is on the ophthalmology faculty at Stanford University School of Medicine, with an academic career blending clinical practice, teaching, research, and administration. She serves as Chief of Ophthalmology and Eye Care Services for the VA Palo Alto Health Care System and as Vice Chair for Education in the Stanford Department of Ophthalmology, after five years as Program Director for the ophthalmology residency.

As an educator she seeks to bring a "precision" approach to graduate medical education, incorporating innovation and research rigor. She is committed to program diversity and inclusion and excited to innovate and implement novel approaches to ophthalmology education. Specific areas of interest include competency-based education, career pathways and career development, and leadership development, with programmatic initiatives such as Stanford Ophthalmology's 4-year research track residency program (SOAR), opportunities for resident elective scholarly activity, and efforts to develop a valuable internship program for incoming ophthalmology residents at Stanford. Dr. Pershing's active research includes efforts to enhance diversity in residency selection, using AI semi-supervised models to augment the application review process, and predictive modeling to optimize cataract surgery case selection and scheduling.

Her broader research interests focus on utilization of big data, biomedical informatics techniques, and evidence-based medicine to study clinical associations and outcomes, health care utilization, disease progression, and cost-effectiveness of ophthalmic treatment, as well as a special interest in the relationship between visual impairment and cognitive impairment. Dr. Pershing is active in big data initiatives and analysis, including collaborative projects at Stanford and serving as site PI for the American Academy of Ophthalmology (AAO) IRIS Registry analytic group at Stanford. She also serves on the American Board of Medical Specialties Database and Information Technology Advisory Committee (DITAC), the AAO Medical Information Technology Committee, and AAO Committee on Aging. Through this and her other work, she is engaged in efforts to use diverse data sources to facilitate improved quality of care, continuing certification, and practice and outcomes assessments. Dr. Pershing is also involved in health policy, including helping to develop CMS episode-based cost measures for MIPS, and she is interested in health care innovation—technology, quality, and delivery systems.

Dr. Pershing also serves as faculty advisor for the Alpha Omega Alpha medical honor society Stanford association, with focus on resident initiatives, and mentors both medical students and undergraduate students.

Academic Appointments

  • Associate Professor - University Medical Line, Ophthalmology

Administrative Appointments

  • Vice Chair for Education, Stanford University Department of Ophthalmology (2023 - Present)
  • Ophthalmology Residency Program Director, Stanford University Medical Center (2018 - 2023)
  • Chief, Ophthalmology and Eye Care Services, VA Palo Alto Health Care System (2013 - Present)

Honors & Awards

  • Stanford Faculty Teaching Award, Stanford Department of Ophthalmology (2014)
  • President's Clinical Science Award, Medical University of South Carolina (2006)
  • American Medical Women’s Association Glasgow-Rubin Certificate of Commendation, Medical University of South Carolina (2006)
  • Merck Award for Academic Excellence, Medical University of South Carolina (2006)
  • Elected Member, Alpha Omega Alpha Medical Honor Society (2004)

Boards, Advisory Committees, Professional Organizations

  • Committee on Aging, American Academy of Ophthalmology (2020 - Present)
  • Database and Information Technology Advisory Committee (DITAC), American Board of Medical Specialties (ABMS) (2022 - Present)
  • Medical Information Technology Committee, American Academy of Ophthalmology (2020 - Present)
  • Board of Directors, Alpha Omega Alpha National Medical Honor Society (2009 - 2020)
  • Working Group and Task Force, American Academy of Ophthalmology IRIS Clinical Data Registry (2012 - 2017)
  • Working Group, Cataract Surgery and Macular Degeneration, International Consortium for Health Outcomes Measurement (2013 - 2016)

Professional Education

  • Residency, Stanford University Medical Center, Ophthalmology (2010)
  • Fellowship, Stanford University - Health Policy and Health Services Research and Health Policy, CA (2013)

2023-24 Courses

Stanford Advisees

Graduate and Fellowship Programs

All Publications

  • Evaluating Visual Acuity in the American Academy of Ophthalmology IRIS® Registry. Ophthalmology science Brant, A., Kolomeyer, N., Goldberg, J. L., Haller, J., Lee, C. S., Lee, A. Y., Lorch, A. C., Miller, J. W., Hyman, L., Pershing, S. 2024; 4 (1): 100352


    To describe visual acuity data representation in the American Academy of Ophthalmology Intelligent Research in Sight (IRIS) Registry and present a data-cleaning strategy.Reliability and validity study.Patients with visual acuity records from 2018 in the IRIS Registry.Visual acuity measurements and metadata were identified and characterized from 2018 IRIS Registry records. Metadata, including laterality, assessment method (distance, near, and unspecified), correction (corrected, uncorrected, and unspecified), and flags for refraction or pinhole assessment were compared between Rome (frozen April 20, 2020) and Chicago (frozen December 24, 2021) versions. We developed a data-cleaning strategy to infer patients' corrected distance visual acuity in their better-seeing eye.Visual acuity data characteristics in the IRIS Registry.The IRIS Registry Chicago data set contains 168 920 049 visual acuity records among 23 001 531 unique patients and 49 968 974 unique patient visit dates in 2018. Visual acuity records were associated with refraction in 5.3% of cases, and with pinhole in 11.0%. Mean (standard deviation) of all measurements was 0.26 (0.41) logarithm of the minimum angle of resolution (logMAR), with a range of - 0.3 to 4.0 A plurality of visual acuity records were labeled corrected (corrected visual acuity [CVA], 39.1%), followed by unspecified (37.6%) and uncorrected (uncorrected visual acuity [UCVA], 23.4%). Corrected visual acuity measurements were paradoxically worse than same day UCVA 15% of the time. In aggregate, mean and median values were similar for CVA and unspecified visual acuity. Most visual acuity measurements were at distance (59.8%, vs. 32.1% unspecified and 8.2% near). Rome contained more duplicate visual acuity records than Chicago (10.8% vs. 1.4%). Near visual acuity was classified with Jaeger notation and (in Chicago only) also assigned logMAR values by Verana Health. LogMAR values for hand motion and light perception visual acuity were lower in Chicago than in Rome. The impact of data entry errors or outliers on analyses may be reduced by filtering and averaging visual acuity per eye over time.The IRIS Registry includes similar visual acuity metadata in Rome and Chicago. Although fewer duplicate records were found in Chicago, both versions include duplicate and atypical measurements (i.e., CVA worse than UCVA on the same day). Analyses may benefit from using algorithms to filter outliers and average visual acuity measurements over time.Proprietary or commercial disclosure may be found found in the Footnotes and Disclosures at the end of this article.

    View details for DOI 10.1016/j.xops.2023.100352

    View details for PubMedID 37869025

    View details for PubMedCentralID PMC10587626

  • Using Natural Language Processing to Identify Different Lens Pathology in Electronic Health Records. American journal of ophthalmology Stein, J. D., Zhou, Y., Andrews, C. A., Kim, J. E., Addis, V., Bixler, J., Grove, N., McMillan, B., Munir, S. Z., Pershing, S., Schultz, J. S., Stagg, B. C., Wang, S. Y., Woreta, F. 2024


    Nearly all published ophthalmology-related Big Data studies rely exclusively upon International Classification of Diseases (ICD) billing codes to identify patients with particular ocular conditions. However, inaccurate or non-specific codes may be used. We assessed whether natural language processing (NLP), as an alternative approach, could more accurately identify lens pathology.Database study comparing the accuracy of NLP versus ICD billing codes to properly identify lens pathology.We developed an NLP algorithm capable of searching free-text lens exam data in the electronic health record (EHR) to identify type(s) of cataract present, cataract density, presence of intraocular lenses, and other lens pathology. We applied our algorithm to 17.5 million lens exam records in the Sight Outcomes Research Collaborative (SOURCE) repository. We selected 4314 unique lens-exam entries and asked 11 clinicians to assess whether all pathology present in the entries had been correctly identified in the NLP algorithm output. The algorithm's sensitivity at accurately identifying lens pathology was compared with that of the ICD codes.The NLP algorithm correctly identified all lens pathology present in 4104 of the 4314 lens-exam entries (95.1%). For less common lens pathology, algorithm findings were corroborated by reviewing clinicians for 100% of mentions of pseudoexfoliation material and 99.7% for phimosis, subluxation, and synechia. Sensitivity at identifying lens pathology was much better for NLP (0.98 (0.96-0.99) than for billing codes (0.49 (0.46-0.53)).Our NLP algorithm identifies and classifies lens abnormalities routinely documented by eye-care professionals with high accuracy. Such algorithms will help researchers to properly identify and classify ocular pathology, broadening the scope of feasible research using real-world data.

    View details for DOI 10.1016/j.ajo.2024.01.030

    View details for PubMedID 38296152

  • Cataract Surgery in the Medicare Merit-Based Incentive Payment System: Episode-Based Cost Measure Development and Evaluation. Ophthalmology science Pershing, S., Sandhu, A. T., Uwilingiyimana, A. S., Glasser, D. B., Morgenstern, A. S., Do, R., Choradia, N., Lin, E., Leoung, J., Shah, M., Liu, A., Lee, J., Fairchild, A., Lam, J., MaCurdy, T. E., Nagavarapu, S., Bhattacharya, J. 2023; 3 (4): 100315


    To characterize the development and performance of a cataract surgery episode-based cost measure for the Medicare Quality Payment Program.Claims-based analysis.Medicare clinicians with cataract surgery claims between June 1, 2016, and May 31, 2017.We limited the analysis to claims with procedure code 66984 (routine cataract surgery), excluding cases with relevant ocular comorbidities. We divided episodes into subgroups by surgery location (Ambulatory Surgery Center [ASC] or Hospital Outpatient Department [HOPD]) and laterality (bilateral when surgeries were within 30 days apart). For the episode-based cost measure, we calculated costs occurring between 60 days before surgery and 90 days after surgery, limited to services identified by an expert committee as related to cataract surgery and under the influence of the cataract surgeon. We attributed costs to the clinician submitting the cataract surgery claim, categorized costs into clinical themes, and calculated episode cost distribution, reliability in detecting clinician-dependent cost variation, and costs with versus without complications. We compared episode-based cost scores with hypothetical "nonselective" cost scores (total Medicare beneficiary costs between 60 days before surgery and 90 days after surgery).Episode costs with and without complications, clinician-dependent variation (proportion of total cost variance), and proportion of costs from cataract surgery-related clinical themes.We identified 583 356 cataract surgery episodes attributed to 10 790 clinicians and 8189 with ≥ 10 episodes during the measurement period. Most surgeries were performed in an ASC (71%) and unilateral (66%). The mean episode cost was $2876. The HOPD surgeries had higher costs; geography and episodes per clinician did not substantially affect costs. The proportion of cost variation from clinician-dependent factors was higher in episode-based compared with nonselective cost measures (94% vs. 39%), and cataract surgery-related clinical themes represented a higher proportion of total costs for episode-based measures. Episodes with complications had higher costs than episodes without complications ($3738 vs. $2276).The cataract surgery episode-based cost measure performs better than a comparable nonselective measure based on cost distribution, clinician-dependent variance, association with cataract surgery-related clinical themes, and quality alignment (higher costs in episodes with complications). Cost measure maintenance and refinement will be important to maintain clinical validity and reliability.Proprietary or commercial disclosure may be found after the references.

    View details for DOI 10.1016/j.xops.2023.100315

    View details for PubMedID 37274014

    View details for PubMedCentralID PMC10232885

  • Impact of Type 2 diabetes mellitus and insulin use on progression to glaucoma surgery in primary open angle glaucoma. Eye (London, England) Sun, M. T., Pershing, S., Goldberg, J. L., Wang, S. Y. 2023


    PURPOSE: To investigate outcomes of primary open-angle glaucoma (POAG) patients with and without type 2 diabetes mellitus (T2DM).METHODS: Retrospective observational study using U.S. nationwide healthcare insurance claims database. Patients ≥40 years old with at least one HbA1c within one year of POAG diagnosis were included. Diabetic factors associated with POAG progression requiring glaucoma surgery were evaluated using multivariable Cox proportional hazards regression models adjusted for demographic, diabetic and glaucoma factors. T2DM diagnosis and use of either oral hypoglycaemic agents or insulin therapy were assessed in association with POAG progression requiring glaucoma surgery.RESULTS: 104,515 POAG patients were included, of which 70,315 (67%) had T2DM. The mean age was 68.9 years (Standard deviation 9.2) and 55% were female. Of those with T2DM, 93% were taking medication (65,468); 95% (62,412) taking oral hypoglycaemic agents, and 34% (22,028) were on insulin. In multivariable analyses, patients with T2DM had a higher hazard of requiring glaucoma surgery (Hazard ratio, HR 1.15, 95% CI 1.09-1.21, p<0.001). Higher mean HbA1c was also a significant predictor of progression requiring glaucoma surgery (HR 1.02, 95% CI 1.01-1.03, p<0.001). When evaluating only patients who were taking antidiabetic medication, after adjusting for confounders, insulin use was associated with a 1.20 higher hazard of requiring glaucoma surgery compared to oral hypoglycaemic agents (95% CI 1.14-1.27, p<0.001), but when stratified by HbA1c, this effect was only significant for those with HbA1c>7.5%.CONCLUSIONS: Higher baseline HbA1c, particularly in patients taking insulin may be associated with higher rates of glaucoma surgery in POAG.

    View details for DOI 10.1038/s41433-023-02734-2

    View details for PubMedID 37740048

  • Identifying Strategies to Reduce Low-Value Preoperative Testing for Low-Risk Procedures: a Qualitative Study of Facilities with High or Recently Improved Levels of Testing. Journal of general internal medicine Harris, A. H., Finlay, A. K., Hagedorn, H. J., Manfredi, L., Jones, G., Kamal, R. N., Sears, E. D., Hawn, M., Eisenberg, D., Pershing, S., Mudumbai, S. 2023


    BACKGROUND: Healthcare agencies and perioperative professional organizations recommend avoiding preoperative screening tests for low-risk surgical procedures. However, low-value preoperative tests are still commonly ordered even for generally healthy patients and active strategies to reduce this testing have not been adequately described.OBJECTIVE: We sought to learn from hospitals with either high levels of testing or that had recently reduced use of low-value screening tests (aka "delta sites") about reasons for testing and active deimplementation strategies they used to effectively improve practice.DESIGN: Qualitative study of semi-structured telephone interviews.PARTICIPANTS: We identified facilities in the US Veterans Health Administration (VHA) with high or recently improved burden of potentially low-value preoperative testing for carpal tunnel release and cataract surgery. We recruited perioperative clinicians to participate.APPROACH: Questions focused on reasons to order preoperative screening tests for patients undergoing low-risk surgery and, more importantly, what strategies had been successfully used to reduce testing. A framework method was used to identify common improvement strategies and specific care delivery innovations.KEY RESULTS: Thirty-five perioperative clinicians (e.g., hand surgeons, ophthalmologists, anesthesiologists, primary care providers, directors of preoperative clinics, nurses) from 29 VHA facilities participated. Facilities that successfully reduced the burden of low-value testing shared many improvement strategies (e.g., building consensus among stakeholders; using evidence/norm-based education and persuasion; clarifying responsibility for ordering tests) to implement different care delivery innovations (e.g., pre-screening to decide if a preop clinic evaluation is necessary; establishing a dedicated preop clinic for low-risk procedures).CONCLUSIONS: We identified a menu of common improvement strategies and specific care delivery innovations that might be helpful for institutions trying to design their own quality improvement programs to reduce low-value preoperative testing given their unique structure, resources, and constraints.

    View details for DOI 10.1007/s11606-023-08287-0

    View details for PubMedID 37407767

  • US Population Disparities in Ophthalmic Care: Blindness and Visual Impairment in the IRIS® Registry (Intelligent Research In Sight). Ophthalmology Brant, A., Kolomeyer, N., Goldberg, J. L., Haller, J., Lee, C. S., Lee, A. Y., Lorch, A. C., Lum, F., Miller, J. W., Parke, D. W., Hyman, L., Pershing, S. 2023


    To evaluate associations of patient characteristics with United States eyecare utilization and likelihood of blindness.Retrospective observational study.19,546,016 patients with 2018 visual acuity (VA) records in American Academy of Ophthalmology IRIS® Registry (Intelligent Research In Sight).Legal blindness (20/200 or worse) and visual impairment (VI) (worse than 20/40) were identified from corrected distance acuity in the better-seeing eye and stratified by patient characteristics. Multivariable logistic regression models evaluated blindness and visually impaired (VI) associations. Blindness was mapped by state and compared to population characteristics. Eyecare utilization was analyzed by comparing population demographics to US Census estimates, and proportional demographic representation among blind/VI patients versus a nationally-representative US population sample (National Health and Nutritional Examination Survey, NHANES).Prevalence and odds ratios for VI and blindness; proportional representation in IRIS Registry, Census, and NHANES by patient demographics.VI was present in 6.98% (n=1,364,935) and blindness in 0.98% (n=190,817) of IRIS Registry patients. Adjusted odds of blindness were highest among patients 85+ years old (OR=11.85, 95%CI=10.33-13.59, versus 0-17 year-olds). Blindness was also positively-associated with smoking (OR=1.13, 95%CI=1.08-1.17), rural location (OR=1.09, 95%CI=1.04-1.14) and Medicaid (OR=3.85, 95%CI=3.57-4.15), Medicare (OR=1.66, 95%CI=1.53-1.82), or no insurance (OR=1.77, 95%CI=1.37-2.27) versus commercial insurance. Hispanic (OR=1.59, 95%CI=1.46-1.74) and Black patients (OR=1.73, 95%CI=1.63-1.84) had higher odds of blindness versus white non-Hispanic patients. Proportional representation in IRIS Registry relative to Census was higher for white than Hispanic (2-4 fold) or Black patients (11-85%) (p<0.001). Blindness was overall less prevalent in NHANES than IRIS Registry; however, prevalence in adults aged 60+ was lowest among Black participants in NHANES (0.54%) and second highest among comparable Black adults in IRIS Registry (1.57%).Legal blindness from low VA was present in 0.98% of IRIS patients and associated with smoking, rural location, public or no insurance, and older age. Compared to US Census estimates, minorities may be underrepresented among ophthalmology patients, and compared to NHANES population estimates, Black individuals may be overrepresented among blind IRIS Registry patients. These findings provide a snapshot of US ophthalmic care and highlight need for initiatives to address disparities in utilization and blindness.

    View details for DOI 10.1016/j.ophtha.2023.06.011

    View details for PubMedID 37331480

  • Visual outcomes of bilaterally blind patients undergoing cataract surgery across seven developing world countries Choi, S., abrant, A., Pershing, S., Gonzalez, N., Ahmed, A., DesLauriers, A., Tabin, G. C. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2023
  • The prevalence and recurrence risk of bare sclera pterygium surgery in the United States. The ocular surface Oke, I., Elze, T., Miller, J. W., Lorch, A. C., Hunter, D. G., Traish, A. S., Pershing, S., Hyman, L., Haller, J. A., Lee, A. Y., Lee, C. S., Lum, F., Miller, J. W., Lorch, A. C. 2023

    View details for DOI 10.1016/j.jtos.2023.05.006

    View details for PubMedID 37257693

  • Thyroid Eye Disease (TED) and its Vision Threatening Manifestations in the Academy IRIS® Registry: 2014-2018. American journal of ophthalmology Ramesh, S., Zhang, Q. E., Sharpe, J., Penne, R., Haller, J., Lum, F., Lee, A. Y., Lee, C. S., Pershing, S., Miller, J. W., Lorch, A., Hyman, L. 2023


    To evaluate prevalence of thyroid eye disease (TED) and associated factors in the American Academy of Ophthalmology IRIS® Registry (Intelligent Research in Sight).Cross-sectional analysis of the IRIS Registry.IRIS Registry patients (18-90 years old) were classified as TED (ICD-9: 242.00, ICD-10: E05.00 on ≥2 visits) or non-TED cases, and prevalence was estimated. Odds ratios (OR) and 95% Confidence Intervals (CIs) were estimated using logistic regression.41,211 TED patients were identified. TED prevalence was 0.09%, showed a unimodal age distribution (highest prevalence in ages 50-59 years (y) (0.12%)), higher rates in females than males (0.12% vs. 0.04%) and in non-Hispanics than Hispanics (0.10% vs. 0.05%). Prevalence differed by race (from 0.08% in Asians to 0.12% in Black/African-Americans), with varying peak ages of prevalence. Factors associated with TED in multivariate analysis included age: ((18-<30y (reference), 30-39y: OR (95%CI) 2.2 (2.0, 2.4), 40-49y: 2.9 (2.7,3.1), 50-59y: 3.3 (3.1, 3. 5), 60-69y: 2.7 (2.54, 2.85), 70+: 1.5 (1.46, 1.64)); femalesex vs male (reference), 3.5 (3.4,3.6),race: White (reference), Blacks: 1.1 (1.1,1.2), Asian: 0.9 (0.8,0.9), Hispanic ethnicity vs not Hispanic (reference), 0.68 (0.6,0.7), smoking status: (never (ref), former: 1.64 (1.6,1.7), current 2.16: (2.1,2.2)) and Type 1 diabetes (yes vs no (reference): 1.87 (1.8, 1.9).This epidemiologic profile of TED includes new observations such as a unimodal age distribution and racial variation in prevalence. Associations with female sex, smoking, and Type 1 diabetes are consistent with prior reports. These findings raise novel questions about TED in different populations. PRéCIS: In this cross-sectional analysis of IRIS® Registry patients, thyroid eye disease was noted to have a unimodal age distribution with younger ages of peak prevalence for Asian, Hispanic and Black patients. Associations with female sex, smoking, and Type 1 diabetes are consistent with prior reports. Patients with severe disease have a slightly different epidemiologic profile. These findings raise novel questions about TED in different populations.

