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11

Outcomes | 2007

Cole Eye Institute

Patients First

283053A.indd 2 6/24/08 9:33:33 AM

Cole Eye Institute1

Outcomes 2007

Patients First

Quality counts when referring patients to hospitals and physicians, so Cleveland Clinic has created a series of Outcomes

books similar to this one for many of its institutes. Designed for a healthcare provider audience, the Outcomes books con-

tain a summary of our surgical and medical trends and approaches, data on patient volume and outcomes, and a review of

new technologies and innovations.

Although we are unable to report all outcomes for all treatments provided at Cleveland Clinic — omission of outcomes for

a particular treatment does not mean we necessarily do not offer that treatment — our goal is to increase outcomes report-

ing each year. When outcomes for a specific treatment are unavailable, we often report process measures that have docu-

mented relationships with improved outcomes. When process measures are unavailable, we report volume measures; a

volume/outcome relationship has been demonstrated for many treatments, particularly those involving surgical technique.

Cleveland Clinic also supports transparent public reporting of healthcare quality data and participates in the following

public reporting initiatives:

• Joint Commission Performance Measurement Initiative (www.qualitycheck.org)

• Centers for Medicare and Medicaid (CMS) Hospital Compare (www.hospitalcompare.hhs.gov)

• Leapfrog Group (www.leapfroggroup.org)

• Ohio Department of Health Service Reporting (www.odh.state.oh.us)

Our commitment to providing accurate, timely information about patient care is designed to help patients and referring

physicians make informed healthcare decisions. We hope you find these data valuable. To view all our Outcomes books,

visit Cleveland Clinic’s Quality and Patient Safety website at clevelandclinic.org/quality/outcomes.

283053A.indd 1 6/24/08 9:33:33 AM

22

Dear Colleague:

I am proud to present the 2007 Cleveland Clinic Outcomes books. These books provide information on results, volumes and innovations

related to Cleveland Clinic care. The books are designed to help you and your patients make informed decisions about treatments and

referrals.

Over the past year, we enhanced our ability to measure outcomes by reorganizing our clinical services into patient-centered institutes. Each

institute combines all the specialties and support services associated with a specific disease or organ system under a single leadership at a

single site. Institutes promote collaboration, encourage innovation and improve patient experience. They make it easier to benchmark and

collect outcomes, as well as implement data-driven changes.

Measuring and reporting outcomes reinforces our commitment to enhancing care and achieving excellence for our patients and referring

physicians. With the institutes model in place, we anticipate greater transparency and more comprehensive outcomes reporting.

Thank you for your interest in Cleveland Clinic’s Outcomes books. I hope you will continue to find them useful.

Sincerely,

Delos M. Cosgrove, MD

CEO and President

283053A.indd 2 6/24/08 9:33:38 AM

what’s insideChairman’s Letter 04

Institute Overview 05

Quality and Outcomes Measures

Cataract Surgery 07

Cornea Surgery 09

Glaucoma Surgery 12

Oculoplastic Surgery 15

Ocular Oncology Surgery 17

Refractive Surgery 19

Vitreoretinal Surgery 21

Strabismus Surgery 24

Patient Experience 26

Innovations 27

New Knowledge 30

Staff Listing 34

Contact Information 36

Institute Locations 36

Cleveland Clinic Overview 37

Online Services 37 eCleveland Clinic DrConnect MyConsult

283053A.indd 3 6/24/08 9:33:39 AM

Outcomes 2007 44

Chairman’s LetterThe faculty and staff of the Cole Eye Institute are excited to present the

second edition of clinical outcomes in Ophthalmology. Our Outcomes book for

2007 represents an aggregation of clinical volumes from the past two years.

Clinical outcomes allow us to understand and objectively measure the

success of our surgical results. Our key evaluatory measures continue to be

visual acuity and the rate of surgical complications, and we continue to use

Early Treatment of Diabetic Retinopathy Study (ETDRS) protocol refraction

as the means of measuring visual acuity. The key measurement variables are

mentioned under each section in the book. In addition to clinical outcomes,

world-class customer service is very important to us. Consequently, we have

spent significant time to understand patient flow process and experience. We

continue to seek best practice measurement processes for both clinical and

administrative areas. We strive to set the standard for excellence through

innovation and consistent follow-up and measurement to evaluate our overall

clinical proficiency.

Our clinical outcomes represent the highest level of achievement in diagnostic

and therapeutic applications. We continue to develop state-of-the-art clinical

applications through our clinical research efforts and basic science initiatives.

We are proud to present our findings and results to our referring physicians,

patients and prospective patients. Thank you for your interest and I hope you

will find the Outcomes book useful.

Hilel Lewis, MD

Chairman, Cole Eye Institute

Ken signature

5 Cole Eye Institute5

Institute OverviewAt Cleveland Clinic Cole Eye Institute, we have assembled a team of the

world’s foremost clinicians and researchers who are committed not only to

delivering the finest healthcare available, but also to improving tomorrow’s

care through innovative basic, clinical and translational research.

We believe that research and patient care are interdependent. Therefore,

we forge synergistic relationships through analytical and integrative

processes, such as surgical outcomes analysis. We are pioneering

treatment protocols for complex vision-threatening disorders through our

clinical trials and aggressive research programs to shorten the gap between

the laboratory discoveries of today and the patient care of tomorrow. Our

goal: Answering tomorrow’s medical problems through today’s laboratory

and research endeavors.

As one of the leading comprehensive eye institutes in the world, we are

able to enhance the lives of our patients and serve our referring physicians

by providing early, accurate diagnosis and excellent, efficient state-of-

the-art care. Our program consistently ranks amongst the highest in the

U.S.News & World Report annual survey. Our market share represents

one of the highest patient volumes seen in the United States by any eye

institute, providing care and ambulatory encounters more than 150,000

times a year. We treat the full range of complex vision disorders and

conditions, as well as offering routine eye care for all ages.

We have invested capital resources to build and maintain a state-of-the-art

facility, which demonstrates our commitment to putting patients first. We

deliver maximum patient comfort, service and quality. We offer primary,

secondary and tertiary ophthalmologic services such as oncology services

and treatment of melanoma of the eye.

Our Institute is specially designed to enable clinicians to develop

tomorrow’s advances; our facility includes an Experimental Surgery Suite

− one of the few in the country with full operating capacity. Training future

eye specialists is greatly enhanced in the Education Pavilion, with the

James P. Storer Conference Center (designed with tele-video technology),

as well as video rooms, resident carrels and ample conference space.

This section will start with the narrative and be followed by statistical data.It is not necessary to keep the background color

Outcomes 2007 6

Vision First Program: Free Screenings for Public School Children

A pioneering collaboration between the Cole Eye Institute, the Cleveland

Browns and the Cleveland Municipal School District helps bring free vision

screenings to kindergarten and first-grade pupils on the Vision First van.

The program was conceived by the mayor of Cleveland and Dr. Hilel Lewis,

Chairman of the Cole Eye Institute, to identify early, current and treat

pediatric eye diseases in children attending the Cleveland Public Schools.

In 2007, the Cleveland Browns became the Vision First van’s sponsor,

helping expand the six-year-old Vision First program’s offerings to include

free glasses for children who need them and visits from players to get

students excited about wearing glasses and encourage them to invest time

in their studies. Each year, the program screens more than 6,000 children

at 88 elementary schools.

The Vision First van is staffed by Elias I. Traboulsi, MD, head of pediatric

ophthalmology at the Cole Eye Institute, program medical director, Heather

Cimino, OD, and Rhonda Wilson, an ophthalmic technician. Together, they

assess the need for glasses as well as test depth perception, the ability

to use both eyes fully, color perception and eye muscle strength on each

student whose parents return a signed permission slip.

The van is fully equipped to perform complete eye exams – and because

the program is designed for young children, it features a system that

lets the staff use letters, numbers and even pictures in the exam. Video

cartoons are another kid-friendly tool used, and plenty of stickers are

handed out as rewards.

This program is important because childhood vision problems, such as

amblyopia, are treatable if caught early enough – but can damage vision

permanently if left untreated. Also, the earlier students who need glasses

get them, the sooner they can start doing better in school.

2007 Key Statistics

Total Clinic Visits 147,003

Total Surgical Procedures 7,717

Total Surgeries 5,016

Total Cataract Procedures 2,543

Total Cornea Procedures 252

Total Glaucoma Procedures 303

Total Retina Procedures 3,464

Total Oncology Procedures 1,091

Total Oculoplastic Procedures 1,395

Total Strabismus Procedures 474

Total Refractive Procedures 1,541

Total Laser Procedures 1,368

Total Intraocular Drug Therapies 1,907

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Cole Eye Institute7

Cataract Surgery

Complications during Cataract Surgery

Postoperative Complications

Complications during Cataract SurgeryComplications during Cataract Surgery

0.1% Iris Trauma0.1% Iris Trauma

97.6% None

1.5% Posterior Capsule Tear

0.8% Zonular Dialysis

N = 2,412

0

2000

4000

6000

8000

10000

97.8% None

1.6% Cystoid Macular Edema1.6% Cystoid Macular Edema

0.4% Epiretinal Membrane0.4% Epiretinal Membrane

0.1% Retinal Detachment0.1% Retinal Detachment

0.1% Vitreous Hemorrhage0.1% Vitreous Hemorrhage

N = 1,644

Cataract surgery is the most commonly performed surgical procedure in ophthalmology, thus representing a significant proportion of the operations performed at the Cole Eye Institute. From January 2006 through September 2007, a total of 2,412 cataract extraction surgeries were performed. Many of these surgeries were completed as part of a combined surgical procedure in conjunction with cornea, glaucoma or retinal surgeries, the results of which are included in those sections of this report. In this section, the results of cataract surgeries performed as a single procedure are described.

Intraoperative complications of cataract surgery were uncommon, occurring in only 2.4 percent of patients. The most common complication was a loss of lens capsule integrity due to either a rupture of the posterior capsule or zonular dialysis, with or without prolapse of vitreous into the anterior segment.

Postoperative complications were also rare, occurring in 2.2 percent of patients. Cystoid macular edema was the most common complication; it was observed in 1.6 percent of patients. Other postoperative complications included epiretinal membrane, retinal detachment and vitreous hemorrhage. Reoperation for one or more of these complications was required in 0.4 percent of patients.

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Outcomes 2007 8

Change in Visual Acuity by Ocular Comorbidity

0

20

40

60

80

100

Axis line weight = 1Line weight for bars and pie pieces = 0.5Use stacked bar sequence shown

Dashed line weight = 0.75 Dash 2 Gap 1

Text 7.5 point RomanAxis labels 7.5 Bold

ETDRS* Visual Acuity ScoreETDRS* Visual Acuity Score

0

20

40

60

80

100

None Cornea Glaucoma Retina Uveitis Other

Ocular Comorbidities

Preop VAPostop VA

The goal of cataract surgery is to improve visual acuity, which was accomplished in the vast majority of our patients. The mean improvement in the ETDRS visual acuity score following cataract surgery was 14.5 letters, representing an improvement in vision of three lines on the visual acuity chart. The overall improvement in vision was seen in patients with or without other eye disease, with significant improvement occurring in patients with other problems including corneal disease, retinal disease, uveitis and glaucoma. In patients without other eye disease, the mean visual acuity score with best glasses correction after surgery was 79.1 letters, corresponding to nearly 20/20 vision.

Early Treatment of Diabetic Retinopathy Study*

Difference Between Actual and Target Refractive Error

0

10

20

30

40

50

60




PercentPercent

0

10

20

30

40

50

60

2 -2 to -1 -1 to 0

Diopters

0 to +1 +1 to +2 2

After cataract surgery, the great majority of patients achieved a refractive outcome that was near the anticipated refractive error. Regardless of the large number of patients with other conditions that can influence the refractive outcome, 81 percent of patients achieved a final spherical equivalent refractive error within 1 diopter of the expected result.

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9 Cole Eye Institute

Cornea SurgeryCorneal transplant surgeons at the Cole Eye Institute perform state-of-the-art transplants for numerous conditions that distort or cloud this normally transparent tissue. The traditional full-thickness procedure, known as penetrating keratoplasty (PK), makes up the bulk of grafts that are performed in our institution. From January 2006 through September 2007, 137 PKs were performed, with 95.6 percent of these grafts remaining clear at three months.

Cole Eye corneal transplant surgeons have also embarked on cutting-edge lamellar corneal transplant procedures in which only the portion of the cornea that is diseased is replaced. Using a procedure called descemet stripping automated endothelial keratoplasty (DSAEK), surgeons may now selectively transplant the endothelium for conditions such as pseudophakic bullous keratopathy and Fuchs endothelial dystrophy. Recipients of this procedure are provided faster visual recovery and more stable and predictable refractive outcomes than with traditional PK. During the above-mentioned period, 45 DSAEKs were performed, with 100 percent of the grafts remaining clear at three months.

Corneal surgeons are also transplanting just the anterior portion of the cornea for conditions such as keratoconus and corneal scarring. This procedure, deep anterior lamellar keratoplasty (DALK), affords the advantage of allowing patients to retain their own healthy endothelium, avoiding the risk of endothelial rejection and other potential complications associated with PK. Over the past two years, 23 DALKs were performed, with 100 percent of the grafts remaining clear at three months.

Graft Clear at 3 Months

AnteriorLamellar

PosteriorLamellar

PenetratingKeratoplasty

Type of Procedure

0

20

40

60

80

100

Percent SurgeriesPercent Surgeries

YesNo

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Outcomes 2007 10

Intraoperative Complications

0

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Intraoperative ComplicationsIntraoperative Complications

0.4% Corneal Graft Edema0.4% Corneal Graft Edema

99.2% None

0.4% Choroidal Hemorrhage

N = 223

Many serious sight-threatening disorders may affect only the surface of the eye, including the cornea. These conditions may disrupt or destroy the corneal stem cells responsible for producing the eye’s healthy cellular surface. Cleveland Clinic surgeons have performed a number of stem cell transplants to restore the ocular surface. In addition, they have created a device that facilitates harvesting the tissue from deceased donor tissue.

For patients with serious disorders who are not candidates for the more common types of corneal transplantation, the cornea may be replaced with an artificial cornea, called a keratoprosthesis. Several of our patients have benefited from this procedure, with excellent visual and anatomical results.

A total of 205 keratoplasty procedures and 18 other corneal procedures with a total of 223 procedures were performed during the previously mentioned period. The vast majority of patients have had successful clinical outcomes with no complications. Intraoperative complications occurred in only 0.9 percent of cases; they consisted of corneal graft edema and choroidal hemorrhage. The postoperative complication rate was 2.7 percent, with most complications being retinal detachment, graft failure and persistent epithelial defect. The reoperation rate after corneal surgery (defined as a return to the OR within 90 days) was 3.8 percent; this was due to failure of graft adhesion in DSAEK cases.

Analysis of intraoperative complications included all surgical procedures performed during this period. Analysis of postoperative complications and surgical outcomes included those patients who had completed three months or more of follow-up. Consequently, the sample sizes reported for intraoperative and postoperative complications differ.

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Change in Visual Acuity by Procedure


Change in visual acuity based on the type of corneal transplant procedure is shown in the graph below. For patients who completed at least three months of follow-up, the mean improvement in ETDRS visual acuity score was 23.9 letters, corresponding to an improvement of five lines of visual acuity.

0

20

40

60

80




0

20

40

60

80

ETDRS Visual Acuity ScoreETDRS Visual Acuity Score

LamellarKeratoplasty

PenetratingKeratoplasty

Type of Procedure

Keratoprosthesis

Preop VAPostop VA

Pie Graph Sequence

24% Total volume24% Total volume

57% Total volume57% Total volume

24% Total volume24% Total volumeRomanRomanBoldBold

97.7% None

0.5% Retinal Detachment0.5% Retinal Detachment 0.5% Graft Failure0.5% Graft Failure

0.5% Persistent Epithelial Defect0.5% Persistent Epithelial Defect

0.9% Other0.9% Other

N = 222

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Outcomes 2007 12

Surgery Type N %

Trabeculectomy 248 55.9

Glaucoma Implant 159 35.9

Revision of Trabeculectomy 19 4.3

Revision of Glaucoma Implant 14 3.2

Other 3 0.7

Total 443 100

Glaucoma Surgery

Surgeries Performed in Patients with ≥ 3 Months Follow-up Data

In 2006 and 2007, a total of 443 glaucoma surgical surgeries were performed at the Cole Eye Institute, ranging from primary trabeculectomy in patients undergoing initial glaucoma surgery to complex combined procedures performed in conjunction with cornea and/or retinal specialists. Combined procedures were performed in 47 percent of patients.