    View details for DOI 10.1016/j.ajo.2023.04.013

    View details for PubMedID 37201696

  • Causes of Childhood Blindness in the United States using the IRIS Registry (Intelligent Research in Sight). Ophthalmology Lim, H. W., Pershing, S., Moshfeghi, D. M., Heo, H., Haque, M. E., Lambert, S. R., IRIS Registry Analytic Center Consortium, Pershing, S., Hyman, L., Haller, J. A., Lee, A. Y., Lee, C. S., Lum, F., Miller, J. W., Lorch, A. 2023


    PURPOSE: To investigate causes of childhood blindness in the United States using the IRIS Registry (Intelligent Research in Sight).DESIGN: Cross-Sectional Study.PARTICIPANTS: Patients ≤18 years of age with visual acuity 20/200 or worse in their better seeing eye in the IRIS Registry during 2018.METHODS: Causes of blindness were classified by anatomical site and specific diagnoses.MAIN OUTCOME MEASURES: Percentages of causes of blindness.RESULTS: Of 81,164 children with 2018 visual acuity data in the IRIS Registry, 961 (1.18%) had visual acuity 20/200 or worse in their better-seeing eye. Leading causes of blindness were retinopathy of prematurity (ROP) in 301 (31.3%), nystagmus in 78 (8.1%), and cataract in 64 (6.7%) patients. The retina was the leading anatomic site (47.7%) followed by optic nerve (11.6%) and lens (10.0%). A total of 52.4% of patients had treatable causes of blindness.CONCLUSIONS: This analysis offers a unique cross-sectional view of childhood blindness in the US using a clinical data registry. More than one-half of blind patients had a treatable cause of blindness.

    View details for DOI 10.1016/j.ophtha.2023.04.004

    View details for PubMedID 37037315

  • Analysis of the Readability and Accountability of Online Patient Education Materials Related to Glaucoma Diagnosis and Treatment. Clinical ophthalmology (Auckland, N.Z.) Cohen, S. A., Fisher, A. C., Pershing, S. 2023; 17: 779-788


    To assess the readability and accountability of online patient education materials related to glaucoma diagnosis and treatment.We conducted a Google search for 10 search terms related to glaucoma diagnosis and 10 search terms related to glaucoma treatment. For each search term, the first 10 patient education websites populated after Google search were assessed for readability and accountability. Readability was assessed using five validated measures: Flesch Reading Ease (FRE), Gunning Fog Index (GFI), Flesch-Kincaid Grade Level (FKGL), Simple Measure of Gobbledygook (SMOG), and New Dale-Chall (NDC). Accountability was assessed using the Journal of the American Medical Association (JAMA) benchmarks. The source of information for each article analyzed was recorded.Of the 200 total websites analyzed, only 11% were written at or below the recommended 6th grade reading level. The average FRE and grade level for 100 glaucoma diagnosis-related articles were 42.02 ± 1.08 and 10.53 ± 1.30, respectively. The average FRE and grade level for 100 glaucoma treatment-related articles were 43.86 ± 1.01 and 11.29 ± 1.54, respectively. Crowdsourced articles were written at the highest average grade level (12.32 ± 0.78), followed by articles written by private practice/independent users (11.22 ± 1.74), national organizations (10.92 ± 1.24), and educational institutions (10.33 ± 1.35). Websites averaged 1.12 ± 1.15 of 4 JAMA accountability metrics.Despite wide variation in the readability and accountability of online patient education materials related to glaucoma diagnosis and treatment, patient education materials are consistently written at levels above the recommended reading level and often lack accountability. Articles from educational institutions and national organizations were often written at lower reading levels but are less frequently encountered after Google search. There is a need for accurate and understandable online information that glaucoma patients can use to inform decisions about their eye health.

    View details for DOI 10.2147/OPTH.S401492

    View details for PubMedID 36923248

    View details for PubMedCentralID PMC10008728

  • Association of Environmental Factors with Age-Related Macular Degeneration using the Intelligent Research in Sight Registry (vol 4, 100195, 2022) OPHTHALMOLOGY SCIENCE Hunt, M. S., Chee, Y. E., Saraf, S. S., Chew, E. Y., Lee, C. S., Lee, A. Y., Manookin, M. B., Pershing, S., Hyman, L., Haller, J. A., Lee, A. Y., Lee, C. S., Lum, F., Miller, J. W., Lorch, A., IRIS Registry Data Analytic Ctr 2023; 3 (1)
  • Effectiveness of Trabeculectomy and Tube Shunt with versus without Concurrent Phacoemulsification OPHTHALMOLOGY GLAUCOMA Ciociola, E. C., Yang, S., Hall, N., Lorch, A. C., Miller, J. W., Friedman, D. S., Boland, M., Elze, T., Zebardast, N., IRIS Registry Data Analyt Ctr Cons 2023; 6 (1): 42-53


    To determine the effectiveness of trabeculectomy and glaucoma drainage device (GDD) surgery performed with concurrent phacoemulsification compared with stand-alone procedures.Multicenter retrospective cohort study.Patients in the Intelligent Research in Sight Registry who underwent trabeculectomy or GDD from 2013 through 2019.The Kaplan-Meier survival analysis was used to determine reoperation rates. Reoperation was defined as any subsequent glaucoma surgery occurring 1 month to 3 years after the initial procedure. Multivariable Cox proportional hazard models were used to determine reoperation risk factors.Reoperation rate, intraocular pressure (IOP), visual acuity, reoperation procedure type, postoperative complications, and predictors of surgical failure.A total of 117 697 eyes undergoing glaucoma surgery alone and 35 657 eyes undergoing surgery with phacoemulsification were included. The cumulative reoperation rates at postoperative years 1 and 3 were 4.9% and 11.5%, respectively, for trabeculectomy alone and 3.0% and 7.3%, respectively, for trabeculectomy combined with phacoemulsification (P < 0.001). The reoperation rates at postoperative 1 and 3 years were 3.8% and 7.8%, respectively, for GDD alone and 2.1% and 5.4%, respectively, for GDD with phacoemulsification (P < 0.001). Stand-alone procedures achieved greater IOP reduction by percentage change from baseline (trabeculectomy alone, 35.3% vs. trabeculectomy with phacoemulsification, 23.1%, P < 0.001; and GDD alone, 36.0% vs. GDD with phacoemulsification, 29.3%; P < 0.001). Visual acuity improved by 0.12 logarithm of the minimum angle of resolution (logMAR) (95% confidence interval [CI], 0.11-0.12) and 0.10 logMAR (95% CI, 0.08-0.11) after trabeculectomy and GDD with phacoemulsification and declined by 0.15 logMAR (95% CI, 0.14-0.15) and 0.12 logMAR (95% CI, 0.11-0.12) after stand-alone trabeculectomy and GDD. The overall documented complication rate was 2.9% for GDD and 1.4% for trabeculectomy. Age, sex, race, ethnicity, baseline IOP, and glaucoma diagnosis and severity were associated with surgical failure risk. The most common reoperation procedure was GDD.Reoperation rates within the first 3 years after trabeculectomy and GDD with and without phacoemulsification were low. Trabeculectomy and GDD with phacoemulsification had lower reoperation rates than those with stand-alone procedures. However, stand-alone procedures resulted in greater IOP reduction compared with combined procedures. Postoperative complications were uncommon overall. Patient age, sex, race, ethnicity, baseline IOP, and glaucoma diagnosis and severity were associated with surgical success.

    View details for DOI 10.1016/j.ogla.2022.07.003

    View details for Web of Science ID 001044474900001

    View details for PubMedID 35840047

    View details for PubMedCentralID PMC9839888

  • Effectiveness of Microinvasive Glaucoma Surgery in the United States: Intelligent Research in Sight Registry Analysis 2013-2019. Ophthalmology Yang, S., Ciociola, E. C., Mitchell, W., Hall, N., Lorch, A. C., Miller, J. W., Friedman, D. S., Boland, M. V., Elze, T., Zebardast, N., IRIS Registry Analytic Center Consortium, Pershing, S., Hyman, L., Haller, J. A., Lee, A. Y., Lee, Lum, F., Miller, J. W., Lorch, A. 2022


    PURPOSE: To evaluate the effectiveness of microinvasive glaucoma surgery (MIGS) with and without concurrent phacoemulsification.DESIGN: Multicenter, retrospective cohort study.PARTICIPANTS: Patients in the Intelligent Research in Sight (IRIS) Registry who underwent Xen gel stent (ab interno) implantation, endoscopic cyclophotocoagulation (ECP), or goniotomy or canaloplasty from 2013 through2019.METHODS: Kaplan-Meier survival analysis was used to assess reoperation rates. We defined reoperation as any subsequent glaucoma surgery occurring 1 month to 3 years after the initial procedure. Multivariable Cox proportional hazard models were used to determine factors predictive of reoperation.MAIN OUTCOME MEASURES: Reoperation rate, mean intraocular pressure (IOP) and visual acuity (VA), postoperative complications, predictors of reoperation, and reoperation procedure type.RESULTS: A total of 79 363 eyes from 57 561 patients were included, with 15 118 eyes (19%) receiving stand-alone MIGS and 64 245 eyes (81%) receiving MIGS concurrent with phacoemulsification. Overall, patients who underwent MIGS concurrently with phacoemulsification showed lower reoperation rates compared with stand-alone MIGS, most pronounced in ECP and goniotomy or canaloplasty. At postoperative year 2, the cumulative reoperation rate for stand-alone procedures was 15% for ECP, 24% for Xen implantation, and 24% for goniotomy or canaloplasty compared with 3% for ECP, 19% for Xen implantation, and 6% for goniotomy or canaloplasty concurrent with phacoemulsification (P < 0.001 for each stand-alone MIGS vs. MIGS with phacoemulsification). Black race, older age, moderate and severe glaucoma, higher baseline IOP, and glaucoma subtype were associated with higher reoperation risk. Although IOP decreased in all groups, stand-alone MIGS showed a more substantial decrease in mean IOP. Complication rates from MIGS were low overall: 1% for ECP, 1% for Xen implantation, and 2% for goniotomy or canaloplasty.CONCLUSIONS: In current United States clinical practice, MIGS has substantially lower reoperation rates when performed with phacoemulsification, especially for ECP and goniotomy or canaloplasty. Approximately one-sixth of patients undergoing stand-alone ECP and one-quarter of patients undergoing stand-alone Xen implantation or goniotomy or canaloplasty require reoperation by 2 years. Black race, diagnosis coding of moderate to severe glaucoma, and higher baseline IOP were associated with higher risk of reoperation after MIGS procedures.FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

    View details for DOI 10.1016/j.ophtha.2022.10.021

    View details for PubMedID 36522820

  • Outcomes of Over 40,000 Eyes Treated for Diabetic Macula Edema in Routine Clinical Practice: A Systematic Review and Meta-analysis. Advances in therapy Mehta, H., Nguyen, V., Barthelmes, D., Pershing, S., Chi, G. C., Dopart, P., Gillies, M. C. 2022


    INTRODUCTION: We investigated effectiveness and safety outcomes of diabetic macula edema (DME) treatment in routine clinical practice.METHODS: A literature search was conducted of peer-reviewed articles published from January 2011 to September 2021. Studies of DME treatment in real-world practice of at least 6months with at least 50 eyes at baseline were included. Randomized controlled trials (RCTs) were excluded. The primary outcome for this meta-analysis was change in visual acuity (VA) 12months after starting treatment.RESULTS: Of 3034 initially identified studies, 138 met selection criteria, representing more than 40,000 eyes. The mean 12-month VA gain was 4.6 letters (95%CI 3.7, 5.4; baseline 58.6) for vascular endothelial growth factor inhibitors (anti-VEGF), 4.4 (2.5, 6.3; baseline 54.2) for steroids, and 2.1 (-1.2, 5.3; baseline 63.6) for macular laser. Australian and New Zealand studies had better baseline VA when initiating treatment compared with Asia, Europe, and North America, translating to better VA at 12months. Fewer anti-VEGF injections were delivered in real-world practice than registrational RCTs. Neither systemic nor ocular safety was consistently reported.CONCLUSIONS: Intravitreal anti-VEGF or steroids for DME generally led to visual gains in real-world practice but these were less impressive than RCTs, with undertreatment and differences in baseline characteristics likely contributing factors.

    View details for DOI 10.1007/s12325-022-02326-8

    View details for PubMedID 36241963

  • The American Academy of Ophthalmology IRIS Registry (Intelligent Research In Sight): current and future state of big data analytics. Current opinion in ophthalmology Pershing, S., Lum, F. 2022; 33 (5): 394-398


    PURPOSE OF REVIEW: To describe the drivers, development, and current state of the American Academy of Ophthalmology IRIS Registry (Intelligent Research In Sight), and analytics involving deidentified aggregate IRIS Registry data.RECENT FINDINGS: The IRIS Registry has a core mission of quality improvement and reporting. In addition, analytic projects performed to date have included characterizing patient populations and diseases, incidence, and prevalence; clinical outcomes and complications; risk factors and effect modifiers; practice patterns; and trends over time. Pipeline projects include application of artificial intelligence and machine learning approaches for predictive modeling and analytics, disease mapping, detecting patterns and identifying cohorts, and optimizing treatment based on patient-specific characteristics.SUMMARY: The IRIS Registry is the nation's largest single specialty clinical registry, with unique data elements specific to ophthalmology. It offers a wealth of opportunities involving big data analytics, including traditional inferential statistics as well as machine learning and artificial intelligence approaches scalable on massive amounts of data.

    View details for DOI 10.1097/ICU.0000000000000869

    View details for PubMedID 35916568

  • Predicting Acute Endophthalmitis for Patients with Cataract Surgery Using Hierarchical and Probabilistic Representation of Clinical Codes INTERNATIONAL JOURNAL OF SEMANTIC COMPUTING Haque, M., Pershing, S. 2022
  • Readability and Accountability of Online Patient Education Materials for Common Retinal Diseases OPHTHALMOLOGY RETINA Cohen, S. A., Pershing, S. 2022; 6 (7): 641-643
  • Relative Importance of Applicant Characteristics in Ophthalmology Residency Interview Selection: A Survey of Program Directors. Journal of academic ophthalmology (2017) Cohen, S. A., Pershing, S. 2022; 14 (2): e246-e256


    Introduction  Ophthalmology residency positions remain competitive. A lack of clarity regarding which residency selection criteria are prioritized by program directors can heighten the stress associated with the match process. While surveys of program directors in several other medical specialties have been conducted to identify the most important residency selection criteria, there is limited data on selection criteria used by ophthalmology residency program directors. The purpose of our study was to survey ophthalmology residency program directors to identify the current state of interview selection decisions-the factors currently considered most important in determining whether to extend an interview invitation to residency applicants. Methods  We developed and distributed a Web-based questionnaire to all U.S. ophthalmology residency program directors. Questions evaluated program demographics and the relative importance of 23 different selection criteria used by ophthalmology residency program directors when evaluating applicants for residency interviews (Likert scale 1-5, with 1 being "not important" and 5 being "very important"). Program directors were also asked to identify the one factor they felt was most important. Results  The overall residency program director response rate was 56.5% (70/124). The selection criteria with the highest average importance scores were core clinical clerkship grades (4.26/5) followed by letters of recommendation (4.06/5), and United States Medical Licensing Examination (USMLE) Step 1 score (4.03/5). The most frequently cited single most important factor for interview selection was core clinical clerkship grades (18/70, 25.7%), with USMLE Step 1 score (9/70, 12.9%) and rotations at the program director's department (6/70, 8.6%) also commonly reported. Conclusion  Our results suggest that core clinical clerkship grades, letters of recommendation, and USMLE Step 1 scores are deemed the most important selection criteria by ophthalmology residency program directors as of a 2021 survey. With changes in clerkship grading for many medical schools and changes in national USMLE Step 1 score reporting, programs will face challenges in evaluating applicants and the relative importance of other selection criteria will likely increase.

    View details for DOI 10.1055/s-0042-1756122

    View details for PubMedID 37388179

    View details for PubMedCentralID PMC9927967

  • Impact of Type 2 Diabetes Mellitus and Insulin Use on Progression to Glaucoma Surgery in Primary Open Angle Glaucoma Sun, M. T., Pershing, S., Goldberg, J. L., Wang, S. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2022
  • Importance of 23 Selection Criteria Considered When Offering Interview Invitations to Ophthalmology Residency Applicants: A Survey of Program Directors Cohen, S., Pershing, S. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2022
  • An evaluation of the content on pediatric ophthalmology fellowship program websites. Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus Cohen, S. A., Pershing, S. 2022

    View details for DOI 10.1016/j.jaapos.2022.03.007

    View details for PubMedID 35659979

  • Trends of PRP and Anti-VEGF for NPDR in the IRIS (R) Registry (Intelligent Research in Sight), 2016-2018 Bair, H., Brant, A., Pershing, S., Mishra, K., Perlroth, A., Xu, C., Do, D. V. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2022
  • Visual Outcomes post-PPV for Tractional Retinal Detachment or Vitreous Hemorrhage in the Intelligent Research in Sight (IRIS) Registry Perlroth, A., Brant, A., Pershing, S., Mishra, K., Bair, H., Xu, C., Do, D. V. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2022
  • Trends for Proliferative Diabetic Retinopathy Vitrectomy Treatments in the IRIS (R) Registry (Intelligent Research in Sight) Xu, C. L., Brant, A., Pershing, S., Mishra, K., Perlroth, A., Bair, H., Do, D. V. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2022
  • Newly Diagnosed Central Serous Chorioretinopathy: Demographics and Epidemiology from the IRIS (R) Registry (Intelligent Research in Sight) Mishra, K., Brant, A., Pershing, S., Perlroth, A., Bair, H., Xu, C., Do, D. V. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2022
  • Progression and Regression of Diabetic Retinopathy in the IRIS (R) Registry (Intelligent Research in Sight) Brant, A., Mishra, K., Perlroth, A., Bair, H., Xu, C., Pershing, S., Do, D. V. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2022
  • Accessibility and Content of Vitreoretinal Surgery Fellowship Program Websites OPHTHALMOLOGY RETINA COHEN, S. A., PERSHING, S. N. 2022; 6 (5): 434-436
  • Adjustable suture technique is associated with fewer strabismus reoperations in the IRIS Registry (Intelligent Research in Sight). Ophthalmology Oke, I., Hall, N., Elze, T., Miller, J. W., Lorch, A. C., Hunter, D. G., IRIS Data Analytics Committee members, Pershing, S., Hyman, L., Haller, J. A., Lee, A. Y., Lee, C. S., Lum, F., Miller, J. W., Lorch, A. 2022


    PURPOSE: To compare the reoperation rates following strabismus surgery with and without adjustable suture technique.DESIGN: Retrospective cohort study: Participants: Patients ≥ 18 years of age in the IRIS Registry who underwent strabismus surgery between January 1st, 2013 and December 31st, 2018.METHODS: Data were collected from the electronic health records of ophthalmology practices participating in the IRIS Registry. The primary exposure of interest was use of the adjustable suture technique, identified by Current Procedural Terminology coding.MAIN OUTCOME MEASURE: The primary outcome was repeat strabismus surgery within one-year of initial strabismus surgery. Odds ratios (OR) were derived from a multivariable logistic regression model evaluating the association between the use of adjustable sutures and reoperation rate, adjusting for patient demographics and surgical factors.RESULTS: A total of 34,872 patients who underwent strabismus surgery during the study interval were identified, 72% of whom underwent horizontal muscle surgery, 17% vertical muscle surgery, and 11% combined horizontal and vertical muscle surgery. Adjustable sutures were used in 18% of cases. The overall reoperation rate within one year of strabismus surgery was 7.7%. The one-year reoperation rate was 6.0% for patients treated with adjustable sutures and 8.1% for patients treated without adjustable sutures (p < 0.001). The multivariable regression model revealed a statistically significant, 30% decrease in odds of reoperation within one year of surgery when adjustable sutures were used (OR = 0.70, 95% CI: 0.62 - 0.78), a 40% increase in those with a history of prior strabismus surgery (OR = 1.40, 95% CI: 1.28 - 1.53), and a 9% increase per decade of age at surgery (OR = 1.09, 95% CI: 1.06 - 1.11).CONCLUSIONS: In adults cared for in practices participating in the IRIS Registry, the adjustable suture technique is associated with an approximately 2% lower reoperation rate within one-year of undergoing horizontal or combined horizontal and vertical strabismus surgery. Adjustable suture use in vertical strabismus surgery alone did not significantly reduce the one-year reoperation rate. A history of prior strabismus surgery is associated with increased odds of reoperation.