The most common procedures performed for glaucoma patients are trabeculectomy and implantation of a glaucoma drainage device. The goal of each of these procedures is reduction of intraocular pressure (IOP) to prevent progressive glaucomatous optic nerve damage and associated loss of vision. A significant IOP reduction was achieved in patients who underwent these procedures at the Cole Eye Institute, as assessed at the three-month follow-up. The mean IOP reduction in patients who underwent trabeculectomy was 6.8 mm Hg, representing a decrease of 29 percent from baseline. In patients who had a glaucoma drainage device implanted, the mean IOP reduction was 12.9 mm Hg, representing a decrease from baseline of 40.2 percent. Glaucoma surgery is not expected to improve visual acuity. ETDRS letter scores show stable post operative acuity,

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Change in Intraocular Pressure

Visual Acuity at 3 Months

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40

Axis line weight = 1Line weight for bars and pie pieces = 0.5

Preop IOPPostop IOP

Use stacked bar sequence shown



Intraocular Pressure (mm Hg)Intraocular Pressure (mm Hg)

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40

Trabeculectomy Glaucoma Implant0

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0

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Preop VA Postop VA


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Outcomes 2007 14



Intraoperative and postoperative complications were uncommon, occurring in less than 3 percent of patients. Details of the incidence and nature of these complications are shown in the charts below. The need to reoperate within 90 days due to postoperative complications or to recurring IOP elevation occurred in 2.4 percent of patients. Despite the high level of complexity of a significant number of glaucoma surgery cases at the Cole Eye Institute, we are able to achieve a high level of efficacy in reducing IOP through surgical intervention, with a low risk of intraoperative or postoperative complications.

0

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4000

6000

8000

10000

Intraoperative ComplicationsIntraoperative Complications


97.7% None

0.9% Hyphema

1.1% Button HoleN = 443

0

2000

4000

6000

8000

10000

Postoperative ComplicationsPostoperative Complications

0.2% Implant Exposure0.2% Implant Exposure

99.1% None

0.2% Choroidal Effusion

0.5% HypotonyN = 443

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Oculoplastic Surgery

Distribution of Oculoplastic Surgeries

71.2% Eyelid

10.5% Orbital

18.3% Lacrimal

N = 792

s

Oculoplastic service outcomes were divided into three categories: eyelid surgery, lacrimal surgery and orbital surgery. There were 792 oculoplastic surgeries performed from January 2006 through September 2007.

Postoperative Complications of Eyelid Surgery

Worsened Dry Eye

4.1% Need Reoperation4.1% Need Reoperation

Worsened Dry Eye


Worsened Dry Eye


Worsened Dry Eye


Worsened Dry Eye


88.2% None

4.5% Worsened Dry Eye

5.5% Need Revision5.5% Need Revision



Eyelid surgery outcome measures included intraoperative complications, postoperative eyelid symmetry and reoperation rate (defined as a return to the OR within 90 days). A total of 564 eyelid surgeries were performed during the above mentioned period. Intraoperative complications were rare, comprising only 0.5 percent of eyelid procedures. Similarly, the reoperation rate was very low, with only 0.9 percent of cases requiring a second procedure.

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Outcomes 2007 16

Postoperative Eyelid Symmetry

Postoperative Eyelid Symmetry

96.6% Excellent

3.4% Good3.4% Good

N = 564

Postoperative eyelid symmetry results were excellent in approximately 96.6 percent of cases and good in the remaining 3.4 percent of cases. Excellent and good eyelid symmetry were defined as a marginal reflex distance (MRD) within 0.5 mm and 1.0 mm of the desired position, respectively.

Postoperative Complications of Lacrimal Surgery

89.8% None

4.1% Need Revision4.1% Need Revision

Worsened Dry Eye



N = 49

Other, 2.0%

None, 89.8%N = 49

Lacrimal surgery outcome measures included intraoperative complications and reoperation rate. A total of 145 lacrimal surgeries were performed from January 2006 through September 2007. There were no intraoperative complications and the reoperation rate was 4.1 percent. Orbital surgery outcome measures included intraoperative complications and reoperation rate. At the Cole Eye Institute, 83 orbital surgeries were performed from January 2006 through September 2007. There were no intraoperative complications, and no patient required reoperation or revision.

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Ocular Oncology Surgery

Treatment of Uveal Melanoma

Treatment of Recurrent Uveal Melanoma

A melanoma is a primary tumor of the skin or eye. In the eye, it arises from the pigmented cells of the uvea (choroid, ciliary body or iris). Uveal melanoma of the eye occurs in 4.3 people per million population per year. It almost always occurs in one eye and is more common in fair-skinned, blue-eyed people. In the past, enucleation was the only treatment for uveal melanoma. In recent years, new methods of treatment have been developed that may be used to save the eye. At Cole Eye Institute, we have increasingly used radioactive plaque for the treatment of uveal melanoma. From July 2006 through December 2007, we have treated 71 new patients with uveal melanoma, with the majority (89 percent) undergoing plaque radiotherapy.

Plaques containing iodine-125 and ruthenium-106 are used at Cole Eye Institute on a regular basis. If tumors are < 5 mm in height, the ruthenium-106 plaque is preferred. The size of the plaque is determined by the diameter of the tumor.

Over the short term, we have observed initial tumor regression with preservation of vision in almost all cases. However, five patients (6 percent) had tumors recur, requiring additional treatment with plaque or enucleation.

Treatment of Uveal Melanoma

89% Plaque Radiotherapy

11% Enucleation11% Enucleation

N = 71Treatment of Recurrent Uveal Melanoma

40%

60% Enucleation60% Enucleation

PlaqueRadiotherapy

N = 5

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Outcomes 2007 18

Fundus photograph showing a dome-shaped pigmented choroidal melanoma in the temporal quadrant of the left eye (A). Three months after iodine-125 plaque radiotherapy, the tumor showed evidence of continued growth with breakthrough Bruchs membrane (B). Repeat plaque radiotherapy was performed. One year after repeat plaque radiotherapy, tumor regression is evident (C).

A

B

C

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Refractive SurgeryOutcomes of laser vision correction are best summarized based on the patient’s preoperative refractive status. Both the type and magnitude of refractive error (nearsightedness or farsightedness) affect the likelihood that uncorrected visual acuity of 20/20 or better will be achieved. Another important factor that indicates the outcome of laser vision correction is the proportion of patients whose final refractive error falls within ± 0.5 diopters of the intended result.

Below are the collective outcomes for laser in-situ keratomileusis with the femtosecond laser (IntraLASIK) and photorefractive keratectomy (PRK), using custom or conventional ablation. In addition to those two outcomes, we also report the proportion of patients with an exceptional outcome (uncorrected acuity of 20/15 or better), and the proportion of patients with uncorrected acuity meeting the requirements for driving without glasses (20/40 or better). From April 2006 through August 2007, 661 eyes were included in this analysis.

Vision Correction after IntraLASIK and PRKLow Myopia (0 to ≤3 Diopters Sphere, ≤ 0.5 D Cylinder)

Vision Correction after IntraLASIK and PRK Moderate Myopic Astigmatism (-3 to -6 Diopters Sphere, ≥0.75 D Cylinder)

0

20

40

60

80

100




Vision Correction after IntraLASIK and PRKLow Myopia (0 to -3 Diopters Sphere, ≤ 0.5 D Cylinder)

Vision Correction after IntraLASIK and PRKLow Myopia (0 to -3 Diopters Sphere, ≤ 0.5 D Cylinder)

20/15 20/20 20/40 0.5 D

PercentPercent

0

20

40

60

80

100

3 months N = 13712 months N = 36

0

20

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60

80

100




Vision Correction after IntraLASIK and PRKModerate Myopic Astigmatism (-3 to -6 Diopters Sphere ≥ 0.75 D Cylinder)

Vision Correction after IntraLASIK and PRKModerate Myopic Astigmatism (-3 to -6 Diopters Sphere ≥ 0.75 D Cylinder)

20/15 20/20 20/40 0.5 D

PercentPercent

0

20

40

60

80

100


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Outcomes 2007 20

Vision Correction after IntraLASIK and PRK Hyperopia (0 to +6 Diopters Sphere, All Eyes)

Vision Correction after IntraLASIK and PRKHigh Myopia (> -6 Diopters Sphere ≥ 0.75 D Cylinder)


0.5 D

PercentPercent

0

20

40

60

80

1003 months N = 26

20/15 20/20 20/40

Greater than 80 percent of myopic eyes achieved uncorrected visual acuity of 20/20 or better, and about 95 percent had a refractive result that fell within ± 0.5 diopters of the desired target. Almost 100 percent achieved uncorrected visual acuity of 20/40 or better, and 40 percent to 50 percent had an exceptional result of uncorrected visual acuity of 20/15 or better. In hyperopic eyes, where a precise refractive outcome is known to be more difficult to achieve after laser vision correction, 50 percent of patients still achieved uncorrected visual acuity of at least 20/20, and 80 percent had a refractive outcome within ± 0.5 diopters of the target outcome. About 96 percent had uncorrected visual acuity of 20/40 or better, and 11.5 percent achieved an exceptional result with uncorrected visual acuity of at least 20/15.

Vision Correction after IntraLASIK and PRKHigh Myopia (>-6 Diopters Sphere, ≥ 0.75 D Cylinder)

0

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100






20/15 20/20 20/40 0.5 D

PercentPercent

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100


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Vitreoretinal Surgery

Change in Visual Acuity




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Preop VA Postop VA


The vitreoretinal department at the Cole Eye Institute has assembled a dedicated surgical team of surgeons, nurses and skilled technicians to deliver world-class care for our patients. This team has developed several new surgical procedures that are now used worldwide for retinal detachment, diabetic macular edema, diabetic traction detachments, macular holes, and pediatric retinal surgery. Members of the team have also helped develop the next generation of vitreoretinal surgical devices.




Vision Improved by > 14 ETDRS Letters by Indication for SurgeryVision Improved by > 14 ETDRS Letters by Indication for Surgery

RhegmatogenousRetinal

Detachment

DiabeticVitrectomy

Indication for Surgery

EpiretinalMembraneDissection

MacularHole

ETDRS ScoreETDRS Score

0

20

40

80

60

Preop VAPostop VA

Change in Visual Acuity by Indication for Surgery

From January 2006 through September 2007, the team handled 633 surgical cases, for which a detailed outcomes analysis was conducted. Some cases were excluded from the analysis of visual outcomes, including emergency cases, cases where protocol visual acuity could not be performed for patient reasons, or cases where patients received postoperative care from another facility. All cases were included in the analysis of intraoperative surgical complications.

The Cole Eye Institute is a tertiary care facility and the vitreoretinal team is called on by patients and other physicians to assist in difficult cases. This is especially true for cases involving complicated retinal detachments and diabetic retinopathy. Overall, the surgical success of the vitreoretinal team was excellent, with achievement of the surgical goals in 91.6 percent of cases. Reoperation was needed in 8.4 percent of cases. Visual acuity improved after surgery, with a mean improvement of 14 letters or almost 3 lines of vision. Vision improved > 3 lines in 42 percent of surgical cases.

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Outcomes 2007 22

Vision Improved by > 14 ETDRS Letters by Indication for Surgery




Vision Improved by > 14 ETDRS Letters by Indication for SurgeryVision Improved by > 14 ETDRS Letters by Indication for Surgery


Detachment

DiabeticVitrectomy


EpiretinalMembraneDissection

MacularHole


0

20

40

80

60

Preop VAPostop VA

During the above mentioned time period, the vitreoretinal team performed 82 surgeries to close a macular hole. Closure of the macular hole was achieved in 100 percent of cases. Vision improved > 3 lines in 44 percent of cases, with a mean change in vision of 12.6 letters or 2.5 lines. Retinal detachment was repaired in 81 patients, with retinal reattachment achieved after one surgery in 79 percent of cases, and after a second procedure in 97 percent of cases. The mean change in vision after retinal detachment repair was an improvement of 12.9 letters or 2.6 lines. Forty-two percent of patients improved 3 or more lines in vision.

Diabetic vitrectomy surgery is among the most complex surgeries performed by a vitreoretinal surgeon. Ninety-eight of these procedures were performed by the vitreoretinal team during this time period. Visual acuity improved by 3 or more lines in 37 percent of cases, with a mean improvement of 11.5 letters or 2.3 lines.

Vision Improved by >14 ETDRS Letters




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Vision Improved by > 14 ETDRS Letters

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Yes No


283053A.indd 22 6/24/08 9:34:18 AM




92.6% None

0.2% Hyphema0.2% Hyphema

1.2% Vitreous Hemorrhage1.2% Vitreous Hemorrhage

0.7% Choroidal Hemorrhage0.7% Choroidal Hemorrhage


4.5% Iatrogenic Break4.5% Iatrogenic Break

MacularHole



Detachment

DiabeticVitrectomy

EpiretinalMembrane

0

20

40

60

80

100Percent

NoneHyphemaVitreous HemorrageIatrogenic BreakChoroidal HemorrhageOther

MacularHole



Detachment

DiabeticVitrectomy

EpiretinalMembrane

Percent

0

20

40

60

80

100NoneHyphemaVitreous HemorrageIatrogenic BreakChoroidal HemorrhageOther

N=1,010

N=1,010

An analysis of intraoperative complications of all vitreoretinal surgical procedures showed that no complications occurred in 92.6 percent of cases. Intraoperative iatrogenic tears were recorded in 4.5 percent of cases; however, when recognized intraoperatively, as in these cases, this complication is easily managed. Other complications included vitreous hemorrhage (1.2 percent), hyphema (0.2 percent) and choroidal hemorrhage (0.7 percent).

An analysis of postoperative complications in patients with at least three months of follow-up revealed that 96.3 percent of cases did not have any postoperative complications. Vitreous hemorrhage was the most common complication (1.1 percent) followed by retinal detachment (0.8 percent), intraocular pressure spike (0.4 percent), corneal edema (0.1 percent), and other complications (1.3 percent).

283053A.indd 23 6/24/08 9:34:18 AM

Outcomes 2007 24

Strabismus Surgery

Adult Strabismus Cases

Pediatric Strabismus CasesAxis line weight = 1Line weight for bars and pie pieces = 0.5Use stacked bar sequence shown



0

10

20

30

40

50

Number of SurgeriesNumber of Surgeries

0

10

20

30

40

50

Esotropia Exotropia DissociatedVertical

Deviations

Diagnosis

IVth NervePalsy

VIth NervePalsy

Hypertropia ThyroidEye

Disease




0

20

40

60

80

Number of SurgeriesNumber of Surgeries

0

20

40

60

80

Esotropia Exotropia IVth NervePalsy

Diagnosis

DissociatedVertical

Deviations

VIth NervePalsy

Hypertropia Nystagmus

283053A.indd 24 6/24/08 9:34:19 AM


Surgical Outcome for Adults

Surgical Outcome for Children

Surgical Outcome for Adults

81% Good (Diplopia disappeared

19% Poor (Overcorrected19% Poor (Overcorrected

and/or anomalous headposition resolved)

or undercorrected)or undercorrected)

Surgical Outcome for Children

94% Good (Deviation < 10 prism

6% Poor (Overcorrected6% Poor (Overcorrected

diopters in primary positionand/or anomalous headposition resolved)

or undercorrected)or undercorrected)

A total of 271 strabismus surgeries were performed from January 2006 through December 2007. Of these, 109 surgeries were on adults (16 years and older) and 162 surgeries were on children under the age of 16. A total of 90 surgeries were for esotropia, 100 for exotropia, 25 for thyroid eye disease, 28 for IVth nerve palsy, 4 for VIth nerve palsy, 13 for dissociated deviations, 9 for hypertropia and 2 for nystagmus. Outcomes were assessed at the latest follow-up exams, which ranged from 1 day to 1 year postoperatively. Outcomes were considered good if constant deviations were < 10 prism diopters in primary position in children and in adults without diplopia, if diplopia disappeared in adults, and if an anomalous head position resolved.