    View details for DOI 10.1016/j.ophtha.2022.04.021

    View details for PubMedID 35500607

  • Readability and accountability of online patient education materials for common retinal diseases. Ophthalmology. Retina Cohen, S. A., Pershing, S. 2022


    Patients often utilize the internet to learn about retinal diseases. Our results demonstrate that online patient education materials related to common retinal diseases are often written at higher than recommended reading levels and lack accountability.

    View details for DOI 10.1016/j.oret.2022.03.015

    View details for PubMedID 35338025

  • Re: Pershing et al.: Bidirectional association between visual impairment and dementia among older adults in the United States over time REPLY OPHTHALMOLOGY Chen, S. P., Azad, A. D., Pershing, S. 2022; 129 (2): E33-E35
  • Accessibility and Content of Vitreoretinal Surgery Fellowship Program Websites. Ophthalmology. Retina Cohen, S. A., Pershing, S. 1800


    Fellowship program websites represent an important information source for applicants. Our results demonstrate that vitreoretinal surgery fellowship websites are inconsistent and often incomplete. Incorporating additional recruitment and education criteria may improve website information potential.

    View details for DOI 10.1016/j.oret.2022.01.002

    View details for PubMedID 35017117

  • #Ophthalmology: Social Media Utilization and Impact in Ophthalmology Journals, Professional Societies, and Eye Health Organizations. Clinical ophthalmology (Auckland, N.Z.) Cohen, S. A., Pershing, S. 2022; 16: 2989-3001


    Aim: To evaluate and quantify social media presence of ophthalmology peer-reviewed journals, professional societies, and eye health organizations, and to determine if there is a correlation between social media utilization and Twitter engagement metrics or journal impact measures.Methods: We searched for online profiles of 100 ophthalmology peer-reviewed journals, 333 professional ophthalmology societies, and 40 eye health organizations on Facebook, Twitter, and Instagram. Impact was quantified by recording the number of "likes" on Facebook and number of followers on Twitter and Instagram. We also used Twitonomy software to obtain advanced Twitter metrics for all journal accounts from 2018 to 2021, and compared to journal impact measured by SCImago Journal Rank (SJR) score, the h-index, and impact factor.Results: Eye health organizations averaged significantly greater Facebooks "likes" and Twitter followers than both peer-reviewed journals and professional societies (p < 0.0001). Of 100 journals studied, 30% were active on Twitter, 25% on Facebook, and 6% on Instagram. Slightly more than half of all journal-affiliated social media accounts were accessible from the journal website. Among journals with active Twitter accounts, total followers, total tweets, average retweets, and average "favorites" were all significantly positively correlated with academic metrics such as the SJR, h-index, and/or impact factor.Conclusion: Greater social media engagement is associated with higher ophthalmology journal impact metrics; however, ophthalmology journals and professional societies lag behind eye health organizations in social media engagement. Although unable to demonstrate causality, social media may be an underutilized visibility, communication, and dissemination tool.

    View details for DOI 10.2147/OPTH.S378795

    View details for PubMedID 36092462

  • Geographic Trends in the Ophthalmology Residency Match: Influence of Program and Applicant Characteristics. Journal of academic ophthalmology (2017) Cohen, S. A., Pershing, S. 2022; 14 (1): e81-e92


    Introduction  The ophthalmology residency match remains competitive. Several prior studies have examined various factors that contribute to a successful match into an ophthalmology residency program; however, the role of geographic location in the ophthalmology residency match process is unclear. The purpose of our study was to evaluate geographic trends in the ophthalmology residency match and to determine whether geographic trends vary based on program level factors such as program rank or funding source and/or applicant factors such as year of training, gender, and medical degree earned. Specifically, we assessed associations with residents training at the residency program affiliated with their medical school and/or within the same geographic region as their medical school, using data obtained through publicly available sources and residency program surveys. Methods  We used the American Medical Association's Fellowship and Residency Electronic Interactive Database database to identify accredited ophthalmology residency programs. Residency program Web sites and email inquiries were used to collect demographic and geographic information for residents in the graduating classes of 2021 to 2023. Statistical analysis included χ 2 testing and multivariate logistic regression. Results  In total, 1,378 residents were included from 110 ophthalmology residency programs and 218 medical schools. Residents who matched at the residency program affiliated with their medical school (18%) were evenly distributed among the Midwest, Northeast, South, and West regions ( p  = 0.2236). Residency programs in the West (31.7%) matched fewer regional medical students compared with programs in the South (61.2%), Midwest (57.4%), and Northeast (58.4%) ( p  < 0.0001). Attending a publicly funded medical school was associated with higher odds of matching into a regional residency program (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.10-1.90; p  = 0.0001) and attending a privately funded medical school was associated with higher odds of matching into a top-ranked residency program (OR, 1.53, 95% CI, 1.34-1.82; p  = 0.0002). Conclusions  The majority of current ophthalmology residents trained at programs in the same geographic region as their medical schools, with nearly 20% of residents training at their medical school-affiliated program. Geographic differences in match results were observed based on resident gender, medical school characteristics, and residency program region.

    View details for DOI 10.1055/s-0042-1743416

    View details for PubMedID 37388479

    View details for PubMedCentralID PMC9927969

  • An Analysis of the Diversity and Inclusion Content Featured on Ophthalmology Residency Program Web Sites. Journal of academic ophthalmology (2017) Cohen, S. A., Cohen, L. E., Pershing, S. 2022; 14 (1): e103-e109


    Introduction  Ophthalmology departments have been stated to be among the least diverse clinical departments at United States medical schools. Improvement requires recruiting a pipeline of diverse trainees. Residency program Web sites represent a potential diversity and inclusion recruitment tool. This study assesses how ophthalmology residency program Web sites demonstrate a commitment to diversity and inclusion. Methods  We analyzed the diversity and inclusion content of 116 ophthalmology residency program Web sites in April 2021. Main outcome measures were the presence of 12 diversity and inclusion elements on program Web sites, based on prior work and Accreditation Council for Graduate Medical Education guidelines: nondiscrimination statement, diversity and inclusion message, community resources, extended faculty or resident biographies (including hobbies, etc.), faculty photos, resident photos, additional financial resources for trainees, wellness resources, mental health resources, health disparities/community engagement, and diversity council. We used Mann-Whitney U and Kruskal-Wallis tests to assess whether residency program characteristics such as rank, size, university affiliation, and geographic location were associated with commitment to diversity and inclusion on affiliated residency Web sites. Results  Ophthalmology residency program Web sites included a mean of 4.4 ± 2.1 diversity elements. Sixteen percent of programs featured more than half (7 + ) of the evaluated diversity elements. The most featured common diversity elements included resident photos (85.3%), faculty photos (78.4%), and community resources (64.3%). Extended faculty biographies (2.6%), mental health resources (9.5%), and diversity council information (11.2%) were less commonly showcased. Top-ranked programs (7.6 ± 1.8, p  < 0.0001) and university-based/-affiliated programs (4.7 ± 2.8, p  = 0.0039) displayed more diversity elements than lower-ranked (4.1 ± 1.8) and community-based programs (2.8 ± 1.7). Conclusion  Most ophthalmology residency program Web sites feature less than half of the 12 diversity and inclusion elements included in this study, suggesting room for improvement. By drawing attention to program diversity and inclusion efforts, Web sites offer a potential tool for residency programs to consider in their recruitment efforts for diverse trainees. Incorporating the diversity and inclusion elements analyzed in this study represents a low-burden way to signal a greater commitment to diversity that could help programs recruit diverse applicants.

    View details for DOI 10.1055/s-0042-1743412

    View details for PubMedID 37388482

    View details for PubMedCentralID PMC9928006

  • PrediCatE: Predicting Acute Endophthalmitis for Patients with Cataract Surgery Haque, E., Pershing, S., IEEE IEEE COMPUTER SOC. 2022: 33-40
  • Evaluation of Website Accessibility and Content for all Glaucoma Fellowship Programs in the United States. Ophthalmology. Glaucoma Cohen, S. A., Fisher, A. C., Pershing, S. 2021


    Fellowship program websites are a critical information source for applicants. Our results demonstrate that information on glaucoma fellowship websites is inconsistent and incomplete. Our study provides a basis for improving glaucoma fellowship website content.

    View details for DOI 10.1016/j.ogla.2021.11.004

    View details for PubMedID 34838811

  • Reply. Ophthalmology Chen, S. P., Azad, A. D., Pershing, S. 2021

    View details for DOI 10.1016/j.ophtha.2021.10.005

    View details for PubMedID 34756773

  • Implicit Bias and the Association of Redaction of Identifiers With Residency Application Screening Scores. JAMA ophthalmology Pershing, S., Stell, L., Fisher, A. C., Goldberg, J. L. 2021


    Importance: Diversity in the ophthalmology profession is important when providing care for an increasingly diverse patient population. However, implicit bias may inadvertently disadvantage underrepresented applicants during resident recruitment and selection.Objective: To evaluate the association of the redaction of applicant identifiers with the review scores on ophthalmology residency applications as an intervention to address implicit bias.Design, Setting, and Participants: In this quality improvement study, 46 faculty members reviewed randomized sets of 462 redacted and unredacted applications from a single academic institution during the 2019-2020 ophthalmology residency application cycle.Interventions: Applications electronically redacted for applicant identifiers, including name, sex or gender, race and ethnicity, and related terms.Main Outcomes and Measures: The main outcome was the distribution of scores on redacted and unredacted applications, stratified by applicant's sex, underrepresentation in medicine (URiM; traditionally comprising American Indian or Alaskan Native, Black, and Hispanic individuals) status, and international medical graduate (IMG) status; the application score beta coefficients for redaction and the applicant and reviewer characteristics were calculated. Applications were scored on a scale of 1 to 9, where 1 was the best score and 9 was the worst score. Scores were evaluated for a significant difference based on redaction among female, URiM, and IMG applicants. Linear regression was used to evaluate the adjusted association of redaction, self-reported applicant characteristics, and reviewer characteristics with scores on ophthalmology residency applications.Results: In this study, 277 applicants (60.0%) were male and 71 (15.4%) had URiM status; 32 faculty reviewers (69.6%) were male and 2 (0.4%) had URiM status. The distribution of scores was similar for redacted vs unredacted applications, with no difference based on sex, URiM status, or IMG status. Applicant's sex, URiM status, and IMG status had no association with scores in multivariable analysis (sex, beta=-0.08; 95% CI, -0.32 to 0.15; P=.26; URiM status, beta=-0.03; (95% CI, -0.36 to 0.30; P=.94; and IMG status, beta=0.39; 95% CI, -0.24 to 1.02; P=.35). In adjusted regression, redaction was not associated with differences in scores (beta=-0.06 points on a 1-9 scale; 95% CI, -0.22 to 0.10 points; P=.48). Factors most associated with better scores were attending a top 20 medical school (beta=-1.06; 95% CI, -1.37 to -0.76; P<.001), holding an additional advanced degree (beta=-0.86; 95% CI, -1.22 to -0.50; P<.001), and having a higher United States Medical Licensing Examination Step 1 score (beta=-0.35 per 10-point increase; 95% CI, -0.45 to -0.26; P<.001).Conclusions and Relevance: This quality improvement study did not detect an association between the redaction of applicant characteristics on ophthalmology residency applications and the application review scores among underrepresented candidates at this institution. Although the study may not have been powered adequately to find a difference, these findings suggest that the association of redaction with application review scores may be preempted by additional approaches to enhance diversity, including pipeline programs, implicit bias training, diversity-centered culture and priorities, and targeted applicant outreach. Programs may adapt this study design to probe their own application screening biases and track over time before-and-after bias-related interventions.

    View details for DOI 10.1001/jamaophthalmol.2021.4323

    View details for PubMedID 34673889

  • Endophthalmitis rate in immediately sequential vs delayed sequential bilateral cataract surgery within the IRIS Registry data. Ophthalmology Lacy, M., Kung, T. H., Owen, J. P., Yanagihara, R. T., Blazes, M., Pershing, S., Hyman, L. G., Van Gelder, R. N., Lee, A. Y., Lee, C. S., IRIS Registry Analytic Center Consortium, Lum, F., Chew, E., Haller, J. A., Lorch, A. C., Miller, J. W. 2021


    PURPOSE: To compare the rate of postoperative endophthalmitis following immediately sequential bilateral cataract surgery (ISBCS) vs delayed sequential bilateral cataract surgery (DSBCS) using the American Academy of Ophthalmology IRIS (Intelligent Research in Sight) Registry database.DESIGN: Retrospective cohort study.SUBJECTS: IRIS Registry patients who underwent cataract surgery during 2013-2018.METHODS: Patients who underwent cataract surgery were divided into two groups: (1) ISBCS and (2) DSBCS (second eye surgery ≥1 day following the first eye surgery) or unilateral surgery. Postoperative endophthalmitis was defined as endophthalmitis occurring within four weeks of surgery by International Classification of Diseases (ICD) code and ICD code with additional clinical criteria.MAIN OUTCOME MEASURES: Rate of postoperative endophthalmitis.RESULTS: Of 5,573,639 IRIS Registry patients who underwent cataract extraction, 165,609 had ISBCS and 5,408,030 had DSBCS or unilateral surgery (3,695,449 DSBCS, 1,712,590 unilateral surgery only). A total of 3,102 participants (0.056%) met study criteria of postoperative endophthalmitis with supporting clinical findings. The rates of endophthalmitis in either surgery eye between the two surgery groups were similar (0.059% in ISBCS group vs 0.056% in DSBCS or unilateral, P=0.53). Although the incidence of endophthalmitis was slightly higher in the ISBCS group compared to the DSBCS or unilateral group, the odds ratio (OR) did not reach statistical significance (1.08, 95% confidence interval: 0.87 - 1.31, P=0.47) after adjusting for age, sex, race, insurance status, and comorbid eye disease. Seven cases of bilateral endophthalmitis with supporting clinical data in the DSBCS group and no cases in the ISBCS group were identified.CONCLUSIONS: Risk of postoperative endophthalmitis was not statistically significantly different between patients who underwent ISBCS and DSBCS or unilateral cataract surgery.

    View details for DOI 10.1016/j.ophtha.2021.07.008

    View details for PubMedID 34265315

  • Black and Blue: Eyes and Dyes Sobel, R., Nirschl, J., Hammer, P., Sanchez, R., Pershing, S., Louie, C., Lin, J. OXFORD UNIV PRESS INC. 2021: 579
  • Endophthalmitis risk following same-day vs delayed sequential bilateral cataract surgery using the Intelligent Research in Sight (IRIS)(R) Registry Lacy, M., Owen, J., Yanagihara, R. T., Blazes, M., Pershing, S., Hyman, L., Van Gelder, R. N., Lee, A. Y., Lee, C. S. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2021
  • Geographic and Socioeconomic Disparities in Uveal Melanoma Treatment, 2004-2016 So, J., Pershing, S., Afshar, A. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2021
  • Age, Gender, and Laterality of Retinal Vascular Occlusion: A Retrospective Study from the IRIS Registry. Ophthalmology. Retina Li, Y., Hall, N. E., Pershing, S., Hyman, L., Haller, J. A., Lee, A. Y., Lee, C. S., Chiang, M., Lum, F., Miller, J. W., Lorch, A., Elze, T. 2021


    PURPOSE: Retinal vascular occlusion is a leading cause of profound irreversible visual loss, but the understanding of the disease is insufficient. We systematically investigated the age, gender, and laterality at the onset of retinal artery occlusion (RAO) and retinal vein occlusion (RVO) in the IRIS Registry (Intelligent Research in Sight).DESIGN: A retrospective registry cohort.PARTICIPANTS: Retinal vascular occlusion cases participating in the IRIS Registry.METHODS: All cases diagnosed as retinal vascular occlusion in the IRIS Registry between 2013 and 2017 were included. Cases with unspecified gender or laterality were excluded when conducting the relevant analyses. Cases were categorized based on diagnosis codes into RAO, with subtypes transient retinal artery occlusion (TRAO), partial retinal artery occlusion (PRAO), branch retinal artery occlusion (BRAO), and central retinal artery occlusion (CRAO), and into RVO, with subtypes venous engorgement (VE), branch retinal vein occlusion (BRVO), and central retinal vein occlusion (CRVO). Age was evaluated as a categorical variable (5-year increments). We investigated the association of age, gender, and laterality with the onset frequency of retinal vascular occlusion subtypes.MAIN OUTCOME MEASURES: The frequency of onset of RAO and RVO subtypes by age, gender and laterality.RESULTS: A total of 1,251,476 retinal vascular occlusion cases were included, 23.8% of which were RAO, while 76.2% were RVO. 1,248,656 and 798,089 cases were selected for analysis relevant to gender and laterality, respectively. The onset frequency of all subtypes increased with age. PRAO, BRAO, CRAO, and CRVO presented more frequently in men (53.5%, 51.3%, 52.6%, 50.4%), while TRAO, VE, and BRVO presented more frequently in women (54.9%, 56.0%, 54.5%). BRVO and all RAO subtypes showed a right-eye onset preference (BRVO 51.0%, TRAO 51.7%, PRAO 54.4%, BRAO 53.5%, CRAO 53.4%), while VE and CRVO exhibited a left-eye onset preference (VE 53.3%, CRVO 50.9%).CONCLUSIONS: While retinal vascular occlusion incidence increases with age regardless of subtypes, we found various subtype-specific disease onset differences related to gender and, in particular, ocular laterality. These findings may improve understanding of the specific etiology of retinal vascular occlusions of different subtypes and their relationship with structural and anatomic asymmetries of the vascular system.

    View details for DOI 10.1016/j.oret.2021.05.004

    View details for PubMedID 33991710

  • Variability and Costs of Low-Value Preoperative Testing for Cataract Surgery Within the Veterans Health Administration. JAMA network open Mudumbai, S. C., Pershing, S., Bowe, T., Kamal, R. N., Sears, E. D., Hawn, M. T., Eisenberg, D., Finlay, A. K., Hagedorn, H., Harris, A. H. 2021; 4 (5): e217470


    Importance: The Choosing Wisely guidelines indicate that preoperative testing is often unnecessary and wasteful for patients undergoing cataract operations. However, little is known about the impact of these widely disseminated guidelines within the US Veterans Health Administration (VHA) system.Objective: To examine the extent, variability, associated factors, and costs of low-value tests (LVTs) prior to cataract operations in the VHA.Design, Setting, and Participants: This cohort study examined records of all patients receiving cataract operations within the VHA in fiscal year 2017 (October 1, 2016, to September 31, 2017). Records from 135 facilities nationwide supporting both ambulatory and inpatient surgery were included.Exposures: A laboratory test occurring within 30 days prior to cataract surgery and within 30 days after clinic evaluation.Main Outcomes and Measures: Overall national and facility-level rates and associated costs of receiving any of 8 common LVTs in the 30 days prior to cataract surgery. The patient characteristics, procedure type, and facility-level factors associated with receiving at least 1 test, the number of tests received, and receipt of a bundle of 4 tests (complete blood count, basic metabolic profile, chest radiograph, and electrocardiogram).Results: A total of 69 070 cataract procedures were identified among 50 106 patients (66 282 [96.0%] men; mean [SD] age, 71.7 [8.1] years; 53 837 [77.9%] White, 10 292 [14.9%] Black). Most of the patient population had either overweight (23 292 [33.7%] patients) or obesity (27 799 [40.2%] patients). Approximately 49% of surgical procedures (33 424 procedures) were preceded by 1 or more LVT with an overall LVT cost of $2 597 623. Among patients receiving LVTs, electrocardiography (7434 patients [29.9%]) was the most common, with some patients also receiving more costly tests, including chest radiographs (489 patients [8.2%]) and pulmonary function tests (127 patients [3.4%]). For receipt of any LVT, the intraclass correlation coefficient was 0.61 (P<.001) at the facility level and 0.06 (P<.001) at the surgeon level, indicating the substantial contribution of the facility to amount of tests given.Conclusions and Relevance: Despite existing guidelines, use of LVTs prior to cataract surgery is both common and costly within a large, national integrated health care system. Our results suggest that publishing evidence-based guidelines alone-such as the Choosing Wisely campaign-may not sufficiently influence individual physician behavior, and that system-level efforts to directly deimplement LVTs may therefore necessary to effect sustained change.

    View details for DOI 10.1001/jamanetworkopen.2021.7470

    View details for PubMedID 33956131

  • Need for Retinal Detachment Reoperation based on Primary Repair Method among Commercially-insured Patients, 2003-2016. American journal of ophthalmology R Reeves, M., Afshar, A. R., Pershing, S. 2021


    PURPOSE: To examine associations between primary repair, patient characteristics, and rhegmatogenous retinal detachment (RRD) reoperation.DESIGN: Retrospective cohort study METHODS: We used administrative claims to identify enrollees with incident RRD treatment by laser barricade, pneumatic retinopexy (PR), pars plana vitrectomy (PPV), or scleral buckle (SB) between 2003 and 2016. Analysis excluded patients with less than three years of continuous enrollment, previous RRD diagnosis, or repair. We determined reoperation frequency (PPV, PR, or SB) within 90 days post-repair and used multivariable logistic regression to identify associations between reoperation and patient and primary repair characteristics.RESULTS: Of 16,190 patients with documented primary RRD repair, 2,918 (18.0%) required reoperation within 90 days. Reoperation was significantly associated with male sex (OR=1.24, p<0.001), pseudophakia (OR=1.25, p<0.001), vitreous hemorrhage (OR=1.22, p=0.001), and worse systemic health (OR=1.19-1.25, p<0.05, for Charlson Comorbidity Index ≥3). Pseudophakia had higher reoperation odds after all primary procedures except PPV. 28.7% of primary PR cases required reoperation, versus 19.1% of SB and 17.9% of PPV repairs. Adjusting for other patient characteristics, PR had highest odds of reoperation (OR=1.90, p<0.001, versus primary PPV). Primary laser barricade had lowest odds of reoperation (OR=0.49, p<0.001). PPV was the most frequent reoperation procedure.CONCLUSIONS: Nearly one in five patients require reoperation within 90 days after primary RRD repair. Cases requiring only primary laser barricade had lowest reoperation odds, likely representing less severe RRDs. Primary PR had highest reoperation odds; PPV and SB were similar to each other. These findings are important for patient education and surgical decision-making.

    View details for DOI 10.1016/j.ajo.2021.04.007

    View details for PubMedID 33895151

  • Development of the Elective Outpatient Percutaneous Coronary Intervention Episode-Based Cost Measure. Circulation. Cardiovascular quality and outcomes Sandhu, A. T., Do, R., Lam, J., Blankenship, J., Van Decker, W., Rich, J., Gonzalez, O., Wu, X., Pershing, S., Lin, E., MaCurdy, T. E., Bhattacharya, J., Nagavarapu, S. 2021: CIRCOUTCOMES119006461


    BACKGROUND: The Merit-Based Incentive Payment System adjusts clinician payments based on a performance score that includes cost measures. With the Centers for Medicare & Medicaid Services, we developed a novel cost measure that compared interventional cardiologists on a targeted set of costs related to elective percutaneous coronary intervention (PCI). We describe the measure and compare it to a hypothetical version including all expenditures post-PCI.METHODS: Measure development was guided by 39 clinician experts. They identified services within 30 days of PCI that could be potentially affected by the interventional cardiologist. Expenditures for these PCI-related services were included as measure costs in a process termed service assignment. We used 1 year of Medicare claims to calculate clinician scores using the final measure that included only PCI-related costs (with service assignment) and a hypothetical version that included all costs post-PCI (without service assignment). We calculated reliability for both measures. This marker of precision breaks measure variance into signal (difference between clinicians) versus noise (difference between PCI episodes for a clinician). We also determined the change in clinician performance quintile between measures.RESULTS: We identified 100 992 elective outpatient PCI episodes from May 2, 2016, to May 1, 2017. Total Medicare expenditures within 30 days of PCI averaged $13 234. After excluding costs unrelated to PCI, average cost was $10 966. For individual clinicians, mean reliability for the hypothetical measure without service assignment was 0.36. After service assignment, final measure reliability increased to 0.53. When evaluated as clinician groups, reliability increased from 0.43 to 0.73 following service assignment. Approximately 66% (2340 of 3527) of clinicians were reclassified into a different performance quintile after excluding unrelated costs.CONCLUSIONS: The elective outpatient PCI cost measure had increased precision and reclassified clinician performance relative to a hypothetical version that included total expenditures.

    View details for DOI 10.1161/CIRCOUTCOMES.119.006461

    View details for PubMedID 33653117

  • Bidirectional Association between Visual Impairment and Dementia Among US Older Adults Over Time. Ophthalmology Chen, S. P., Azad, A. D., Pershing, S. 2021


    OBJECTIVE: While visual impairment has been shown to be associated with worse cognitive performance among older adults, the temporal relationship between the two remains subject to debate. Our objective was to investigate the longitudinal impact of visual impairment on cognitive function and vice versa.DESIGN: Retrospective, time-to-event study.SUBJECTS, PARTICIPANTS, AND/OR CONTROLS: National Health and Aging Trends Study (NHATS) participants from 2011-2018 cycles.METHODS, INTERVENTION, OR TESTING: A total of 10,676 participants aged 65 years and older were included. Cox proportional hazards regression models evaluated the impact of baseline visual impairment (VI) on subsequent dementia and impact of baseline dementia on subsequent VI. Models were adjusted for potential confounding variables, including demographics, clinical comorbidities, and hearing and physical function limitations.MAIN OUTCOME MEASURES: Hazard ratio for incident dementia among participants with baseline self-reported VI and hazard ratio for incident VI among participants with baseline dementia.RESULTS: Of the 10,676 participants included in the analysis, approximately 40% were between the ages of 65-74 years, 40% were between 75-84 years, and the remaining 20% were 85 years and older. The majority were female (59%), and 68% self-identified as non-Hispanic White. Among participants with normal cognitive status at baseline, subsequent dementia was observed in 1,753 (16%), and among participants with normal self-reported vision at baseline, subsequent VI was reported in 2,371 (22%). In adjusted regression models, participants with baseline VI had higher likelihood of developing dementia over subsequent follow-up (HR=2.3, 95% CI: 2.0-2.6 p<0.001). Similarly, participants with baseline dementia had higher likelihood of developing self-reported VI over time (HR=2.5, 95% CI: 2.2-2.8, p<0.001).CONCLUSIONS: Self-reported visual impairment in the US Medicare population is associated with greater likelihood of dementia over time, and dementia is similarly associated with greater likelihood of visual impairment over time. Associations are likely multifactorial and bidirectional, and could be explained by intervening variables in the path from visual impairment to dementia, or vice versa, or by common risk factors for pathological processes in both eyes and brain. These findings suggest need for early identification of older adults with visual compromise, and consideration of visual disability in the cognitively impaired.

    View details for DOI 10.1016/j.ophtha.2021.02.021

    View details for PubMedID 33647283

  • Systemic Corticosteroid Use after Central Serous Chorioretinopathy Diagnosis OPHTHALMOLOGY Azad, A. D., Zhou, M., Afshar, A. R., Bakri, S. J., Pershing, S. 2021; 128 (1): 121–29
  • The Impact of COVID-19 on Missed Ophthalmology Clinic Visits CLINICAL OPHTHALMOLOGY Brant, A. R., Pershing, S., Hess, O., Rooney, D., Goldberg, J., Tabin, G., Wang, S. Y. 2021; 15: 4645-4657


    To measure the COVID-19 pandemic impact on missed ophthalmology clinic visits and the influence of patient and eye disease characteristics on likelihood of missing clinic visits before and during the pandemic.A retrospective observational study analyzing eye clinic patients at a large tertiary care academic institution. We identified patients scheduled for eye care during pre-COVID-19 (January 1-February 29, 2020) and early COVID-19 (March 16-May 31, 2020) time periods. Missed appointment frequency and characteristics were evaluated during each time period. Multivariable logistic regression models were developed to examine adjusted odds of having at least one missed appointment during a given time period. Covariates included age, sex, race/ethnicity, marital status, preferred language (non-English vs English), insurance, distance from clinic, and diagnosis.Overall, 82.0% (n = 11,998) of pre-COVID-19 patients completed all scheduled visits, compared to only 59.3% (n = 9020) during COVID-19. Missed visits increased dramatically in late March 2020, then improved week by week through the end of May 2020. General ophthalmology/cataract and strabismus clinics had the highest rates of missed clinic visits during the COVID-19 period; neuro-ophthalmology, retina, cornea, oculoplastics and glaucoma had the lowest. Females, Blacks, Hispanics, Asians, ages 50+, and married patients had higher adjusted odds of missing clinic visits, both pre-COVID-19 and during COVID-19. Asian, elderly, and cataract patients had the highest adjusted odds of missing clinic visits during COVID-19 and had significant increases in odds compared to pre-COVID-19. Non-married, diabetic macular edema, and wet age-related macular degeneration patients had the lowest adjusted odds of missed visits during COVID-19.Missed clinic visits increased dramatically during the COVID-19 pandemic, particularly among elderly and nonwhite patients. These findings reflect differences in eye care delivery during the pandemic, and they indicate opportunities to target barriers to care, even during non-pandemic eras.

    View details for DOI 10.2147/OPTH.S341739

    View details for Web of Science ID 000730419000002

    View details for PubMedID 34916776

    View details for PubMedCentralID PMC8667753

  • Comparing cataract surgery complication rates in veterans receiving VA and community care. Health services research Rosen, A. K., Vanneman, M. E., O'Brien, W. J., Pershing, S., Wagner, T. H., Beilstein-Wedel, E., Lo, J., Chen, Q., Cockerham, G. C., Shwartz, M. 2020


    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

  • Big data requirements for artificial intelligence. Current opinion in ophthalmology Wang, S. Y., Pershing, S., Lee, A. Y., AAO Taskforce on AI and AAO Medical Information Technology Committee 2020


    PURPOSE OF REVIEW: To summarize how big data and artificial intelligence technologies have evolved, their current state, and next steps to enable future generations of artificial intelligence for ophthalmology.RECENT FINDINGS: Big data in health care is ever increasing in volume and variety, enabled by the widespread adoption of electronic health records (EHRs) and standards for health data information exchange, such as Digital Imaging and Communications in Medicine and Fast Healthcare Interoperability Resources. Simultaneously, the development of powerful cloud-based storage and computing architectures supports a fertile environment for big data and artificial intelligence in health care. The high volume and velocity of imaging and structured data in ophthalmology and is one of the reasons why ophthalmology is at the forefront of artificial intelligence research. Still needed are consensus labeling conventions for performing supervised learning on big data, promotion of data sharing and reuse, standards for sharing artificial intelligence model architectures, and access to artificial intelligence models through open application program interfaces (APIs).SUMMARY: Future requirements for big data and artificial intelligence include fostering reproducible science, continuing open innovation, and supporting the clinical use of artificial intelligence by promoting standards for data labels, data sharing, artificial intelligence model architecture sharing, and accessible code and APIs.

    View details for DOI 10.1097/ICU.0000000000000676

    View details for PubMedID 32657996

  • Intraocular Pressure Changes after Cataract Surgery in Patients with and without Glaucoma: An Informatics-Based Approach. Ophthalmology. Glaucoma Wang, S. Y., Azad, A. D., Lin, S. C., Hernandez-Boussard, T., Pershing, S. 2020


    PURPOSE: To evaluate changes in intraocular pressure (IOP) after cataract surgery among patients with or without glaucoma using automated extraction of data from electronic health records (EHRs).DESIGN: Retrospective cohort study.PARTICIPANTS: Adults who underwent standalone cataract surgery at a single academic center from 2009-2018.METHODS: Patient information was identified from procedure and billing codes, demographic tables, medication orders, clinical notes, and eye examination fields in the EHR. A previously validated natural language processing pipeline was used to identify laterality of cataract surgery from operative notes and laterality of eye medications from medication orders. Cox proportional hazards modeling evaluated factors associated with the main outcome of sustained postoperative IOP reduction.MAIN OUTCOME MEASURES: Sustained post-cataract surgery IOP reduction, measured at 14 months or the last follow-up while using equal or fewer glaucoma medications compared with baseline and without additional glaucoma laser or surgery on the operative eye.RESULTS: The median follow-up for 7574 eyes of 4883 patients who underwent cataract surgery was 244 days. The mean preoperative IOP for all patients was 15.2 mmHg (standard deviation [SD], 3.4 mmHg), which decreased to 14.2 mmHg (SD, 3.0 mmHg) at 12 months after surgery. Patients with IOP of 21.0 mmHg or more showed mean postoperative IOP reduction ranging from -6.2 to -6.9 mmHg. Cataract surgery was more likely to yield sustained IOP reduction for patients with primary open-angle glaucoma (hazard ratio [HR], 1.19; 95% confidence interval, 1.05-1.36) or narrow angles or angle closure (HR, 1.21; 95% confidence interval, 1.08-1.34) compared with patients without glaucoma. Those with a higher baseline IOP were more likely to achieve postoperative IOP reduction (HR, 1.06 per 1-mmHg increase in baseline IOP; 95% confidence interval, 1.05-1.07).CONCLUSIONS: Our results suggest that patients with primary open-angle glaucoma or with narrow angles or chronic angle closure were more likely to achieve sustained IOP reduction after cataract surgery. Patients with higher baseline IOP had increasingly higher odds of achieving reduction in IOP. This evidence demonstrates the potential usefulness of a pipeline for automated extraction of ophthalmic surgical outcomes from EHR to answer key clinical questions on a large scale.

    View details for DOI 10.1016/j.ogla.2020.06.002

    View details for PubMedID 32703703

  • Ophthalmology Consultation to Detect Endogenous Endophthalmitis: Clinical Characteristics in Consulted Versus Diagnosed Cases Among At-Risk Inpatients OPHTHALMIC SURGERY LASERS & IMAGING RETINA Wang, K., Krishnan, G., Pershing, S. 2020; 51 (3): 159-+


    Predisposing factors for ophthalmology consultations and endogenous endophthalmitis were compared among inpatients with systemic infection.This was a retrospective cohort study in a tertiary care hospital between January 1, 2010, and December 31, 2014. Multivariable logistic regression was utilized.There were 9,527 encounters identified with systemic infection. The 5-year incidence rate was 8.4% (803/9,527) for consultations and 0.3% (25/9,527) for endophthalmitis. Factors most associated with consultations included positive fungal blood cultures and HIV. Factors most associated with endophthalmitis included positive blood fungal cultures and endocarditis. Four of 25 endophthalmitis patients lacked positive blood cultures; six of 20 endophthalmitis patients with adequate mentation were asymptomatic.Positive blood fungal cultures were strongly associated with both endophthalmitis and consultations. Endocarditis was strongly associated with endophthalmitis but less associated with consultation and may warrant increased attention. Neither presence of symptoms nor positive cultures may be sufficiently accurate to determine need for consultation. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:159-169.].

    View details for DOI 10.3928/23258160-20200228-05

    View details for Web of Science ID 000522489100005

    View details for PubMedID 32211906

  • Receipt of Eye Care Services among Medicare Beneficiaries with and without Dementia. Ophthalmology Pershing, S., Goldstein, M. K., Henderson, V. W., Bundorf, M. K., Lu, Y., Rahman, M., Stein, J. D. 2020


    PURPOSE: To examine the relationship between dementia status and receipt of eye care among US Medicare beneficiaries.DESIGN: Retrospective, claims-based analysis.PARTICIPANTS: A 20% representative sample of Medicare beneficiaries who received care between January 1, 2006, and December 31,2015.METHODS: Dementia was identified from diagnosis codes documented in a beneficiary's first 3 years of observed Medicare enrollment. Eye care visits were identified from provider specialty codes on each encounter claim. We used multivariable Cox proportional hazards regression models with time-varying covariates to compare the likelihood of receiving eye care between beneficiaries with and without dementia. All models were adjusted for potential confounders, including demographics, urban/rural residence, systemic health (Charlson Index), and ocular comorbidities.MAIN OUTCOME MEASURES: Hazard ratio (HR) and 95% confidence interval (CI) for (1) being seen by any eye care provider (ophthalmologist or optometrist); (2) being seen by an ophthalmologist specifically; and (3) receiving cataract surgery (among beneficiaries with ophthalmologist encounters).RESULTS: A total of 4451200 beneficiaries met inclusion criteria; 3805718 (85.5%) received eye care during the study period, and 391 556 (8.8%) had diagnosed dementia. Some 73.4% of beneficiaries diagnosed with dementia saw an eye care provider during the study period and 55.4% saw an ophthalmologist versus 86.7% and 74.0% of beneficiaries, respectively, without dementia diagnoses. Compared with those without dementia diagnoses, beneficiaries with diagnosed dementia had lower likelihood of seeing any eye care provider (adjusted HR, 0.69; 95% CI, 0.69-0.70) and were less likely to see an ophthalmologist (adjusted HR, 0.55; 95% CI, 0.55-0.55). Among the subset of beneficiaries who did see ophthalmologists, those with diagnosed dementia were also less likely to receive cataract surgery than beneficiaries without diagnosed dementia (HR, 0.62; 95% CI, 0.62-0.63) and less likely to receive a cataract diagnosis (18% vs. 82%).CONCLUSIONS: US Medicare beneficiaries diagnosed with dementia are less likely to receive eye care thanthose without diagnosed dementia. Depending on visual acuity and functional status, this may have implications for injury prevention, physical and cognitive function, and quality of life. Further work is needed to identify barriers to receiving eye care, determine eye care services and settings that provide greatest value topatients with dementia, and implement measures to improve access to appropriate eye care.