A total of 17 adults and 73 children had esotropia. Outcomes were good in 14 adults and in 68 children. Poor results occurred in 1 adult and 2 children. All 3 were initially undercorrected. Two of the 3 were reoperated with good outcomes. No follow-up data were available on 2 adults and 3 children. A total of 45 adults and 55 children were operated on for exotropia. Results were good in 35 adults and 47 children, whereas results were poor in 8 adults and 2 children. The 2 children were undercorrected; 1 was reoperated with a good outcome. Six adults were undercorrected and 2 were overcorrected. Three of the undercorrected adults previously had scleral buckles, 1 had a torn muscle and 1 had bilateral internuclear ophthalmoplegia. Follow-up was not available for 2 adults and 5 children.

Surgery was done for IVth nerve palsy on 12 adults and 16 children. Hypertropia or head tilt resolved in 9 adults and 13 children, but were poor in 1 adult and 2 children who were undercorrected. Both children were reoperated; one had a good outcome after a second procedure and the other had a good outcome after a third procedure. No follow-up was available in 2 adults and 1 child. VIth nerve palsy was addressed in 1 child and 2 adults. The child had 2 procedures; the first result was poor and the second one was good. One adult had a good outcome and 1 did not return for follow-up.

Twenty-five procedures were done for thyroid eye disease on 20 adult patients. One patient had a good result after 3 procedures; another had a good result after 2. They had initially been undercorrected. Eleven patients had diplopia resolved after the initial surgery. Of the 6 remaining with a poor outcome, all were undercorrected except one who was overcorrected. Outcome could not be assessed in 1 patient who did not return for follow-up. Five adults and 4 children had a vertical deviation, or hypertropia. One adult needed 2 procedures to achieve a good outcome. Two of the 5 adults had a poor outcome due to being undercorrected. One of these adults previously had an orbital fracture, and the other one had AMD and a retinal detachment repaired 3 of the 4 children had a good outcome. The 1 poor outcome resulted in an undercorrection. One did not return for follow-up.

Two children were operated on for an abnormal head posture due to nystagmus. Both had a good result.

N=151

N=97

283053A.indd 25 6/24/08 9:34:19 AM

Outcomes 2007 26

Overall Rating of Care 2007

Overall Rating of Provider Care 2007

Would Recommend Provider 2007

Outpatient - Cole Eye Institute We ask our patients about their experiences and satisfaction with the services provided by our staff. Although our patients are already indicating we provide excellent care, we are committed to continuous improvement.

Patient Experience

Excellent

N=1,622

PercentPercent

0

100

80

60

40

20

Very Good Good Fair Poor

N=1,621

Excellent

PercentPercent

0

100

80

60

40

20

Very Good Good Fair Poor

N=1,579

ExtremelyLikely

PercentPercent

0

100

80

60

40

20

VeryLikely

SomewhatLikely

SomewhatUnlikely

VeryUnlikely

overide master page items to change color tab283053A.indd 26 6/24/08 9:34:19 AM

Cole Eye Institute27

InnovationsRetinopathy of Prematurity (ROP)Retinopathy of Prematurity (ROP), a leading cause of childhood blindness worldwide, has no FDA-approved medical therapy. ROP involves initial destruction of retinal vessels during hyperoxia and the subsequent abnormal growth of blood vessels in response to low oxygen states. These vessels bleed and can exert traction, causing retinal detachments.

The current paradigm for preventing unfavorable outcomes from ROP is centered on the treatment of the angiogenesis seen in ROP by limiting the substrate-causing pathologic neovascularization through destructive laser ablation of the retina. However, another novel approach to preventing vision loss from ROP is to direct the orderly development of retinal vessels during phase I by stimulating a key transcription factor, hypoxia inducible factor-1 (HIF-1), that is inhibited by the hyperoxia of phase I.

Using a gene reporter system, Jonathan Sears, MD, and associates at the Cole Eye Institute have uncovered small molecules with rapid onset and a short half life that enable the retina to develop in an orderly and sequential fashion during hyperoxia, a phase that normally causes vascular obliteration. This induces the normal development of the retina and eliminates the stimulus for pathologic blood vessel growth and subsequent retinal detachment.

Multiple Advantages Make DALK an Excellent Alternative to PK in Eyes with Anterior Corneal Pathologies

Penetrating keratoplasty (PK) remains the gold standard surgery for eyes with corneal disease needing transplantation. This full-thickness procedure is highly effective in restoring vision, but its drawbacks include a prolonged recovery, a fragile wound and the attendant risk of endothelial rejection.

Deep anterior lamellar keratoplasty (DALK), in which the anterior and middle layers of the diseased cornea are replaced with healthy donor tissue, was developed as an alternative procedure to PK in eyes with a normal Descemet’s membrane and endothelial cells. However, DALK is more technically challenging and takes longer to perform than PK, so it has not been widely adopted by corneal transplant surgeons.

Despite the downside of a prolonged procedure and because DALK has significant advantages, Cole Eye Institute corneal surgeon Bennie H. Jeng, MD, mastered the technique for DALK and began offering it to appropriate patients about one year ago.

“One of the major advantages of DALK over PK is that it eliminates the chance of endothelial rejection, which accounts for nearly all cases of graft rejection. In addition, the cornea is much stronger after DALK compared with PK, which minimizes the risk for late trauma-induced wound dehiscence that can persist for decades after PK,” he says. Furthermore, DALK cuts healing time and time to visual recovery to half of the time as for PK. The opportunity to provide faster visual rehabilitation and reduced long-term risks of graft rejection and wound dehiscence more than justify the extra time it takes to do this procedure.

In Dr. Jeng’s experience, the functional outcomes achieved with DALK have been excellent and comparable to those of PK for similar indications. To date, there have been no long-term postoperative complications or any episodes of rejection. However, because of the technically challenging nature of the procedure, the DALK technique may occasionally need to be converted to a full-thickness transplant. Dr. Jeng’s intraoperative conversion rate from DALK to PK has been about 5 percent.

Diffuse Illumination view of the right eye of a patient three months after DALK for keratoconus (top).

Slit-beam view demonstrates a trace amount of interface haze which later faded away. Final BCVA after all sutures were removed was 20/20 (bottom).

283053A.indd 27 6/24/08 9:34:23 AM

Outcomes 2007 28

Prophylactic mitomycin-C: Definitely Effective, But is it Safe? PRK (photorefractive keratectomy) continues to represent a safe and effective refractive surgery procedure that is often a good alternative to LASIK (laser assisted in situ keratomileusis) and is even the procedure of choice for some patients. However, a risk for development of severe subepithelial corneal opacity, especially after corrections for high myopia, is one of the major disadvantages of PRK. While haze after PRK occurs in only a small proportion of patients who undergo higher-level corrections, it can be a major clinical problem because of its effect on vision and association with regression.

At Cleveland Clinic’s Cole Eye Institute, Steven E. Wilson, MD, has been a leader in research to understand the pathogenesis of the haze and factors that affect its development. Recently, Dr. Wilson and colleagues reported findings from studies in rabbits undertaken to delineate the cellular mechanisms accounting for the benefit of prophylactic treatment with mitomycin-C (MMC) and to examine the effects of varying exposure time and MMC concentration [ J Refract Surg 2007; 22:562-74 ]. The results raise questions about potential long-term deleterious consequences of intraoperative MMC and have implications for clinical practice.

Images reprinted with permission from SLACK Incorporated: Netto, M. V., Mohan, R. R., Sinha, S., Sharma, A., Gupta, P. C, & Wilson, S. E. (2006). Effect of prophylactic and therapeutic mitomycin C on corneal apoptosis, cellular proliferation, haze, and long-term keratocyte density in rabbits. Journal of Refractive Surgery, 22(6), 562-574.

Sutureless Technique Reduces Morbidity of Müller Muscle-Conjunctiva Resection Ptosis RepairMüller muscle-conjunctiva resection is an excellent procedure for treating mild ptosis of the upper eyelid. However, the sutures placed for wound closure can be irritating and cause corneal abrasion.

A few years ago at Cleveland Clinic’s Cole Eye Institute, oculoplastic surgeon Julian D. Perry, MD, began using fibrin sealant (Tisseel, Baxter AG Industries, Vienna, Austria) for conjunctival closure in Müller muscle-conjunctiva resection, recognizing that the material is soft and likely to be gentler to the cornea than sutures. Recently, he and colleagues reported their collective experience with this technique in a retrospective series of 53 consecutive eyelids of 33 patients operated on between January 2002 and January 2004 [Ophthal Plast Reconstr Surg 2006;22:184-7].