    View details for DOI 10.1016/j.ophtha.2020.02.022

    View details for PubMedID 32317179

  • Sex Differences in the Repair of Retinal Detachments in the United States. American journal of ophthalmology Callaway, N. F., Vail, D. n., Al-Moujahed, A. n., Ludwig, C. n., Ji, M. H., Mahajan, V. B., Pershing, S. n., Moshfeghi, D. M. 2020


    To determine differences between women and men in the repair of rhegmatogenous retinal detachments (RRD) in the United States.Retrospective cohort study.SETTING: A large insurance claims database.Subjects with an incident RRD between 2007-2015.Demographic data, comorbid ocular conditions associated with RRD,systemic comorbidities,and surgical intervention (pneumatic retinopexy (PR), pars plana vitrectomy (PPV), laser barricade, or scleral buckle (SB)) were collected.Odds of receipt of surgical intervention for incident RRD, time to repair, type of intervention, and the rate of reoperation by sex.The study period included 133 million eligible records with 61,071 cases of incident RRD meeting inclusion criteria among which 43% (n = 26,289) were women. Women had 34% reduced odds of receipt of surgical repairof an RRD (OR 0.66, 95% CI 0.59 - 0.73, p<0.001) after adjusting for confounders. This effect persisted in all sensitivity models. Among patients that received repair, women were more often delayed (0.17 days, p = 0.04). Women were more likely to undergo primary laser barricade (RRR 1.68, p < 0.001), primary SB (RRR 1.15, p < 0.001), and PR (RRR 1.07, p < 0.04) than men. The odds of reoperation were lower in women (OR 0.91, 95% CI 0.85 - 0.96, p=0.002) after adjustment.Insured women are less likely than insured men to receive surgical intervention for an RRD. If the odds of repair were equal between women and men in the U.S. then 781 more women would receive surgery each year, or 7,029 more during the study period. Women are more likely to have the repair performed with scleral buckle and laser barricade. The reason for thesesex differences in RRD repair remains unknown and requires further investigation.

    View details for DOI 10.1016/j.ajo.2020.06.039

    View details for PubMedID 32640255

  • The New USMLE Step 1 Paradigm: An Opportunity to Cultivate Diversity of Excellence. Academic medicine : journal of the Association of American Medical Colleges Pershing, S. n., Co, J. P., Katznelson, L. n. 2020


    The February 2020 announcement that United States Medical Licensing Examination (USMLE) Step 1 results will be reported as pass/fail instead of numerical scores has been controversial. Step 1 scores have played a key role in residency selection, including screening for interviews. Although Step 1 scores are viewed as an objective criterion, they have been shown to disadvantage female and underrepresented minority applicants, cause student anxiety and financial burden, and affect student well-being. Furthermore, Step 1 scores incompletely predict applicants' overall residency performance. With this paradigm shift in Step 1 score reporting, residency programs will have fewer objective, standardized metrics for selection decisions, which may lead to greater emphasis on USMLE Step 2 Clinical Knowledge scores or yield unintended consequences such as shifting weight to metrics such as medical school reputation).Yet, greater breadth in residency selection metrics will better serve both applicants and programs. Some students excel in coursework, others in research or leadership. All factors should be recognized, and broader metrics should be implemented to promote and recognize diversity of excellence. Given the need for metrics for residency selection as well as for a more holistic approach to evaluating residency applicants, assessment during medical school should be revisited and made more meaningful. Another opportunity may involve use of situational judgement tests to predict professionalism and performance on other competencies. It will be important to evaluate the impact of the new Step 1 paradigm and related initiatives going forward. Residency application overload must also be addressed.

    View details for DOI 10.1097/ACM.0000000000003512

    View details for PubMedID 32433311

  • Artificial Intelligence in Global Ophthalmology: Using Machine Learning to Improve Cataract Surgery Outcomes at Ethiopian Outreaches. Journal of cataract and refractive surgery Brant, A. R., Hinkle, J. n., Shi, S. n., Hess, O. n., Zubair, T. n., Pershing, S. n., Tabin, G. C. 2020


    Differences between target and implanted intraocular lens (IOL) power in Ethiopian cataract outreach campaigns were evaluated and machine learning (ML) applied to optimize IOL inventory and minimize avoidable refractive error. Patients from Ethiopian cataract campaigns with available target and implanted IOL records were identified and the diopter difference between the two measured. A gradient descent (an ML algorithm) was used to generate an optimal IOL inventory and measured the model's performance across varying surplus levels.Only 45.6% of patients received their target IOL power and 23.6% received underpowered IOLs with current inventory (50% surplus). The ML-generated IOL inventory ensured that >99.5% of patients received their target IOL when using only 39% IOL surplus.In Ethiopian cataract campaigns, the majority of patients have avoidable postoperative refractive error secondary to suboptimal IOL inventory. Optimizing IOL inventory using our ML model might eliminate refractive error from insufficient inventory and reduce costs.

    View details for DOI 10.1097/j.jcrs.0000000000000407

    View details for PubMedID 32932371

  • Systemic Corticosteroid Use after Central Serous Chorioretinopathy Diagnosis. Ophthalmology Azad, A. D., Zhou, M. n., Afshar, A. R., Bakri, S. J., Pershing, S. n. 2020


    To analyze frequency of systemic corticosteroid prescriptions before and after central serous chorioretinopathy (CSC) diagnosis.Retrospective claims-based analysis.A nationally-representative sample of commercial insurance beneficiaries who received care between 2007-2015.We limited the study population to beneficiaries with incident CSC diagnosed by an eye care provider, excluding those with other major ophthalmologic comorbidities. We developed a non-CSC comparison cohort matched to CSC patients on age, sex, general health (Charlson Comorbidity Index), and geographic region. We compared systemic corticosteroid prescriptions before and after CSC diagnosis and by diagnosing provider type (optometrist versus ophthalmologist), and evaluated likelihood of receiving steroids among CSC patients versus matched controls using logistic and Cox proportional hazard regression models.Frequency of systemic corticosteroid prescriptions among CSC patients within 12 months pre-diagnosis and at 6, 12, and 24 months post-diagnosis; median time to steroid initiation and discontinuation and odds of receiving post-diagnosis steroids among CSC patients and controls.We identified 3418 CSC patients. Nearly 39% (n=1326) were prescribed systemic steroids at some point during the analysis period, compared to 23% of matched controls (4033 of 17,178 patients). Over 12% of CSC patients (n=430) received steroids within a year pre-diagnosis, and nearly 12% (n=404) received steroids within 1 year post-diagnosis. Most patients who received post-diagnosis steroids were steroid-naïve (n=231). The most common steroid prescribed was oral prednisone (an approximately 1-month supply). Among those receiving steroids, CSC patients had longer median time to first post-diagnosis steroid prescription (1.82 years versus 0.50 years for controls) and longer time to last steroid prescription (1.62 years versus 0.35 years for non-CSC patients). Although CSC patients were significantly less likely to receive steroids at 6 months post-diagnosis compared to matched non-CSC patients (OR=0.72, 95%CI=0.59-0.89), they were significantly more likely to receive steroids by 2 years post-diagnosis. Prescribing patterns were similar for patients diagnosed by an ophthalmologist versus optometrist.Despite evidence showing steroids contribute to CSC development, many patients continue to be prescribed systemic corticosteroids after CSC diagnosis. Our results suggest a need for greater communication and collaboration among providers to ensure clinical practice reflects evidence-based recommendations.

    View details for DOI 10.1016/j.ophtha.2020.06.056

    View details for PubMedID 32619546

  • Smoking Is Associated with Higher Intraocular Pressure Regardless of Glaucoma: A Retrospective Study of 12.5 Million Patients Using the Intelligent Research in Sight (IRIS®) Registry. Ophthalmology. Glaucoma Lee, C. S., Owen, J. P., Yanagihara, R. T., Lorch, A. n., Pershing, S. n., Hyman, L. n., Miller, J. W., Haller, J. A., Chiang, M. F., Lum, F. n., Lee, A. Y. 2020; 3 (4): 253–61


    To compare the average intraocular pressure (IOP) among smokers, past smokers, and never smokers using the American Academy of Ophthalmology Intelligent Research in Sight (IRIS®) Registry.Retrospective database study of the IRIS® Registry data.Intelligent Research in Sight Registry patients who were seen by an eye care provider during 2017.Patients were divided into current smoker, past smoker, and never smoker categories. The IOP was based on an average measurement, and separate analyses were performed in patients with and without a glaucoma diagnosis based on International Classification of Diseases (Ninth Edition and Tenth Edition) codes. Stratified, descriptive statistics by glaucoma status were determined, and the relationship between smoking and IOP was assessed with a multivariate linear regression model.Mean IOP.A total of 12 535 013 patients were included. Compared with never smokers, current and past smokers showed a statistically significantly higher IOP by 0.92 mmHg (95% confidence interval [CI], 0.88-0.95 mmHg) and 0.77 mmHg (95% CI, 0.75-0.79 mmHg), respectively, after adjusting for age, gender, glaucoma, age-related macular degeneration, diabetic retinopathy, cataract, glaucoma surgery, cataract surgery, and first-order interactions. In addition, the difference in IOP between current and never smokers was the highest in the fourth decade, regardless of the glaucoma status (glaucoma group, 1.14 mmHg [95% CI, 1.00-1.29 mmHg]; without glaucoma group, 0.68 mmHg [95% CI, 0.65-0.71 mmHg]).Current smokers and past smokers have higher IOP than patients who never smoked. This difference is higher in patients with an underlying glaucoma diagnosis.

    View details for DOI 10.1016/j.ogla.2020.03.008

    View details for PubMedID 33008558

    View details for PubMedCentralID PMC7532983

  • Cataract Surgery Complexity and Surgical Complication Rates among Medicare Beneficiaries with and without Dementia. American journal of ophthalmology Pershing, S. n., Henderson, V. W., Goldstein, M. K., Lu, Y. n., Bundorf, M. K., Rahman, M. n., Stein, J. D. 2020


    To evaluate cataract surgery complexity and complications among US Medicare beneficiaries with and without dementia.Retrospective claims-based cohort study PARTICIPANTS: A 20% representative sample of Medicare beneficiaries, 2006-2015.Dementia was identified from diagnosis codes on or prior to each beneficiary's first-eye cataract surgery. For each surgery, we identified setting, routine versus complex coding, anesthesia provider type, duration, and any postoperative hospitalization. We evaluated 30- and 90-day complication rates-return to operating room, endophthalmitis, suprachoroidal hemorrhage, retinal detachment, retinal tear, macular edema, glaucoma, or choroidal detachment-and used adjusted regression models to evaluate likelihood of surgical characteristics and complications. Complications analyses were stratified by second-eye cataract surgery within 90 days postoperatively.We identified 457,128 beneficiaries undergoing first-eye cataract surgery, 23,332 (5.1%) with dementia. None of the evaluated surgical complications were more likely in dementia-diagnosed beneficiaries. There was also no difference in likelihood of non-ambulatory surgery center setting, anesthesiologist provider, or postoperative hospitalization. Dementia-diagnosed beneficiaries were more likely to have surgeries coded as complex (15.6% of cases versus 8.8%, p<0.0001), and surgeries exceeding 30 minutes (OR=1.21, 95%CI=1.17-1.25).Among US Medicare beneficiaries undergoing cataract surgery, those with dementia are more likely to have "complex" surgery" lasting over 30 minutes. However, they do not have greater likelihood of surgical complications, higher-acuity setting, advanced anesthesia care, or postoperative hospitalization. This may be influenced by case selection and may suggest missed opportunities to improve vision. Future research is needed to identify dementia patients likely to benefit from cataract surgery.

    View details for DOI 10.1016/j.ajo.2020.08.025

    View details for PubMedID 32828874

  • Association of Visual Impairment With Risk of Incident Dementia in a Women's Health Initiative Population. JAMA ophthalmology Tran, E. M., Stefanick, M. L., Henderson, V. W., Rapp, S. R., Chen, J. C., Armstrong, N. M., Espeland, M. A., Gower, E. W., Shadyab, A. H., Li, W. n., Stone, K. L., Pershing, S. n. 2020


    Dementia affects a large and growing population of older adults. Although past studies suggest an association between vision and cognitive impairment, there are limited data regarding longitudinal associations of vision with dementia.To evaluate associations between visual impairment and risk of cognitive impairment.A secondary analysis of a prospective longitudinal cohort study compared the likelihood of incident dementia or mild cognitive impairment (MCI) among women with and without baseline visual impairment using multivariable Cox proportional hazards regression models adjusting for characteristics of participants enrolled in Women's Health Initiative (WHI) ancillary studies. The participants comprised community-dwelling older women (age, 66-84 years) concurrently enrolled in WHI Sight Examination (enrollment 2000-2002) and WHI Memory Study (enrollment 1996-1998, ongoing). The study was conducted from 2000 to the present.Objectively measured visual impairment at 3 thresholds (visual acuity worse than 20/40, 20/80, or 20/100) and self-reported visual impairment (determined using composite survey responses).Hazard ratios (HRs) and 95% CIs for incident cognitive impairment after baseline eye examination were determined. Cognitive impairment (probable dementia or MCI) was based on cognitive testing, clinical assessment, and centralized review and adjudication. Models for (1) probable dementia, (2) MCI, and (3) probable dementia or MCI were evaluated.A total of 1061 women (mean [SD] age, 73.8 [3.7] years) were identified; 206 of these women (19.4%) had self-reported visual impairment and 183 women (17.2%) had objective visual impairment. Forty-two women (4.0%) were ultimately classified with probable dementia and 28 women (2.6%) with MCI that did not progress to dementia. Mean post-eye examination follow-up was 3.8 (1.8) years (range, 0-7 years). Women with vs without baseline objective visual impairment were more likely to develop dementia. Greatest risk for dementia was among women with visual acuity of 20/100 or worse at baseline (HR, 5.66; 95% CI, 1.75-18.37), followed by 20/80 or worse (HR, 5.20; 95% CI, 1.94-13.95), and 20/40 or worse (HR, 2.14; 95% CI, 1.08-4.21). Findings were similar for risk of MCI, with the greatest risk among women with baseline visual acuity of 20/100 or worse (HR, 6.43; 95% CI, 1.66-24.85).In secondary analysis of a prospective longitudinal cohort study of older women with formal vision and cognitive function testing, objective visual impairment appears to be associated with an increased risk of incident dementia. However, incident cases of dementia and the proportion of those with visual impairment were low. Research is needed to evaluate the effect of specific ophthalmic interventions on dementia.

    View details for DOI 10.1001/jamaophthalmol.2020.0959

    View details for PubMedID 32297918

  • Association of Rhegmatogenous Retinal Detachment and Outcomes With the Day of the Week That Patients Undergo a Repair or Receive a Diagnosis. JAMA ophthalmology Vail, D., Pan, C., Pershing, S., Mruthyunjaya, P. 2019


    Importance: Because variation in care on weekends has been reported in many surgical fields, it is of interest if variations were noted for care patterns of rhegmatogenous retinal detachments (RRDs).Objective: To assess the association between modality of RRD repair and day of the week that patients receive a diagnosis or undergo RRD repair.Design, Setting, and Participants: A retrospective claims-based cohort analysis was performed of primary RRD surgery for 38 144 commercially insured patients in the United States who received a diagnosis of incident RRD between January 1, 2008, and December 31, 2016, and underwent repair within 14 days of diagnosis. Multinomial regression models were used to assess patients' likelihood of repair with different modalities, logistic regression models were used to assess patients' likelihood of reoperation, and linear regression models were used to assess time from diagnosis to repair. Data analysis was performed from March 9 to September 5, 2019.Exposures: Day of the week that the patient received a diagnosis of RRD or underwent RRD repair.Main Outcome and Measures: Modality of repair, time from diagnosis to repair, and 30-day reoperation rate.Results: Among the 38 144 patients in the study (23 031 men [60.4%]; mean [SD] age at diagnosis, 56.8 [13.4] years), pneumatic retinopexy (PR) was more likely to occur when patients received a diagnosis of RRD on Friday (relative risk ratio [RRR], 1.37; 95% CI, 1.17-1.60), Saturday (RRR, 1.73; 95% CI, 1.36-2.20), or Sunday (RRR, 1.53; 95% CI, 1.08-2.17) compared with Wednesday. Pneumatic retinopexy was more likely to be used for surgical procedures on Friday (RRR, 1.55; 95% CI, 1.33-1.80), Saturday (RRR, 2.03; 95% CI, 1.61-2.56), Sunday (RRR, 2.28; 95% CI, 1.55-3.35), or Monday (RRR, 1.70; 95% CI, 1.46-1.98). Patients undergoing PR on Sundays were more likely to receive another procedure (PR, scleral buckle, or pars plana vitrectomy) within 30 days (odds ratio, 1.62; 95% CI, 1.07-2.45). An association between the need for reoperation for repairs performed via scleral buckle or pars plana vitrectomy and the day of the week of the initial repair was not identified. Patients who received a diagnosis on a Friday waited a mean of 0.28 days (95% CI, 0.20-0.36 days) longer for repair than patients who received a diagnosis on a Wednesday.Conclusions and Relevance: These findings suggest that management of RRD varies according to the day of the week that diagnosis and repair occurs, with PR disproportionately likely to be used to repair RRDs during the weekend. Ophthalmologists should be aware that these results suggest that patients undergoing PR on Sundays may be more likely to require reoperation within 30 days.

    View details for DOI 10.1001/jamaophthalmol.2019.5253

    View details for PubMedID 31855233

  • Risk factors for incident central serous retinopathy: case-control analysis of a US national managed care population BRITISH JOURNAL OF OPHTHALMOLOGY Zhou, M., Bakri, S. J., Pershing, S. 2019; 103 (12): 1784–88
  • Automated extraction of ophthalmic surgery outcomes from the electronic health record. International journal of medical informatics Wang, S. Y., Pershing, S., Tran, E., Hernandez-Boussard, T. 2019; 133: 104007


    OBJECTIVE: Comprehensive analysis of ophthalmic surgical outcomes is often restricted by limited methodologies for efficiently and accurately extracting clinical information from electronic health record (EHR) systems because much is in free-text form. This study aims to utilize advanced methods to automate extraction of clinical concepts from the EHR free text to study visual acuity (VA), intraocular pressure (IOP), and medication outcomes of cataract and glaucoma surgeries.METHODS: Patients who underwent cataract or glaucoma surgery at an academic medical center between 2009 and 2018 were identified by Current Procedural Terminology codes. Rule-based algorithms were developed and used on EHR clinical narrative text to extract intraocular lens (IOL) power and implant type, as well as to create a surgery laterality classifier. MedEx (version 1.3.7) was used on free-text clinical notes to extract information on eye medications and compared to information from medication orders. Random samples of free-text notes were reviewed by two independent masked annotators to assess inter-annotator agreement on outcome variable classification and accuracy of classifiers. VA and IOP were available from semi-structured fields.RESULTS: This study cohort included 6347 unique patients, with 8550 stand-alone cataract surgeries, 451 combined cataract/glaucoma surgeries, and 961 glaucoma surgeries without concurrent cataract surgery. The rule-based laterality classifier achieved 100% accuracy compared to manual review of a sample of operative notes by independent masked annotators. For cataract surgery alone, glaucoma surgery alone, or combined cataract/glaucoma surgeries, our automated extraction algorithm achieved 99-100% accuracy compared to manual annotation of samples of notes from each group, including IOL model and IOL power for cataract surgeries, and glaucoma implant for glaucoma surgeries. For glaucoma medications, there was 90.7% inter-annotator agreement. After adjudication, 85.0% of medications identified by MedEx determined to be correct. Determination of surgical laterality enabled evaluation of pre- and postoperative VA and IOP for operative eyes.CONCLUSION: This text-processing pipeline can accurately capture surgical laterality and implant model usage from free-text operative notes of cataract and glaucoma surgeries, enabling extraction of clinical outcomes including visual acuities, intraocular pressure, and medications from the EHR system. Use of this approach with EHRs to assess ophthalmic surgical outcomes can benefit research groups interested in studying the safety and clinical efficacies of different surgical approaches.

    View details for DOI 10.1016/j.ijmedinf.2019.104007

    View details for PubMedID 31706228

  • Endophthalmitis after Cataract Surgery in the United States: A Report from the Intelligent Research in Sight Registry, 2013-2017. Ophthalmology Pershing, S., Lum, F., Hsu, S., Kelly, S., Chiang, M. F., Rich, W. L., Parke, D. W. 2019


    PURPOSE: To determine recent incidence and visual outcomes for acute-onset endophthalmitis after cataract surgery performed in the United States.DESIGN: Retrospective cohort study.PARTICIPANTS: United States cataract surgery patients, 2013-2017 (5 401 686 patients).METHODS: Cases of acute-onset postoperative endophthalmitis occurring within 30 days after cataract surgery were identified using diagnosis codes in the American Academy of Ophthalmology IRIS (Intelligent Research in Sight) Registry database, drawn from electronic health records in ophthalmology practices across the nation. Annual and aggregate 5-year incidences were determined for all cataract surgeries andspecifically for standalone procedures versus those combined with other ophthalmic surgeries. Patientcharacteristics were compared. Mean and median visual acuity was determined at 1 month preoperative aswell as 1 week, 1 month, and 3 months postoperative among patients with and without endophthalmitis.MAIN OUTCOME MEASURES: Incidence of acute-onset postoperative endophthalmitis after cataract surgery.RESULTS: A total of 8 542 838 eyes underwent cataract surgery, 3629 of which developed acute-onset endophthalmitis (0.04%; 95% confidence interval, 0.04%-0.04%). Endophthalmitis incidence was highest among patients aged 0 to 17 years (0.37% over 5 years), followed by patients aged 18 to 44 years (0.18% over 5 years; P < 0.0001). Endophthalmitis occurred 4 times more often after combined cases (cataract with other ophthalmic procedures) than after standalone cataract surgeries (0.20% vs. 0.04% of cases), and occurred in 0.35% of patients receiving anterior vitrectomy. Mean 3-month postoperative visual acuity was 20/100 (median, 20/50) among endophthalmitis patients, versus a mean of approximately 20/40 (median, 20/30) among patients without endophthalmitis. However, 4% of endophthalmitis patients still achieved 20/20 or better visual acuity, and 44% achieved 20/40 or better visual acuity at 3 months.CONCLUSIONS: Acute-onset endophthalmitis occurred in 0.04% of 8542838 cataract surgeries performed in the United States between 2013 and 2017. Risk factors may include younger age, cataract surgery combined with other ophthalmic surgeries, and anterior vitrectomy. Visual acuity outcomes vary; however, patients can recover excellent vision after surgery. Big data from clinical registries like the IRIS Registry has great potential for evaluating rare conditions such as endophthalmitis, including developing benchmarks, longer-term time trend investigation, and comprehensive analysis of risk factors and prophylaxis.

    View details for DOI 10.1016/j.ophtha.2019.08.026

    View details for PubMedID 31611015

  • Gender Differences in Surgical Intervention Rate and Timing for Rhegmatogenous Retinal Detachments Among US Commercially Insured Patients From 2007-2015 Callaway, N. F., Vail, D., Pershing, S., Ludwig, C. A., Moshfeghi, D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019
  • Refining Metrics for Assessing the Quality of Care of Patients Undergoing Cataract Surgery for Use in Big Data Analyses Weinlander, E., Talwar, N., Weizer, J., Saleem, S., Pershing, S., Stagg, B., Mwanza, J., Lynch, A., Sugar, A., Lee, P. P., Stein, J. D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019
  • Characterizing Geographic Variation in Surgical Management of Rhegmatogenous Retinal Detachment Vail, D., Pershing, S. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019
  • Differences in Receiving Eye Care Based on Dementia Status Pershing, S., Goldstein, M. K., Henderson, V. W., Lu, Y., Bundorf, M., Rahman, M., Andrews, C., Stein, J. D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2019
  • Risk factors for incident central serous retinopathy: case-control analysis of a US national managed care population. The British journal of ophthalmology Zhou, M., Bakri, S. J., Pershing, S. 2019


    AIM: To evaluate clinical comorbidities and steroid use as risk factors for central serous retinopathy (CSR).METHODS: Using national insurance databases, we conducted a case-control study of beneficiaries with an incident diagnosis of CSR between 2007 and 2015 (n=35492) and randomly selected controls matched on age-based and sex-based propensity scores (n=177460).RESULTS: The mean age (SD) of cases was 49.1 (12.2) years, and the majority (69.2%) were male. Cases were more likely to have received steroids in the past year (OR 1.14, 95% CI 1.09 to 1.19, p<0.001) and to have comorbid Cushing's syndrome (OR 2.19, 95%CI 1.33 to 3.59, p=0.002), age-related macular degeneration (OR 5.24, 95%CI 5.00 to 5.49, p<0.001), diabetic macular oedema (OR 2.05, 95%CI 1.71 to 2.47, p<0.001) and diabetes mellitus (OR 1.44, 95%CI 1.33 to 1.56, p<0.001). Glaucoma was associated with lower odds of CSR (OR 0.54, 95%CI 0.51 to 0.56, p<0.001). Patients with other previously hypothesised risk factors (including essential hypertension, pregnancy, other autoimmune disease, sleep disorders, Helicobacter pylori infection and gastro-oesophageal reflux disease) had lower odds of CSR.CONCLUSIONS: Male middle-aged patients with recent steroid exposure were significantly more likely to develop CSR. Other risk factors include diabetes mellitus, diabetic macular oedema and age-related macular degeneration. Other previously hypothesised risk factors did not appear to confer increased risk. More research is needed to confirm and examine underlying pathophysiology.

    View details for PubMedID 30872284

  • Differences in Cataract Surgery Rates Based on Dementia Status JOURNAL OF ALZHEIMERS DISEASE Pershing, S., Henderson, V. W., Bundorf, M., Lu, Y., Rahman, M., Andrews, C. A., Goldstein, M., Stein, J. D. 2019; 69 (2): 423–32

    View details for DOI 10.3233/JAD-181292

    View details for Web of Science ID 000470879800009

  • Understanding Patient Attitudes Toward Multifocal Intraocular Lenses in Online Medical Forums Through Sentiment Analysis Wang, S. Y., Hernandez-Boussard, T., Chang, R. T., Pershing, S., OhnoMachado, L., Seroussi, B. IOS PRESS. 2019: 1378–82

    View details for DOI 10.3233/SHT1190453

    View details for Web of Science ID 000569653400278

  • Understanding Patient Attitudes Toward Multifocal Intraocular Lenses in Online Medical Forums Through Sentiment Analysis. Studies in health technology and informatics Wang, S. Y., Hernandez-Boussard, T. n., Chang, R. T., Pershing, S. n. 2019; 264: 1378–82


    Multifocal intraocular lens implants (IOLs) are a premium option for cataract surgery which patients may purchase to achieve improved spectacle-independence for near vision but may have trade-offs with visual quality. We demonstrate the use of sentiment analysis to evaluate multifocal lenses discussed on MedHelp, a leading online health forum. A search for "multifocal IOL" was performed on on November 1, 2016, yielding relevant patient posts. Sentiment analysis was performed using IBM's Watson, which extracted 30,066 unique keywords and their associated sentiment scores from 7495 posts written by 1474 unique patient users. Keywords associated with monovision, monofocal, and toric lenses had positive mean sentiment, significantly higher than for keywords associated with multifocals, which had negative mean sentiment (p < 0.001, ANOVA). Many keywords represented complaints and were associated with negative sentiment, including glare, halo, and ghosting. Sentiment analysis can provide insights into patient perspectives towards multifocal lenses by interpreting online patient posts.

    View details for DOI 10.3233/SHTI190453

    View details for PubMedID 31438152

  • Characteristics of Ophthalmology Trials Registered in, 2007-2018. American journal of ophthalmology Turner, B. n., Rajeshuni, N. n., Tran, E. M., Ludwig, C. A., Tauqeer, Z. n., Weeks, B. n., Kinde, B. n., Pershing, S. n. 2019


    To perform a comprehensive analysis of characteristics of ophthalmology trials registered in study METHODS: All 4,203 ophthalmologic clinical trials registered on between October 1, 2007, and April 30, 2018 were identified using Medical Subject Heading (MeSH) terms. Disease condition terms were verified by manual review. Trial characteristics were assessed through frequency calculations. Hazard ratio and 95% confidence intervals were determined for characteristics associated with early discontinuation.The majority of trials were multi-armed (73.6%), single-site (69.4%), randomized (64.8%), and had <100 enrollees (66.3%). Thirty-three percent utilized a data monitoring committee (DMC), and 50.6% incorporated blinding. 51.6% were funded by industry, while 2.6% by the National Institute of Health (NIH). NIH trials were significantly more likely to address oncologic (NIH=15.5%, Other=3%, Industry=1.5%; p<0.001) or pediatric disease (NIH=20.9%, Other=5.9%, Industry=1.4%; p<0.001). Industry-sponsored trials (69.6% of phase 3 trials) and were significantly more likely to be randomized (Industry=68.7%, NIH=58.9%, Other=60.8%; p<0.001) and blinded (Industry=57.2%, NIH=42.7%, Other=43.5%; p<0.001). 359 trials (8.5%) were discontinued early and 530 trials (12.6%) had unknown status. Trials were less likely to be discontinued if funded by sources other than industry (HR 0.72; 95% CI 0.55-0.95; p=0.021) and/or had a DMC (HR 0.71, 95% CI 0.55-0.92, p=0.010).Ophthalmology trials in the past decade reveal heterogeneity across study funding sources. NIH trials were more likely to support historically underfunded subspecialties, while Industry trials were more likely to face early discontinuation. These trends emphasize the importance of carefully monitored and methodologically-sound trials with deliberate funding allocation.

    View details for DOI 10.1016/j.ajo.2019.11.004

    View details for PubMedID 31730839

  • The Relative Impact of Patient, Physician, and Geographic Factors on Variation in Primary Rhegmatogenous Retinal Detachment Management. Ophthalmology Vail, D. n., Pershing, S. n., Reeves, M. G., Afshar, A. R. 2019


    To evaluate geographic variation and characterize the relative contributions of patient characteristics, physician practice, and geographic region on variation in primary rhegmatogenous retinal detachment (RRD) management.Retrospective claims-based analysis.Commercially insured patients with incident RRD diagnosed between 2008 and 2016 (12 779 patients).We determined whether patients underwent primary RRD repair within 60 days of diagnosis and identified repair type. We characterized physicians using physician identifier variables and characterized geography by Combined Statistical Areas or Core-Based Statistical Area. We used multilevel mixed effects logistic regression models to evaluate patient-, physician-, and geographic-level variation in whether patients underwent RRD repair and used multilevel mixed effects multinomial models to characterize variation in repair type. For each model, we evaluated patient fixed effects and physician random effects nested within geographic random effects. We estimated intraclass correlation coefficients and variance partition coefficients, respectively, to compare relative contributions of patient, physician, and geography to overall variation.Odds ratios for RRD repair and variation estimates for patient, physician, and geography.Most incident RRD patients received treatment within 60 days post-diagnosis. Pars plana vitrectomy was most common (49%), followed by laser barricade (23%), scleral buckle and pneumatic retinopexy (both 11%), and cryotherapy (5%). Physician-level variation showed greater impact on receipt of any treatment than geographic-level variation (estimated variance coefficients of 1.09 and 0.32, respectively). Patient-level characteristics represented approximately 82% of overall variation in receipt of any repair, versus 16% from physician-level and 2% from geographic-level factors. Among RRD patients who underwent repair, estimated variance coefficients were 0.07 for geography and 3.37 for physician. Physician-level factors represented approximately 50% of total variation in repair type, followed by patient-level (49%), and geographic-level (1%) factors.Rhegmatogenous retinal detachment repair decisions are influenced by patient-level and physician-level factors, less so by geographic variation. Patient characteristics account for most of the variation in receipt of repair, and physician practice accounts for most of the variation in choice of procedure. These findings indicate a need for additional studies to understand drivers behind differences in care and clinical outcomes and to identify barriers in access to care.

    View details for DOI 10.1016/j.ophtha.2019.04.019

    View details for PubMedID 30981916

  • Use of Bevacizumab and Ranibizumab for Wet Age-Related Macular Degeneration: Influence of CATT Results and Introduction of Aflibercept. American journal of ophthalmology Pershing, S. n., Talwar, N. n., Armenti, S. T., Grubbs, J. n., Rosenthal, J. M., Dedania, V. S., Stein, J. D. 2019


    To assess whether publication of Comparison of Age-related macular degeneration Treatment Trial (CATT) results and introduction of aflibercept to the marketplace affected intravitreal bevacizumab and ranibizumab utilization.Retrospective analysis of treatment patterns.We calculated weekly bevacizumab and ranibizumab utilization during 3 timeframes: (1) before CATT publication, (2) between CATT publication (4/28/2011) and assignment of a unique aflibercept billing code (1/1/2013), and (3) afterwards for 164188 Medicare beneficiaries with neovascular macular degeneration receiving ≥1 anti-Vascular Endothelial Growth Factor injections from 1/1/2008 to 12/31/2014. We identified ophthalmologists who predominantly (≥80%) administered bevacizumab or ranibizumab, and evaluated changes in preferences over the 3 periods. We replicated analyses on 881381 commercially-insured beneficiaries.Among 317 ophthalmologists administering predominantly ranibizumab to Medicare beneficiaries pre-CATT, 221 (69.7%) reduced ranibizumab utilization post-CATT, whereas 96 (30.3%) continued using ranibizumab ≥80% of the time. Findings were reversed among 1041 ophthalmologists who predominantly administered bevacizumab pre-CATT-777 (74.6%) continued bevacizumab-predominant use while 264 (25.4%) reduced bevacizumab utilization post-CATT. Among the 145 ophthalmologists who predominantly administered ranibizumab before aflibercept's availability, 77 (53.1%) reduced ranibizumab utilization and 68 (46.9%) continued using ranibizumab ≥80% of the time after aflibercept became available. Corresponding numbers among the 909 ophthalmologists who predominantly administered bevacizumab pre-aflibercept were 381 (41.9%) reducing and 528 (58.1%) continuing bevacizumab-predominant use. Similar results were observed for commercially-insured patients.Many ophthalmologists who favored ranibizumab switched to bevacizumab after CATT publication while most who favored bevacizumab prior to CATT publication continued favoring it afterwards. Aflibercept's introduction had little impact on preferences for ranibizumab or bevacizumab.

    View details for DOI 10.1016/j.ajo.2019.05.011

    View details for PubMedID 31100217

  • Development and validation of a predictive model for American Society of Anesthesiologists Physical Status. BMC health services research Mudumbai, S. C., Pershing, S. n., Bowe, T. n., Kamal, R. N., Sears, E. D., Finlay, A. K., Eisenberg, D. n., Hawn, M. T., Weng, Y. n., Trickey, A. W., Mariano, E. R., Harris, A. H. 2019; 19 (1): 859


    The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes.Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator.Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.

    View details for DOI 10.1186/s12913-019-4640-x

    View details for PubMedID 31752856

  • Choice of Primary Rhegmatogenous Retinal Detachment Repair Method in US Commercially Insured and Medicare Advantage Patients, 2003-2016 AMERICAN JOURNAL OF OPHTHALMOLOGY Reeves, M., Pershing, S., Afshar, A. R. 2018; 196: 82-90
  • Choice of Primary Rhegmatogenous Retinal Detachment Repair Method in US Commercially-insured and Medicare Advantage Patients, 2003-2016. American journal of ophthalmology Reeves, M., Pershing, S., Afshar, A. R. 2018


    PURPOSE: To evaluate trends for rhegmatogenous retinal detachment (RRD) repair, and the influence of patient characteristics on repair type in a large US population including children and adults, between 2003-2016.DESIGN: Retrospective cohort study.SETTING: Administrative claims for beneficiaries in a large nationwide managed-care network, including Medicare Advantage, employer-sponsored, or commercial insurance.POPULATION: Beneficiaries undergoing RRD primary repair procedures.MAIN OUTCOME MEASURE: RRD repair procedure type.RESULTS: We identified 31,995 beneficiaries with RRD over the study period, mean age 59.8 years. Ocular comorbidities, including pseudophakia (16.9%), vitreous hemorrhage (14.6%), myopia (2.9%), and lattice degeneration (11.0%), were more common among RRD than non-RRD patients. Pars plana vitrectomy (PPV) was consistently the most common repair procedure, increasing over time. Scleral buckle utilization declined and utilization of other procedures remained relatively constant. After adjusting for age, demographics, and geographic region, PPV was more likely among patients with pseudophakia (OR=1.81, p<0.001) and vitreous hemorrhage (OR=1.38, p<0.001). Lattice degeneration (OR=1.42, p<0.001) and younger age were associated with higher odds of scleral buckle. Pneumatic retinopexy was more likely among patients with better systemic health and less likely among patients with ocular comorbidities including vitreous hemorrhage or lattice degeneration.CONCLUSIONS: PPV is increasingly the most common RRD repair procedure across a broadly-representative US population. However, other techniques are still preferred for some patients and, in aggregate, choice of repair procedure appears influenced by patient characteristics in a manner consistent with recommendations in the literature.

    View details for PubMedID 30144442

  • An Analysis of Medicare Reimbursement to Ophthalmologists: Years 2012 to 2013 AMERICAN JOURNAL OF OPHTHALMOLOGY Han, E., Baisiwala, S., Jain, A., Bundorf, M., Pershing, S. 2017; 182: 133–40


    To analyze trends in utilization and payment of ophthalmic services in the Medicare population for years 2012 and 2013.Retrospective, cross-sectional study.A retrospective cross-sectional observational analysis was performed using publicly available Medicare Physician and Other Supplier aggregate file and the Physician and Other Supplier Public Use File. Variables analyzed included aggregate beneficiary demographics, Medicare payments to ophthalmologists, ophthalmic medical services provided, and the most common Medicare-reimbursed ophthalmic services.In 2013, total Medicare Part B reimbursement for ophthalmology was $5.8 billion, an increase of 3.6% from the previous year. From 2012 to 2013, the total number of ophthalmology services rendered increased by 2.2%, while average dollar amount reimbursed per ophthalmic service decreased by 5.4%. The top 5 highest reimbursed services accounted for 85% of total ophthalmic Medicare payments in 2013, an 11% increase from 2012. During 2013, drug reimbursement represented 32.8% of the total Medicare payments to ophthalmologists. Ranibizumab and aflibercept alone accounted for 95% of the entire $1.9 billion in drug reimbursements ophthalmologists in 2013.Medicare Part B reimbursement for ophthalmologists was primarily driven by use of anti-vascular endothelial growth factor (anti-VEGF) injections from 2012 to 2013. Of the total drug payments to ophthalmologists, biologic anti-VEGF agents ranibizumab and aflibercept accounted for 95% of all drug reimbursement. This is in contrast to other specialties, in which drug reimbursement represented only a small portion of Medicare reimbursement.

    View details for PubMedID 28784553

  • Association of Vision Loss With Cognition in Older Adults JAMA OPHTHALMOLOGY Chen, S. P., Bhattacharya, J., Pershing, S. 2017; 135 (9): 963–70


    Visual dysfunction and poor cognition are highly prevalent among older adults; however, the relationship is not well defined.To evaluate the association of measured and self-reported visual impairment (VI) with cognition in older US adults.Cross-sectional analysis of 2 national data sets: the National Health and Nutrition Examination Survey (NHANES), 1999-2002, and the National Health and Aging Trends Study (NHATS), 2011-2015. The NHANES was composed of a civilian, noninstitutionalized community, and the NHATS comprised Medicare beneficiaries in the contiguous United States. Vision was measured at distance, near, and by self-report in the NHANES and by self-report alone in the NHATS. Sample weights were used to ensure result generalizability.The NHANES measured Digit Symbol Substitution Test (DSST) score and relative DSST impairment (DSST score ≤28, lowest quartile in study cohort), and the NHATS measured probable or possible dementia, classified per NHATS protocol.The NHANES comprised 2975 respondents aged 60 years and older who completed the DSST measuring cognitive performance. Mean (SD) age was 72 (8) years, 52% of participants were women (n = 1527), and 61% were non-Hispanic white (n = 1818). The NHATS included 30 202 respondents aged 65 years and older with dementia status assessment. The largest proportion (40%; n = 12 212) were between 75 and 84 years of age. Fifty-eight percent were women (n = 17 659), and 69% were non-Hispanic white (n = 20 842). In the NHANES, distance VI (β = -5.1; 95% CI, -8.6 to -1.6; odds ratio [OR], 2.8; 95% CI, 1.1-6.7) and subjective VI (β = -5.3; 95% CI, -8.0 to -2.6; OR, 2.7; 95% CI, 1.6-4.8) were both associated with lower DSST scores and higher odds of DSST impairment after full adjustment with covariates. Near VI was associated with lower DSST scores but not higher odds of DSST impairment. The NHATS data corroborated these results, with all vision variables associated with higher odds of dementia after full adjustment (distance VI: OR, 1.9; 95% CI, 1.6-2.2; near VI: OR, 2.6; 95% CI, 2.2-3.1; either distance or near VI: OR, 2.1; 95% CI, 1.8-2.4).In a nationally representative sample of older US adults, vision dysfunction at distance and based on self-reports was associated with poor cognitive function. This was substantiated by a representative sample of US Medicare beneficiaries using self-reported visual function, reinforcing the value of identifying patients with visual compromise. Further study of longitudinal interactions between vision and cognition is warranted.