The findings of their review document that the sutureless technique can be a good alternative to traditional suture closure. Even though the material apposes only the conjunctiva and not deeper tissues, no cases of wound dehiscence were observed, and anatomic outcomes were comparable to those achieved with traditional sutures in terms of achieved margin reflex distance and bilateral eyelid symmetry. However, patients benefited with improved postoperative comfort and there were no cases of keratopathy or other complications attributable to the fibrin sealant.

Preoperative photo shows left upper eyelid ptosis.

One week after Conjunctival Mullerectomy ptosis repair using fibrin glue.

283053A.indd 28 6/24/08 9:34:27 AM


Advanced Corneal Imaging Sheds Light on Refractive Shift After DSAEKSurgeons at Cleveland Clinic Cole Eye Institute have been performing Descemet’s stripping and automated endothelial keratoplasty (DSAEK), a new corneal transplant procedure, as part of an IRB-approved prospective study and believe they have confirmed the reason many patients who have had this surgery experience a slight shift toward farsightedness.

In DSAEK, which is an alternative to penetrating keratoplasty, a microkeratome is used to create a donor disc composed of posterior stroma, Descemet’s membrane and endothelium that is transplanted onto the posterior stroma of the recipient cornea. This technique often produces donor lenticles that are thicker in the periphery, and investigators have speculated that this plays an important role in the development of hyperopia. William J. Dupps Jr., MD, PhD, a refractive surgeon and corneal specialist and David M. Meisler, MD, have found that non-uniform thickness profiles and variable central graft thicknesses both contribute to refractive shift after DSAEK.

Cole Eye Instiute Anesthesiology

Subtenon’s Cannula Infusion

Subtenon’s lidocaine injection has been proven to reduce postoperative pain and systemic analgesia requirements in strabismus surgery. Staff of the Section for the Cole Eye Institute Anesthesia have advanced their experience with the technique. Marc Feldman, MD, traveled to Middlesbrough, UK, to see and learn the technique from Chandra Kumar, MBBS, at the James Cook Hospital.

Medial Canthal Block

The medial canthal block, a new needle technique, is being used and further developed at Cole Eye Institute. The purpose of this technique is to provide optimal regional anesthesia for the dacryocystorhinostomy procedure to correct chronic tearing of the eyes. J. Victor Ryckman, MD, is developing resident educational and assessment materials for ophthalmic anesthesia.

Preoperative photo shows left upper eyelid ptosis.

One week after Conjunctival Mullerectomy ptosis repair using fibrin glue.

283053A.indd 29 6/24/08 9:34:29 AM

Outcomes 2007 30

New KnowledgeJournal ArticlesAmbrosio R Jr, Jardim D, Netto MV, Wilson SE. Management of unsuccessful LASIK surgery. Compr Ophthalmol Update. 2007 May;8(3):125-141.

Bakri S, Singh AD, Lowder CY, Chalita MR, Li Y, Izatt JA, Rollins AM, Huang D. Imaging of iris lesions with high-speed optical coherence tomography. Ophthalmic Surg Lasers Imaging. 2007 Jan;38(1):27-34.

Bakri SJ, Sears JE, Lewis H. Management of macular hole and submacular hemorrhage in the same eye. Graefes Arch Clin Exp Ophthalmol. 2007 Apr;245(4):609-611.

Bhatnagar P, Kaiser PK, Smith SD, Meisler DM, Lewis H, Sears JE. Reopening of previously closed macular holes after cataract extraction. Am J Ophthalmol. 2007 Aug;144(2):252-259.

Brasil MVOM, Rockwood EJ, Smith SD. Comparison of silicone and polypropylene Ahmed Glaucoma Valve implants. J Glaucoma. 2007 Jan;16(1):36-41.

Brasil OFM, Smith SD, Galor A, Lowder CY, Sears JE, Kaiser PK. Predictive factors for short-term visual outcome after intravitreal triamcinolone acetonide injection for diabetic macular oedema: an optical coherence tomography study. Br J Ophthalmol. 2007 Jun;91(6):761-765.

Chan WM, Andrews C, Dragan L, Fredrick D, Armstrong L, Lyons C, Geraghty MT, Hunter DG, Yazdani A, Traboulsi EI, Pott JWR, Gutowski NJ, Ellard S, Young E, Hanisch F, Koc F, Schnall B, Engle EC. Three novel mutations in KIF21A highlight the importance of the third coiled-coil stalk domain in the etiology of CFEOM1. BMC Genet. 2007 May 18;8:26.

Cohen VML, Singh AD. Comments on: Basal cell carcinoma of the eyelids. Compr Ophthalmol Update. 2007 Jan;8(1):15-16.

Dupps WJ Jr, Netto MV, Herekar S, Krueger RR. Surface wave elastometry of the cornea in porcine and human donor eyes. J Refract Surg. 2007 Jan;23(1):66-75.

Dupps WJ Jr, Jeng BH, Meisler DM. Narrow-strip conjunctival autograft for treatment of pterygium. Ophthalmology. 2007 Feb;114(2):227-231.

Dupps WJ Jr. Hysteresis: New mechanospeak for the ophthalmologist. J Cataract Refract Surg. 2007 Sep;33(9):1499-1501.

Galor A, Margolis R, Kaiser PK, Lowder CY. Vitreous band formation and the sustained-release, intravitreal fluocinolone (Retisert) implant. Arch Ophthalmol. 2007 Jun;125(6):836-838.

Galor A, Hall GS, Procop GW, Tuohy M, Millstein ME, Jeng BH. Rapid species determination of Nocardia keratitis using pyrosequencing technology. Am J Ophthalmol. 2007 Jan;143(1):182-183.

Galor A, Ference SJ, Singh AD, Lee MS, Stevens GHJ, Perez VL, Peereboom DM. Maculopathy as a complication of blood-brain barrier disruption in patients with central nervous system lymphoma. Am J Ophthalmol. 2007 Jul;144(1):45-49.

Hoppe G, Rayborn ME, Sears JE. Diurnal rhythm of the chromatin protein Hmgb1 in rat photoreceptors is under circadian regulation. J Comp Neurol. 2007 Mar 10;501(2):219-230.

Jeng BH, Hall GS, Schoenfield L, Meisler DM. The fusarium keratitis outbreak: not done yet? Arch Ophthalmol. 2007 Jul;125(7):981-983.

For a complete list of

Cole Eye Institute 2007

publications go to

www.clevelandclinic.org/

quality/outcomes

283053A.indd 30 6/24/08 9:34:29 AM


Margolis R, Lowder CY. Sarcoidosis. Curr Opin Ophthalmol. 2007 Nov;18(6):470-475.

Margolis R, Brasil OFM, Lowder CY, Smith SD, Moshfeghi DM, Sears JE, Kaiser PK. Multifocal posterior necrotizing retinitis. Am J Ophthalmol. 2007 Jun;143(6):1003-1008.

Margolis R, Lowder CY, Sears JE, Kaiser PK. Intravitreal bevacizumab for macular edema due to occlusive vasculitis. Semin Ophthalmol. 2007 Apr;22(2):105-108.

Medeiros FW, Stapleton WM, Hammel J, Krueger RR, Netto MV, Wilson SE. Wavefront analysis comparison of LASIK outcomes with the femtosecond laser and mechanical microkeratomes. J Refract Surg. 2007 Nov;23(9):880-887.

Meisler DM, Dupps WJ Jr, Covert DJ, Koenig SB. Use of an air-fluid exchange system to promote graft adhesion during Descemet’s stripping automated endothelial keratoplasty. J Cataract Refract Surg. 2007 May;33(5):770-772.

Netto MV, Mohan RR, Medeiros FW, Dupps WJ Jr, Sinha S, Krueger RR, Stapleton WM, Rayborn M, Suto C, Wilson SE. Femtosecond laser and microkeratome corneal flaps: comparison of stromal wound healing and inflammation. J Refract Surg. 2007 Sep;23(7):667-676.

Netto MV, Chalita MR, Krueger RR. Corneal haze following PRK with mitomycin C as a retreatment versus prophylactic use in the contralateral eye. J Refract Surg. 2007 Jan;23(1):96-98.

Qian Y, Kosmorsky G, Kaiser PK. Retinal manifestations of cerebroretinal vasculopathy. Semin Ophthalmol. 2007 Jul;22(3):163-165.

Radhakrishnan S, See J, Smith SD, Nolan WP, Ce Z, Friedman DS, Huang D, Li Y, Aung T, Chew PTK. Reproducibility of anterior chamber angle measurements obtained with anterior segment optical coherence tomography. Invest Ophthalmol Vis Sci. 2007 Aug;48(8):3683-3688.

Radhakrishnan S, Bala E, Peachey NS, Lewis H, Traboulsi EI. Bilateral macular lesions in a 10-year-old girl. Am J Ophthalmol. 2007 Jan;143(1):184-185.

Roberts RA, Gans RE. Comparison of horizontal and vertical dynamic visual acuity in patients with vestibular dysfunction and nonvestibular dizziness. J Am Acad Audiol. 2007 Mar;18(3):236-244.

Schachat AP. Peers review, editors decide, and then, what? Am J Ophthalmol. 2007 Apr;143(4):677-678.

Jeng BH, Holland GN, Lowder CY, Deegan WF III, Raizman MB, Meisler DM. Anterior segment and external ocular disorders associated with human immunodeficiency virus disease. Surv Ophthalmol. 2007 Jul;52(4):329-368.

Kaiser PK. Verteporfin photodynamic therapy and anti-angiogenic drugs: potential for combination therapy in exudative age-related macular degeneration. Curr Med Res Opin. 2007 Mar;23(3):477-487.

Kaiser PK, Do DV. Ranibizumab for the treatment of neovascular AMD. Int J Clin Pract. 2007 Mar;61(3):501-509.

Kaiser PK, Brown DM, Zhang K, Hudson HL, Holz FG, Shapiro H, Schneider S, Acharya NR. Ranibizumab for predominantly classic neovascular age-related macular degeneration: Subgroup analysis of first-year ANCHOR results. Am J Ophthalmol. 2007 Dec;144(6):850-857.

Kaiser PK, Goldberg MF, Davis AA. Posterior juxtascleral depot administration of anecortave acetate. Surv Ophthalmol. 2007 Jan;52 Suppl 1:S62-S69.

Kaiser PK, Blodi BA, Shapiro H, Acharya NR. Angiographic and optical coherence tomographic results of the MARINA study of ranibizumab in neovascular age-related macular degeneration. Ophthalmology. 2007 Oct;114(10):1868-1875.

Koenig SB, Covert DJ, Dupps WJ Jr, Meisler DM. Visual acuity, refractive error, and endothelial cell density six months after Descemet stripping and automated endothelial keratoplasty (DSAEK). Cornea. 2007 Jul;26(6):670-674.

Koenig SB, Dupps WJ Jr, Covert DJ, Meisler DM. Simple technique to unfold the donor corneal lenticule during Descemet’s stripping and automated endothelial keratoplasty. J Cataract Refract Surg. 2007 Feb;33(2):189-190.

Krueger RR, Dupps WJ Jr. Biomechanical effects of femtosecond and microkeratome-based flap creation: prospective contralateral examination of two patients. J Refract Surg. 2007 Oct;23(8):800-807.

Lewis H. Sutureless microincision vitrectomy surgery: unclear benefit, uncertain safety. Am J Ophthalmol. 2007 Oct;144(4):613-615.

Li Y, Netto MV, Shekhar R, Krueger RR, Huang D. A longitudinal study of LASIK flap and stromal thickness with high-speed optical coherence tomography. Ophthalmology. 2007 Jun;114(6):1124-1132.

Margolis R, Brasil OFM, Lowder CY, Singh RP, Kaiser PK, Smith SD, Perez VL, Sonnie C, Sears JE. Vitrectomy for the diagnosis and management of uveitis of unknown cause. Ophthalmology. 2007 Oct;114(10):1893-1897.

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Outcomes 2007 32

Schorderet DF, Tiab L, Gaillard MC, Lorenz B, Klainguti G, Kerrison JB, Traboulsi EI, Munier FL. Novel mutations in FRMD7 in X-linked congenital nystagmus. Mutation in brief #963. Online. Hum Mutat. 2007 May;28(5):525.

Sears JE, Sonnie C. Anatomic success of lens-sparing vitrectomy with and without scleral buckle for stage 4 retinopathy of prematurity. Am J Ophthalmol. 2007 May;143(5):810-813.

See JLS, Chew PTK, Smith SD, Nolan WP, Chan YH, Huang D, Zheng C, Foster PJ, Aung T, Friedman DS. Changes in anterior segment morphology in response to illumination and after laser iridotomy in Asian eyes: an anterior segment OCT study. Br J Ophthalmol. 2007 Nov;91(11):1485-1489.

Singh AD, Sisley K, Xu Y, Li J, Faber P, Plummer SJ, Mudhar HS, Rennie IG, Kessler PM, Casey G, Williams BG. Reduced expression of autotaxin predicts survival in uveal melanoma. Br J Ophthalmol. 2007 Oct;91(10):1385-1392.

Singh R, Kaiser PK. Advances in AMD imaging. Int Ophthalmol Clin. 2007 Winter;47(1):65-74.

Singh RP, Kaiser PK. Treatment of co-existent occult choroidal neovascular membrane and macular hole. Surv Ophthalmol. 2007 Sep;52(5):547-550.

Singh RP, Schachat A. Ranibizumab in the treatment of age-related macular degeneration. Aging Health. 2007 Feb;3(1):9-14.

Singh RP, Kaiser PK. Role of ranibizumab in management of macular degeneration. Indian J Ophthalmol. 2007 Nov;55(6):421-425.

Taban M, Singh RP, Chung JY, Lowder CY, Perez VL, Kaiser PK. Sterile endophthalmitis after intravitreal triamcinolone: a possible association with uveitis. Am J Ophthalmol. 2007 Jul;144(1):50-54.

Taban M, Langston RHS, Lowder CY. Scleritis in a person with stiff-person syndrome. Ocul Immunol Inflamm. 2007 Jan;15(1):37-39.

Taban M, Taban M, Lee MS, Smith SD, Heyka R, Kosmorsky GS. Prevalence of optic nerve edema in patients on peripheral hemodialysis. Ophthalmology. 2007 Aug;114(8):1580-1583.

Taban M, Lewis H, Lee MS. Nonarteritic anterior ischemic optic neuropathy and ‘visual field defects’ following vitrectomy: could they be related? Graefes Arch Clin Exp Ophthalmol. 2007 Apr;245(4):600-605.

Taban M, Memoracion-Peralta DSA, Wang H, Al-Gazali LI, Traboulsi EI. Cohen syndrome: Report of nine cases and review of the literature, with emphasis on ophthalmic features. J AAPOS. 2007 Oct;11(5):431-437.

Taban M, Kosmorsky GS, Singh AD, Sears JE. Choroidal folds secondary to parasellar meningioma. Eye. 2007 Jan;21(1):147-150.

Thornton I, Puri A, Xu M, Krueger RR. Low-dose mitomycin C as a prophylaxis for corneal haze in myopic surface ablation. Am J Ophthalmol. 2007 Nov;144(5):673-681.

Traboulsi EI. Congenital cranial dysinnervation disorders and more. J AAPOS. 2007 Jun;11(3):215-217.

Ufret-Vincenty RL, Singh RP, Lowder CY, Kaiser PK. Cytomegalovirus retinitis after fluocinolone acetonide (Retisert) implant. Am J Ophthalmol. 2007 Feb;143(2):334-335.

Waheed NK, Young LH. Intraocular foreign body related endophthalmitis. Int Ophthalmol Clin. 2007 Spring;47(2):165-171.

Wilson SE, Perry HD. Long-term resolution of chronic dry eye symptoms and signs after topical cyclosporine treatment. Ophthalmology. 2007 Jan;114(1):76-79.

Wilson SE, Chaurasia SS, Medeiros FW. Apoptosis in the initiation, modulation and termination of the corneal wound healing response. Exp Eye Res. 2007 Sep;85(3):305-311.

Wilson SE, Stulting RD. Agreement of physician treatment practices with the international task force guidelines for diagnosis and treatment of dry eye disease. Cornea. 2007 Apr;26(3):284-289.

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Book ChaptersBollinger K, Smith SD. Ophthalmic viscosurgical devices. In: Henderson BA, ed. Essentials of cataract surgery. Thorofare, NJ: SLACK; 2007:63-68.