    View details for PubMedID 28817745

    View details for PubMedCentralID PMC5710542

  • Have the CATT Trial Results and Introduction of Aflibercept to the Marketplace Influenced Utilization of Bevacizumab and Ranibizumab for Retinal Diseases? Armenti, S. T., Grubbs, J., Dedania, V., Talwar, N., Rosenthal, J. M., Pershing, S., Stein, J. D. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2017
  • Systemic predictors of diabetic eye disease development and severity Tran, E., Goldberg, J. L., Pershing, S. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2017
  • Trends in Hospitalization and Incidence Rate for Syphilitic Uveitis in the United States from 1998-2009. American journal of ophthalmology Albini, T., Callaway, N. F., Pershing, S., Wang, S. K., Moshfeghi, A. A., Moshfeghi, D. M. 2017


    This study evaluates the annual incidence of syphilitic uveitis in the US and trends in hospital admissions over time.Retrospective, longitudinal incidence rate analysis of the National Inpatient Sample (NIS) data from 1998 to 2009.The NIS is a de-identified, random sample dataset of inpatient hospitalizations from 46 states. The number of cases of syphilitic uveitis was defined by (1) International Classification of Diseases, 9th Revision (ICD-9) code for syphilis and uveitis or (2) ICD-9 code for syphilitic uveitis. Annual case count, incidence rate, and trend over time were calculated. Multivariate logistic regression was used to evaluate associated factors for a syphilitic uveitis diagnosis.The study included 455 310 286 hospitalizations during a 12-year study period with a mean of 37 942 524 patients annually. Syphilis and uveitis was recorded for 1861 patients (155 annually) and syphilitic uveitis was diagnosed in 204 subjects (average of 17 cases annually). There was no change in the incidence of syphilitic uveitis, using either definition, over the study period (P for trend = .46). The mean annual incidence of syphilis and uveitis was 0.0004%, or 4 per million. Syphilitic uveitis had an annual incidence of 0.000045%, or 0.45 per million. The odds of syphilitic uveitis were lower among women (odds ratio [OR] 0.40, CI 0.28-0.57) and increased with comorbid acquired immunodeficiency syndrome (OR 4.52, CI 3.01-6.79).We report the first incidence of syphilitic uveitis in the United States. Fortunately, this remains a rare condition. The results demonstrate no change in the number of inpatient admissions for syphilitic uveitis during the study period.

    View details for DOI 10.1016/j.ajo.2017.05.013

    View details for PubMedID 28549847

  • Self-Reported Receipt of Dilated Fundus Exams among Patients with Diabetes: Medicare Expenditure Panel Survey, 2002-2013. American journal of ophthalmology Tien Tran, E. M., Bhattacharya, J., Pershing, S. 2017


    To evaluate self-reported adherence to diabetic retinopathy screening examinations among diabetic subjects.Retrospective, population-based cross-sectional study.Medical Expenditure Panel Survey (MEPS) consolidated full-year and prescribed drugs data from 2002-2013 were reviewed; multivariable logistic regression was used to identify patient characteristics as potential barriers to receiving examinations.Of 13 299 persons in the MEPS sample, only 39.62% (95% confidence interval [CI] 38.56%-40.67%) reported receiving annual dilated eye examinations, and 90.31% (CI 89.70%-90.91%) reported ever having received an eye examination. Significant factors related to ever receiving an eye examination included completed high school (odds ratio [OR] = 1.53; CI, 1.33-1.75), bachelor's degree or higher (OR = 1.94; CI, 1.56-2.41), private health insurance (OR = 2.07; CI, 1.70-2.52), public insurance (OR = 1.90; CI, 1.56-2.31), household income >400% of the poverty threshold (OR = 1.75; CI, 1.36-2.25), prescribed diabetes medication (OR = 1.45; CI, 1.27-1.65), diabetic kidney disease (OR = 1.31; CI, 1.08-1.59), prior foot examination (OR = 1.49; CI, 1.28-1.74), prior hemoglobin A1c test (OR = 1.45; CI, 1.28-1.64), and having a usual care provider (OR = 1.50; CI, 1.25-1.80). Self-reported Asian ethnicity (OR = 0.51; CI, 0.39-0.65), needing assistance for at least 3 months (OR = 0.79; CI, 0.62-1.00), and proxy needed to fill out the survey (OR = 0.72; CI, 0.61-0.85) were associated with lower odds of reporting ever having received a dilated eye examination.In this national-representative sample, 90.31% of patients with diabetes reported ever having a dilated eye examination; only 39.62% reported receiving one annually as recommended. These low rates appear associated with possibly modifiable factors, including having a regular care provider, increasing access to care, enrollment in health insurance, and higher education.

    View details for DOI 10.1016/j.ajo.2017.04.009

    View details for PubMedID 28455116

  • Determining the Value of Home Monitoring of Patients With Age-Related Macular Degeneration. JAMA ophthalmology Pershing, S. n., Stein, J. D. 2017; 135 (5): 459–60

    View details for PubMedID 28358963

  • Cataract Surgery Complications and Revisit Rates Among Three States AMERICAN JOURNAL OF OPHTHALMOLOGY Pershing, S., Morrison, D. E., Hernandez-Boussard, T. 2016; 171: 130-138


    To characterize population-based 30-day procedure-related readmissions (revisits) following cataract surgery.Ambulatory cataract surgery performed in California, Florida, or New York DESIGN: Retrospective cohort study.This study used all-capture state administrative datasets. Cataract procedures from CA, FL, and NY state ambulatory surgery settings were identified using ICD-9-CM and CPT codes. Thirty-day readmissions (revisits) were identified in inpatient, ambulatory, and emergency department settings across each state RESULTS: Across the three states, the all-cause 30-day readmission rate was 6.0% and the procedure-related readmission (revisit) rate was 1.0%. Procedure-related revisits were highest for patients aged 20-29 (2.9%) and 30-39 (2.3%) and lowest for patients aged 70-79 (0.9%). Multivariate associations between clinical characteristics and 30-day procedure-related revisits included age 20-29 (Odds Ratio [OR]: 3.13; 95% Confidence Intervals [CI]: 2.33-4.20) and age 30-39 (OR: 2.35; CI: 1.91-2.89) compared to age 70-79, male gender (OR: 1.29; CI: 1.24-1.34), races black (OR: 1.37; CI: 1.27-1.48) and Hispanic (OR: 1.16; CI: 1.08-1.24) compared to white, and Medicaid insurance (OR: 1.18, CI: 1.07-1.30) compared to Medicare. Diabetes was also associated with increased 30-day procedure-related revisits (OR: 1.093, CI: 1.024-1.168).Cataract surgery is a common and, in aggregate, expensive procedure. Complication-related revisits follow a similar trend as surgical complications in large-scale population data, and may be useful as a preliminary, screening, outcome measure. Our results highlight the importance of age as a risk factor for cataract surgery readmissions, and suggest a relationship between black or Hispanic race, Medicaid insurance, and diabetes associated with higher risk for cataract surgery complications.

    View details for DOI 10.1016/j.ajo.2016.08.036

    View details for Web of Science ID 000388545800018

    View details for PubMedID 27615607

  • Integrating the Internship into Ophthalmology Residency Programs: Association of University Professors of Ophthalmology American Academy of Ophthalmology White Paper. Ophthalmology Oetting, T. A., Alfonso, E. C., Arnold, A., Cantor, L. B., Carter, K., Cruz, O. A., Feldon, S., Mondino, B., Parke, D. W., Pershing, S., Uhler, T., Volpe, N. J. 2016; 123 (9): 2037-2041


    Future ophthalmologists will need to have broad skills to thrive in complex health care organizations. However, training for ophthalmologists does not take advantage of all of the postgraduate years (PGYs). Although the traditional residency years seem to have little excess capacity, enhancing the internship year does offer an opportunity to expand the time for ophthalmology training in the same 4 PGYs. Integrating the internship year into residency would allow control of all of the PGYs, allowing our profession to optimize training for ophthalmology. In this white paper, we propose that we could capture an additional 6 months of training time by integrating basic ophthalmology training into the intern year. This would allow 6 additional months to expand training in areas such as quality improvement or time for "mini-fellowships" to allow graduates to develop a deeper set of skills.

    View details for DOI 10.1016/j.ophtha.2016.06.021

    View details for PubMedID 27423312

  • Factors associated with Endogenous Endophthalmitis and Ophthalmology Consults in an Inpatient Setting Wang, K., Krishnan, G., Pershing, S. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2016
  • Defining a Minimum Set of Standardized Patient-centered Outcome Measures for Macular Degeneration. American journal of ophthalmology Rodrigues, I. A., Sprinkhuizen, S. M., Barthelmes, D., Blumenkranz, M., Cheung, G., Haller, J., Johnston, R., Kim, R., Klaver, C., McKibbin, M., Ngah, N. F., Pershing, S., Shankar, D., Tamura, H., Tufail, A., Weng, C. Y., Westborg, I., Yelf, C., Yoshimura, N., Gillies, M. C. 2016; 168: 1-12


    To define a minimum set of outcome measures for tracking, comparing, and improving macular degeneration care.Recommendations from working-group of international experts in macular degeneration outcomes registry development and patient advocates, facilitated by the International Consortium for Health Outcomes Measurement (ICHOM).Modified Delphi technique, supported by structured teleconferences, followed by online-surveys to drive consensus decisions. Potential outcomes were identified through literature review of outcomes collected in existing registries and reported in major clinical trials. Outcomes were refined by the working-group and selected based upon impact on patients, relationship to good clinical care and feasibility of measurement in routine clinical practice.Standardized measurement of the following outcomes is recommended: visual functioning and quality of life (distance visual acuity, mobility and independence, emotional well-being, reading and accessing information); number of treatments; complications of treatment; and disease-control. Proposed data-collection sources include administrative, clinical data during routine clinical visits and patient-reported sources annually. Recording the following clinical characteristics is recommended to enable risk-adjustment: age; gender; ethnicity; smoking status; baseline visual acuity in both eyes; type of macular degeneration; presence of geographic atrophy, subretinal fibrosis or pigment epithelial detachment; previous macular degeneration treatment; ocular co-morbidities.The recommended minimum outcomes and pragmatic reporting standards should enable standardized, meaningful assessments and comparisons of macular degeneration treatment outcomes. Adoption could accelerate global improvements in standardized data-gathering and reporting of patient-centered outcomes. This can facilitate informed decisions by patients and health care providers, plus allow long-term monitoring of aggregate data, ultimately improving understanding of disease progression and treatment responses.

    View details for DOI 10.1016/j.ajo.2016.04.012

    View details for PubMedID 27131774

  • Predictive modeling of risk factors and complications of cataract surgery. European journal of ophthalmology Gaskin, G. L., Pershing, S., Cole, T. S., Shah, N. H. 2016; 26 (4): 328-337


    Cataract surgery is generally safe; however, severe complications exist. Preexisting conditions are known to predispose patients to intraoperative and postoperative complications. This study quantifies the relationship between aggregated preoperative risk factors and cataract surgery complications, and builds a model predicting outcomes on an individual level, given a constellation of patient characteristics.This study utilized a retrospective cohort of patients age 40 years or older who received cataract surgery. Risk factors, complications, and demographic information were extracted from the Electronic Health Record based on International Classification of Diseases, 9th edition codes, Current Procedural Terminology codes, drug prescription information, and text data mining. We used a bootstrapped least absolute shrinkage and selection operator model to identify highly associated variables. We built random forest classifiers for each complication to create predictive models.Our data corroborated existing literature, including the association of intraoperative complications, complex cataract surgery, black race, and/or prior eye surgery with increased risk of any postoperative complications. We also found other, less well-described risk factors, including diabetes mellitus, young age (<60 years), and hyperopia, as risk factors for complex cataract surgery and intraoperative and postoperative complications. Our predictive models outperformed existing published models.The aggregated risk factors and complications described here can guide new avenues of research and provide specific, personalized risk assessment for a patient considering cataract surgery. Furthermore, the predictive capacity of our models can enable risk stratification of patients, which has utility as a teaching tool as well as informing quality/value-based reimbursements.

    View details for DOI 10.5301/ejo.5000706

    View details for PubMedID 26692059

    View details for PubMedCentralID PMC4930873

  • Physician Utilization Patterns for VEGF-Inhibitor Drugs in the 2012 United States Medicare Population: Bevacizumab, Ranibizumab, and Aflibercept OPHTHALMIC SURGERY LASERS & IMAGING RETINA Baisiwala, S., Bundorf, M. K., Pershing, S. 2016; 47 (6): 555-562


    To evaluate variation in physician use of vascular endothelial growth factor (VEGF) inhibitors.Population-based analysis of comprehensive, publicly available 2012 Medicare claims, aggregated by physician specialty and service type - including intravitreal injections of bevacizumab (Avastin; Genentech, South San Francisco, CA), ranibizumab (Lucentis; Genetech, South San Francisco, CA), and aflibercept (Eylea; Regeneron, Tarrytown, NY). Physicians were characterized by total patients treated, proportion treated with each drug, total intravitreal injection payments, and proportion of total payments for each drug.The authors identified 2,869 ophthalmologists. On average, each treated 203 patients with VEGF-inhibitors, 75.9% of which were treated with bevacizumab. Using all three agents was the most common practice (1,121 physicians), closely followed by using bevacizumab only (1,061 physicians). Ranibizumab accounted for most payments, but bevacizumab was the largest payment source for a sizeable proportion of physicians who used only/mostly bevacizumab.Most ophthalmologists use multiple VEGF inhibitors, but vary in their relative use. A subset of ophthalmologists predominantly use ranibizumab, but ophthalmologists overall use more bevacizumab despite financial incentives favoring ranibizumab. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:555-562.].

    View details for DOI 10.3928/23258160-20160601-07

    View details for Web of Science ID 000393095900008

    View details for PubMedID 27327285

  • Supply and Perceived Demand for Teleophthalmology in Triage and Consultations in California Emergency Departments JAMA OPHTHALMOLOGY Wedekind, L., Sainani, K., Pershing, S. 2016; 134 (5): 537-543


    Determining the perceived supply and potential demand for teleophthalmology in emergency departments could help mitigate coverage gaps in emergency ophthalmic care.To evaluate the perceived current need for and availability of ophthalmologist coverage in California emergency departments and the potential effect of telemedicine for ophthalmology triage and consultation.Surveys were remotely administered to 187 of the 254 emergency departments throughout California via the telephone and Internet from June 30 to September 23, 2014. Emergency department nurse managers and physicians from all emergency departments listed in the California Office of Statewide Health Planning and Development database were individually surveyed to assess facility characteristics and resources as well as the perceived usefulness of teleophthalmology consultation. Data analysis was conducted from June 30, 2014, to March 11, 2015.Perceived availability of ophthalmology consultation coverage and perceived effect of telemedicine ophthalmology consultation at each facility.Of the 187 emergency departments surveyed, 18 of 37 rural facilities (48.6%) reported availability of emergency ophthalmology coverage, compared with 112 of 150 nonrural facilities (74.7%). Rural facilities reported a mean (SD) of 23.72 (14.15) miles between the facility and referral location, while nonrural facilities reported a mean of 4.41 (10.23) miles (19.3% difference). On a scale of 1 to 5 (where 1 signifies very low value and 5 signifies very high value), 124 of 187 nurse managers (66.3%) and 80 of 121 physicians (66.1%) rated teleophthalmology as having high or very high value for triage purposes. The most frequently cited potential advantage of emergency teleophthalmology was assistance in patient triage and immediate real-time electronic communication, and the most frequently cited potential disadvantages were unknown cost of contracting and maintenance and concern that eye trauma might make photographs or videos less conclusive.Availability of ophthalmology coverage for emergency eye care is limited, particularly among rural emergency departments in California. Surveyed emergency department nurse managers and physicians indicated moderately high interest and perceived value for a teleophthalmology solution for remote triage and consultation. Overall, the study suggests that teleophthalmology could play a role in mitigating coverage gaps in emergency ophthalmic care and could be further investigated through similar studies in other regions.

    View details for DOI 10.1001/jamaophthalmol.2016.0316

    View details for Web of Science ID 000375796100016

  • Supply and Perceived Demand for Teleophthalmology in Triage and Consultations in California Emergency Departments. JAMA ophthalmology Wedekind, L., Sainani, K., Pershing, S. 2016


    Determining the perceived supply and potential demand for teleophthalmology in emergency departments could help mitigate coverage gaps in emergency ophthalmic care.To evaluate the perceived current need for and availability of ophthalmologist coverage in California emergency departments and the potential effect of telemedicine for ophthalmology triage and consultation.Surveys were remotely administered to 187 of the 254 emergency departments throughout California via the telephone and Internet from June 30 to September 23, 2014. Emergency department nurse managers and physicians from all emergency departments listed in the California Office of Statewide Health Planning and Development database were individually surveyed to assess facility characteristics and resources as well as the perceived usefulness of teleophthalmology consultation. Data analysis was conducted from June 30, 2014, to March 11, 2015.Perceived availability of ophthalmology consultation coverage and perceived effect of telemedicine ophthalmology consultation at each facility.Of the 187 emergency departments surveyed, 18 of 37 rural facilities (48.6%) reported availability of emergency ophthalmology coverage, compared with 112 of 150 nonrural facilities (74.7%). Rural facilities reported a mean (SD) of 23.72 (14.15) miles between the facility and referral location, while nonrural facilities reported a mean of 4.41 (10.23) miles (19.3% difference). On a scale of 1 to 5 (where 1 signifies very low value and 5 signifies very high value), 124 of 187 nurse managers (66.3%) and 80 of 121 physicians (66.1%) rated teleophthalmology as having high or very high value for triage purposes. The most frequently cited potential advantage of emergency teleophthalmology was assistance in patient triage and immediate real-time electronic communication, and the most frequently cited potential disadvantages were unknown cost of contracting and maintenance and concern that eye trauma might make photographs or videos less conclusive.Availability of ophthalmology coverage for emergency eye care is limited, particularly among rural emergency departments in California. Surveyed emergency department nurse managers and physicians indicated moderately high interest and perceived value for a teleophthalmology solution for remote triage and consultation. Overall, the study suggests that teleophthalmology could play a role in mitigating coverage gaps in emergency ophthalmic care and could be further investigated through similar studies in other regions.

    View details for DOI 10.1001/jamaophthalmol.2016.0316

    View details for PubMedID 27010537

  • A Proposed Minimum Standard Set of Outcome Measures for Cataract Surgery. JAMA ophthalmology Mahmud, I., Kelley, T., Stowell, C., Haripriya, A., Boman, A., Kossler, I., Morlet, N., Pershing, S., Pesudovs, K., Goh, P. P., Sparrow, J. M., Lundström, M. 2015; 133 (11): 1247-1252


    Aligning outcome measures for cataract surgery, one of the most frequently performed procedures globally, may facilitate international comparisons that can drive improvements in the outcomes most meaningful to patients.To propose a minimum standard set of outcome measures for cataract surgery that enables global comparisons.A working group of international experts in cataract outcomes and registries was convened, along with a patient advocate, to agree on a consensus of outcome measures for cataract surgery. In a modified Delphi process, the group met regularly between November 10, 2012, and November 21, 2013, to discuss which outcomes to include in a standard set. Included factors were based on extant literature, existing registries, and the experience of group members. Similarly, a series of consensus discussions were held to determine a set of risk factors to be gathered for each patient. The final shortlist was compiled into a standard set. Analysis was performed from November 22, 2013, to April 5, 2014.Development of a recommended standard set encompassing preoperative metrics including patient risk factors, intraoperative factors including surgical complications, and postoperative cataract surgery outcomes.The recommended standard set encompasses all patients treated for cataracts by 1 of 4 surgical approaches (phacoemulsification, sutured manual extracapsular cataract extraction, sutureless manual extracapsular cataract extraction, or intracapsular cataract extraction). The recommended metrics to be recorded preoperatively include demographics, ocular history and comorbidities, preoperative visual acuity, and patient-reported visual function. The recommended outcomes were split into intraoperative and postoperative metrics. Intraoperative outcomes include capsule-related problems, dislocation of lens nucleus fragments into the vitreous, and other complications. Postoperative outcomes include visual acuity, refractive error, patient-reported visual function, and early and late complications of surgery. The suggested follow-up for collection of postoperative outcomes is up to 3 months.A minimum standard set of outcome measures for cataract surgery is important for meaningful comparison across contexts. The proposed data set is a compromise between all useful data and the practicalities of data collection.

    View details for DOI 10.1001/jamaophthalmol.2015.2810

    View details for PubMedID 26291752

  • Reply: To PMID 25486541. American journal of ophthalmology Pershing, S., Vaziri, K., Albini, T. A., Moshfeghi, D. M., Moshfeghi, A. A. 2015; 160 (2): 392-?

    View details for DOI 10.1016/j.ajo.2015.04.037

    View details for PubMedID 26187878

  • Risk factors predictive of endogenous endophthalmitis among hospitalized patients with hematogenous infections in the united states. American journal of ophthalmology Vaziri, K., Pershing, S., Albini, T. A., Moshfeghi, D. M., Moshfeghi, A. A. 2015; 159 (3): 498-504


    To identify potential risk factors associated with endogenous endophthalmitis among hospitalized patients with hematogenous infections.Retrospective cross-sectional study.MarketScan Commercial Claims and Encounters, and Medicare Supplemental and Coordination of Benefit inpatient databases from the years 2007-2011 were obtained. Utilizing ICD-9 codes, logistic regression was used to identify potential predictors/comorbidities for developing endophthalmitis in patients with hematogenous infections.Among inpatients with hematogenous infections, the overall incidence rate of presumed endogenous endophthalmitis was 0.05%-0.4% among patients with fungemia and 0.04% among patients with bacteremia. Comorbid human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) (OR = 4.27; CI, 1.55-11.8; P = .005), tuberculosis (OR = 8.5; CI, 1.2-61.5; P = .03), endocarditis (OR = 8.3; CI, 4.9-13.9; P < .0001), bacterial meningitis (OR = 3.8; CI, 1.2-12.0; P = .023), fungal meningitis (OR = 59.1; CI, 14.1-247.8; P < .0001), internal organ abscess (OR = 2.9; CI, 1.2-6.4; P = .02), lymphoma/leukemia (OR = 2.9; CI, 1.6-5.3; P < .0001), skin abscess/cellulitis (OR = 1.75; CI, 1.1-2.8; P = .02), pyogenic arthritis (OR = 4.2; CI, 1.8-9.6; P = .001), diabetes with ophthalmic manifestations (OR = 7.0; CI, 1.7-28.3; P = .006), and urinary tract infection (OR = 0.04; CI, 0.3-0.9; P = .023) were each significantly associated with a diagnosis of endogenous endophthalmitis. Patients aged 0-17 years (OR = 2.61; CI, 1.2-5.7; P = .02), 45-54 years (OR = 3.4; CI, 2.0-5.4; P < .0001), and 55-64 years (OR = 2.9; CI, 1.8-4.8; P < .0001); those having length of stay of 3-10 days (OR = 1.9; CI, 1.1-3.3; P = .01), 11-30 days (OR = 3.1; CI, 1.8-5.5; P < .0001), and 31+ days (OR = 5.3; CI, 2.7-10.4; P < .0001); and those with intensive care unit/neonatal intensive care unit (ICU/NICU) admissions (OR = 1.5; CI, 1.4-1.6; P < .0001) were all more likely to be diagnosed with endogenous endophthalmitis.Endogenous endophthalmitis is rare among hospitalized patients in the United States. Among patients with hematogenous infections, odds of endogenous endophthalmitis were higher for children and middle-aged patients, and for patients with endocarditis, bacterial meningitis, lymphoma/leukemia, HIV/AIDS, internal organ abscess, diabetes with ophthalmic manifestations, skin cellulitis/abscess, pyogenic arthritis, tuberculosis, longer hospital stays, and/or ICU/NICU admission.

    View details for DOI 10.1016/j.ajo.2014.11.032

    View details for PubMedID 25486541

  • Treating age-related macular degeneration: comparing the use of two drugs among medicare and veterans affairs populations. Health affairs Pershing, S., Pal Chee, C., Asch, S. M., Baker, L. C., Boothroyd, D., Wagner, T. H., Bundorf, M. K. 2015; 34 (2): 229-238


    While new biologics have revolutionized the treatment of age-related macular degeneration-the leading cause of severe vision loss among older adults-these new drugs have also raised concerns over the economic impact of medical innovation. The two leading agents are similar in effectiveness but vary greatly in price-up to $2,000 per injection for ranibizumab compared to $50 for bevacizumab. We examined the diffusion of these drugs in fee-for-service Medicare and Veterans Affairs (VA) systems during 2005-11, in part to assess the impact that differing financial incentives had on prescribing. Physicians treating Medicare patients have a direct financial incentive to prescribe the more expensive agent (ranibizumab), while VA physicians do not. Medicare injections of the more expensive ranibizumab peaked in 2007 at 47 percent. Beginning in 2009 the less expensive bevacizumab became the predominant therapy for Medicare patients, accounting for more than 60 percent of injections. For VA patients, the distribution of injections across the two drugs was relatively equal, particularly from 2009 to 2011. Our analysis indicates that there are opportunities in both the VA and Medicare to adopt more value-conscious treatment patterns and that multiple mechanisms exist to influence utilization.

    View details for DOI 10.1377/hlthaff.2014.1032

    View details for PubMedID 25646102

  • Treating age-related macular degeneration: comparing the use of two drugs among medicare and veterans affairs populations. Health affairs Pershing, S., Pal Chee, C., Asch, S. M., Baker, L. C., Boothroyd, D., Wagner, T. H., Bundorf, M. K. 2015; 34 (2): 229-238

    View details for DOI 10.1377/hlthaff.2014.1032

    View details for PubMedID 25646102

  • Clinical-Pathologic Correlation: Vitrectomy With Epiretinal and Internal Limiting Membrane Peel OPHTHALMIC SURGERY LASERS & IMAGING RETINA Demarchis, E. H., Pershing, S., Moshfeghi, D. M. 2014; 45 (3): 218-221


    To correlate clinical and pathologic findings in vitreoretinal surgeries with epiretinal membrane (ERM) and internal limiting membrane (ILM) peels.A retrospective review of the clinical and pathologic reports for 698 vitrectomy specimens involving ERM and/or ILM peels from 2008 to 2012.Labeling with clear operative clinical diagnoses - ERM, ILM or both - was available for 520 of 698 cases; 492 cases had a corresponding pathology result. Combined ERM-ILM specimens were the dominant clinical and pathologic diagnosis. Over 43% had differing operative and pathologic diagnoses, with 79.6% of cases labeled as ERMs, 75.0% of cases labeled as ILMs, and 22.1% cases labeled as ERM-ILM demonstrating incongruous specimens on pathology.It can be difficult to determine the nature of membranes pre- or intraoperatively. Combined ERM-ILM specimens may be more common than previously recognized, implying that the two membranes are not always distinct and surgically separable. [Ophthalmic Surg Lasers Imaging Retina. 2014;45:218-221.].

    View details for DOI 10.3928/23258160-20140411-01

    View details for Web of Science ID 000338322300006

  • iPhone Photography of Eye Pathology for Remote Triage He, L., Myung, D., Pershing, S., Chang, R. ASSOC RESEARCH VISION OPHTHALMOLOGY INC. 2014
  • Cost-Effectiveness of Treatment of Diabetic Macular Edema ANNALS OF INTERNAL MEDICINE Pershing, S., Enns, E. A., Matesic, B., Owens, D. K., Goldhaber-Fiebert, J. D. 2014; 160 (1): 18-?


    Macular edema is the most common cause of vision loss among patients with diabetes.To determine the cost-effectiveness of different treatments of diabetic macular edema (DME).Markov model.Published literature and expert opinion.Patients with clinically significant DME.Lifetime.Societal.Laser treatment, intraocular injections of triamcinolone or a vascular endothelial growth factor (VEGF) inhibitor, or a combination of both.Discounted costs, gains in quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).All treatments except laser monotherapy substantially reduced costs, and all treatments except triamcinolone monotherapy increased QALYs. Laser treatment plus a VEGF inhibitor achieved the greatest benefit, gaining 0.56 QALYs at a cost of $6975 for an ICER of $12 410 per QALY compared with laser treatment plus triamcinolone. Monotherapy with a VEGF inhibitor achieved similar outcomes to combination therapy with laser treatment plus a VEGF inhibitor. Laser monotherapy and triamcinolone monotherapy were less effective and more costly than combination therapy.VEGF inhibitor monotherapy was sometimes preferred over laser treatment plus a VEGF inhibitor, depending on the reduction in quality of life with loss of visual acuity. When the VEGF inhibitor bevacizumab was as effective as ranibizumab, it was preferable because of its lower cost.Long-term outcome data for treated and untreated diseases are limited.The most effective treatment of DME is VEGF inhibitor injections with or without laser treatment. This therapy compares favorably with cost-effective interventions for other conditions.Agency for Healthcare Research and Quality.

    View details for Web of Science ID 000330249700003

    View details for PubMedCentralID PMC4020006

  • Restructuring medical education to meet current and future health care needs. Academic medicine Pershing, S., Fuchs, V. R. 2013; 88 (12): 1798-1801


    U.S. health care is changing, and it will continue to change across multiple dimensions: a different mix of patients; more ambulatory, chronic care and less acute, inpatient care; an older population; expanded insurance coverage; a team approach to care; rapid growth of subspecialty care; growing emphasis on cost-effective care; and rapid technological change. These changes demand a corresponding evolution in physician roles and training. However, despite innovation in content and teaching methods, there has been little alteration to the basic structure of medical education since the Flexner Report sparked widespread reform in 1910. Looking to the future, medical education might evolve to include preparation for a team approach to care via practical training for multispecialty collaborative practice and preparing physicians to be leaders of primary care teams that include nonphysician providers; shorter training for some physicians via flexible pathways and "fast tracks" at each phase of training; cost-effective care in clinical practice; increased training in geriatrics; and "on ramps" and "off ramps" along the physician career path for flexible training over a lifetime. Although the challenges facing the health care system are great, meeting changing health care needs must begin at the foundation, in medical education.

    View details for DOI 10.1097/ACM.0000000000000020

    View details for PubMedID 24128642

  • Ocular hypertension and intraocular pressure asymmetry after intravitreal injection of anti-vascular endothelial growth factor agents. Ophthalmic surgery, lasers & imaging retina Pershing, S., Bakri, S. J., Moshfeghi, D. M. 2013; 44 (5): 460-464


    To evaluate elevated intraocular pressure (IOP) after intravitreal injections of vascular endothelial growth factor (VEGF) inhibitors and contribute toward the recognition and understanding of its mechanisms, pattern, and treatment.Retrospective case series of VEGF-inhibitor injections at two academic centers (Stanford University and Mayo Clinic) over 4 years. Cases were evaluated for IOP elevation (≥ 24 mm Hg) or asymmetry (≥ 3 mm Hg IOP difference between eyes on three visits).Twenty-one eyes were identified with pathologically elevated IOP after treatment. Most had delayed-onset (average: 15 months after treatment, after 10 injections) elevation. IOP-lowering therapy was required in 81%. More consecutive visits with IOP asymmetry occurred in patients developing ocular hypertension (11.1% pre-diagnosis vs 66.7% post-diagnosis; OR = 9.00, P = .003).Elevated IOP may occur after ranibizumab or bevacizumab injections, often exhibiting a delayed and perhaps cumulative effect. The authors found significant bilateral IOP asymmetry in patients developing unilateral glaucoma after VEGF-inhibitor injections, a potential early indicator or proxy for pathologic IOP elevation. [Ophthalmic Surg Lasers Imaging Retina. 2013;44:460-464.].

    View details for DOI 10.3928/23258160-20130909-07

    View details for PubMedID 24044708

  • Trends in ophthalmic manifestations of methicillin-resistant Staphylococcus aureus (MRSA) in a northern California pediatric population 40th Annual Fall Meeting of the American-Society-of-Ophthalmic-Plastic-and-Reconstructive-Surgery Amato, M., Pershing, S., Walvick, M., Tanaka, S. MOSBY-ELSEVIER. 2013: 243–47


    To determine pediatric clinical trends of ocular and periocular methicillin-resistant Staphylococcus aureus (MRSA) in a large northern California healthcare system.This study was a retrospective cross-sectional review of all pediatric cases (aged 0-18) with culture-positive ophthalmic MRSA isolates identified between January 2002 and December 2009. Medical record review included history, presentation, infection site, acquisition (community or nosocomial), antibiotic sensitivity/resistance, treatment, and clinical outcome. Incidence was classified by year, sex, and age. Parameters were analyzed for statistical significance by trend and χ(2) analysis.A total of 399 ocular and periocular MRSA cases were included. Cases trended upward from 2002 to 2009, peaking in 2006. Of the 137 pediatric cases (0-18 years), 58% were community acquired. Conjunctivitis was the predominant presentation (40%), followed by stye/chalazion (25%), orbital cellulitis/abscess (19%), dacryocystitis (11%) and brow abscess (3%). Significant predictors for ocular infection with MRSA included male sex (61%), neonates (38%), and multiple infection sites on the body (38%). Resistance was high to bacitracin (80.9%) and ofloxacin (48.3%) but remained low for trimethoprim/sulfamethoxazole (8.7%). Topical therapy was effective in 29% of cases; oral antibiotics, in 47%. Intravenous therapy was required in 12% of cases and incision/drainage or surgery in 19%. Initial oral antibiotic treatment, primarily cephalosporins (24%), was ineffective in 37% of patients. There was a significant increase in resistance to antibiotic therapy (P < 0.001) during the study period. No patients developed permanent visual impairment.Pediatric ocular and periocular MRSA is increasing in incidence and resistance in our patient population. Outcomes can be improved by early recognition, proper antibiotic selection, and obtaining cultures and sensitivities when resistant or severe ocular infections are present.

    View details for DOI 10.1016/j.jaapos.2012.12.151

    View details for Web of Science ID 000321224900004

    View details for PubMedID 23623773

  • The importance of keeping a broad differential in retina clinic: the spectrum of ophthalmic disease seen by retina specialists in a tertiary outpatient clinic setting. Ophthalmic surgery, lasers & imaging retina Fijalkowski, N., Pershing, S., Moshfeghi, D. M. 2013; 44 (2): 133-139


    To describe the new patient population referred to retina specialists at tertiary ophthalmic academic centers in the United States.Retrospective chart review of all new patients seen by retina specialists at Stanford University from 2008 to 2011.Retina specialists saw 7,197 new patients during the study period, with a mean age of 52.2 ± 25.6 years (range: 0 to 108 years). Younger patients (0 to 10 years) were more likely male (P < .001) while older patients were more likely female (P < .01 for 61 to 70, 81+ years). The most common diagnoses were diabetic eye disease (17.0%), retinopathy of prematurity (9.9%) and age-related macular degeneration (9.5%).Retina specialists treat patients of all ages, and the most common diagnoses vary with age and gender. Patients present to retinal clinic with a vast spectrum of disease from various ophthalmic and systemic etiologies; therefore, it is important to maintain a broad differential diagnosis.

    View details for DOI 10.3928/23258160-20130313-06

    View details for PubMedID 23510039

  • Phacoemulsification versus extracapsular cataract extraction: where do we stand? CURRENT OPINION IN OPHTHALMOLOGY Pershing, S., Kumar, A. 2011; 22 (1): 37-42


    Cataract surgery at present is divisible into two general techniques: manual extracapsular cataract extraction and phacoemulsification--with ECCE further separated into the traditional form and small-incision cataract surgery. This review will discuss updates in surgical techniques, outcome comparisons, cost analysis, and the continued role of extracapsular cataract extraction in Western countries.Surgical techniques for manual extracapsular cataract extraction have undergone much refinement, with numerous descriptions of techniques in a recent literature. Studies that have emerged in the last several years allow us to compare surgical results between different techniques and suggest that there is little difference in final outcome when each surgery is done well. Overall cost-effectiveness and suitability of each technique vary based on location and facilities.Manual extracapsular cataract extraction (especially small-incision versions) occupies an important place in modern cataract surgery, and, while not a replacement for phacoemulsification in Western countries, should be part of a cataract surgeon's overall skill set.

    View details for DOI 10.1097/ICU.0b013e3283414fb3

    View details for Web of Science ID 000285135500009

    View details for PubMedID 21088578

  • Cytomegalovirus Infection with MRI Signal Abnormalities Affecting the Optic Nerves, Optic Chiasm, and Optic Tracts JOURNAL OF NEURO-OPHTHALMOLOGY Pershing, S., Dunn, J., Khan, A., Liao, Y. J. 2009; 29 (3): 223-226


    A 49-year-old woman who had been immunosuppressed after a renal transplant developed bilateral severe visual loss. Visual acuities were finger counting and hand movements in the two eyes. Both optic nerves were pale. There were no other ophthalmic abnormalities. Brain MRI disclosed marked signal abnormalities involving the optic nerves, optic chiasm, and optic tracts. Cerebrospinal fluid polymerase chain reaction (PCR) was positive for cytomegalovirus. Treatment did not restore vision. Such extensive clinical and imaging involvement of the anterior visual pathway, which has been previously reported with other herpes viruses, illustrates the propensity for this family of viruses to track along axons.

    View details for Web of Science ID 000270048700011

    View details for PubMedID 19726946

  • Comparison of anterior vitrectorhexis and continuous curvilinear capsulorhexis in pediatric cataract and intraocular lens implantation. surgery: A 10-year analysis JOURNAL OF AAPOS Wilson, M. E., Trivedi, R. H., Bartholomew, L. R., Pershing, S. 2007; 11 (5): 443-446


    To analyze the rate of inadvertent anterior lens capsular tears with vitrectorhexis or continuous curvilinear capsulorhexis (CCC) in pediatric cataract and intraocular lens (IOL) implantation surgery between January 1, 1997, and December 31, 2006.Retrospective chart review, collecting for each eye: age at cataract surgery, type of anterior capsulotomy, any tearing of the capsule, and if yes, details of the tear.A total of 737 eyes were reviewed. Cases with a ruptured lens capsule that occurred prior to surgery were excluded. Eyes that received an anterior capsulotomy by any other method (n = 27) or eyes that did not receive an IOL (n = 100) were reviewed but excluded from final comparative analysis. Of the remaining 339 eyes, 19 eyes (5.6%) were noted to develop an anterior capsule tear (vitrectorhexis, 12 of 226 eyes, 5.3%; CCC, 7 of 113, 6.2%). These tears occurred during anterior capsulotomy in seven eyes, hydrodissection in one, cataract removal in three, and IOL insertion/manipulation in eight. In eyes operated for cataract at or before 72 months of age, the manual CCC technique was more likely to develop a tear (relative risk, 3.09) compared with eyes of older children (>72 months of age), where the vitrectorhexis technique was more likely to develop a tear (relative risk, 3.14).Vitrectorhexis is well suited for use in children less than 6 years of age due to their highly elastic anterior lens capsule. For children aged 6 years and older, manual CCC is the best technique because, by that age, capsule control and ease of capsulotomy completion has improved.

    View details for DOI 10.1016/j.jaapos.2007.03.012

    View details for Web of Science ID 000250386400006

    View details for PubMedID 17532240