Chen B, Perry JD, Foster JA. Evaluation of an adult with orbital tumor. In: Singh AD, ed. Clinical ophthalmic oncology. Philadelphia, PA: Saunders Elsevier; 2007:524-527.

Langston RHS. Fluidics/pumps. In: Henderson BA, ed. Essentials of cataract surgery. Thorofare, NJ: SLACK; 2007:83-90.

Perry JD. Examination techniques. In: Singh AD, ed. Clinical ophthalmic oncology. Philadelphia, PA: Saunders Elsevier; 2007:59-61.

Proffer PL, Foster JA, Perry JD. Evaluation of a child with orbital tumor. In: Singh AD, ed. Clinical ophthalmic oncology. Philadelphia, PA: Saunders Elsevier; 2007:520-523.

Singh AD, Lewis H, Schachat AP, Peereboom D. Lymphoma of the retina and CNS. In: Singh AD, ed. Clinical ophthalmic oncology. Philadelphia, PA: Saunders Elsevier; 2007:372-377.

Singh RP, Singh AD. Ocular paraneoplastic diseases. In: Singh AD, ed. Clinical ophthalmic oncology. Philadelphia, PA: Saunders Elsevier; 2007:378-384.

Taban M, Perry JD. Examination techniques. In: Singh AD, ed. Clinical ophthalmic oncology. Philadelphia, PA: Saunders Elsevier; 2007:505-506.

Taban M, Perry JD. Classification of orbital tumors. In: Singh AD, ed. Clinical ophthalmic oncology. Philadelphia, PA: Saunders Elsevier; 2007:517-519.

Traboulsi EI, Heur M, Singh AD. Tumors of the retinal pigment epithelium. In: Singh AD, ed. Clinical ophthalmic oncology. Philadelphia, PA: Saunders Elsevier; 2007:358-365.

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Outcomes 2007 34

Staff Listing

ChairmanHilel Lewis, MD

Vice Chairman for Clinical Affairs Andrew P. Schachat, MD

Vice Chairman for Education Elias I. Traboulsi, MD

Quality Review Officer Edward J. Rockwood, MD

Surgical Outcomes Team Scott D. Smith, MD, MPH

Monica Jain, MBBS, MHA

Cornea/External Diseases William J. Dupps Jr., MD, PhD

Bennie H. Jeng, MD

Roger H.S. Langston, MD

David M. Meisler, MD

Allen S. Roth, MD

Steven E. Wilson, MD

Regional Ophthalmology Richard E. Gans, MD, FACS

Philip N. Goldberg, MD

Lisa D. Lystad, MD

Shari Martyn, MD

Michael Millstein, MD

Allen S. Roth, MD

David B. Sholiton, MD, FACS

GlaucomaEdward J. Rockwood, MD

Scott D. Smith, MD, MPH

Keratorefractive Surgery Ronald R. Krueger, MD

Steven E. Wilson, MD

Neuro-OphthalmologyGregory S. Kosmorsky, DO

Lisa D. Lystad, MD

Vitreo-RetinalFroncie A. Gutman, MD

Peter K. Kaiser, MD

Hilel Lewis, MD

Andrew P. Schachat, MD

Jonathan E. Sears, MD

Rishi P. Singh, MD

Nadia K. Waheed, MD, MPH

Pediatrics/StrabismusAndreas Marcotty, MD

Elias I. Traboulsi, MD

OculoplasticsJulian D. Perry, MD

Oncology/Eye TumorsArun D. Singh, MD

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UveitisCareen Y. Lowder, MD, PhD

Optometry David Barnhart, OD

Anita Chitluri, OD

Heather L. Cimino, OD

Ann Laurenzi, OD, FAAO

Rosemary Perl, OD

William E. Sax, OD

Mindy Toabe, OD, FAAO

Diane Tucker, OD, FAAO, FCOVD

Research Staff Joe G. Hollyfield, PhD

Bela Anand-Apte, MD, PhD

Sherry Ball, PhD

Vera Bonilha, PhD

Shyam Chaurasia, PhD

John W. Crabb, PhD

Greg Grossman, PhD

Xiaorong Gu, PhD

Stephanie A. Hagstrom, PhD

George Hoppe, PhD

Harmeet Kaur, PhD

Lisa Kuttner-Kondo, PhD

Kwok Peng Ng, PhD

Neal S. Peachey, PhD

Jian Hu Qi, PhD

Mary E. Rayborn, MS

Priyadarshini Senanayake, PhD

Abhijit Roy Sinha, PhD

Jing Xie, PhD

Xianglin Yuan, PhD

Cole Eye Institute AnesthesiologyArmin Schubert, MD, MBA, Chairman, General Anesthesiology

Marc Feldman, MD, Section Head

Maria Inton-Santos, MD

J. Victor Ryckman, MD

Sara Spagnuolo, MD

Some physicians may practice in multiple locations. For a detailed list including staff photos, please visit clevelandclinic.org/staff

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Outcomes 2007 36

Contact Information Institute LocationsGeneral Patient Referral

24/7 hospital transfers or physician consults 800.553.5056

Cole Eye Institute Appointments/Referrals

216.444.2020 or 800.223.2273, ext. 42020

On the Web at clevelandclinic.org/eye

Additional Contact InformationGeneral Information

216.444.2200

Hospital Patient Information

216.444.2000

Patient Appointments

216.444.2273 or 800.223.2273

Special Assistance for Out-of-State Patients

Complimentary assistance for out-of-state patients and families 800.223.2273, ext. 55580, or email [email protected]

International Center

Complimentary assistance for international patients and families 800.884.9551 or 001.631.439.1578 or visit clevelandclinic.org/ic

Cleveland Clinic in Florida

866.293.7866

For address corrections or changes, please call 800.890.2467 clevelandclinic.org

Main Campus

9500 Euclid Avenue Cleveland, OH 44195

Ophthalmology at Beachwood

25101 Chagrin Blvd. Beachwood, OH 44122 216.831.0120

Ophthalmology at Independence

5001 Rockside Road Crown Center II Independence, OH 44131 216.986.4000

Ophthalmology at South Pointe

4110 Warrensville Center Road Warrensville Heights, OH 44122 216.752.2263

Ophthalmology at Strongsville

16761 SouthPark Center Strongsville, OH 44136 440.878.2500

Ophthalmology at Twinsburg

2365 Edison Blvd. Twinsburg, OH 44087 330.963.4843

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Cleveland Clinic Overview Online Services

Cleveland Clinic, founded in 1921, is a nonprofit multispecialty academic medical center that integrates clinical and hospital care with research and education. Today, 1,800 Cleveland Clinic physicians and scientists practice in 120 medical specialties and subspecialties, annually recording more than 3 million patient visits and more than 70,000 surgeries.

In 2007, Cleveland Clinic restructured its practice, bundling all clinical specialties into integrated practice units called institutes. An institute combines all the specialties surrounding a specific organ or disease system under a single roof. Each institute has a single leader and focuses the energies of multiple professionals onto the patient. From access and communication to point-of-care service, institutes will improve the patient experience at Cleveland Clinic.

Cleveland Clinic’s main campus, with 37 buildings on 140 acres in Cleveland, Ohio, includes a 1,000-bed hospital, outpatient clinic, specialty institutes and supporting labs and facilities. Cleveland Clinic also operates 14 family health centers; eight community hospitals; two affiliate hospitals; a 150-bed hospital and clinic in Weston, Fla.; and health and wellness centers in Palm Beach, Fla., and Toronto, Canada. Cleveland Clinic Abu Dhabi (United Arab Emirates), a multispecialty care hospital and clinic, is scheduled to open in 2011.

At the Cleveland Clinic Lerner Research Institute, hundreds of principal investigators, project scientists, research associates and postdoctoral fellows are involved in laboratory-based research. Total annual research expenditures exceed $150 million from federal agencies, non-federal societies and associations, and endowment funds. In an effort to bring research from bench to bedside, Cleveland Clinic physicians are involved in more than 2,400 clinical studies at any given time.

In September 2004, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University opened and will graduate its first 32 students as physician-scientists in 2009.

Cleveland Clinic is consistently ranked among the top hospitals in America by U.S.News & World Report, and our heart and heart surgery program has been ranked No. 1 since 1995.

For more information about Cleveland Clinic, visit clevelandclinic.org.

eCleveland CliniceCleveland Clinic uses state-of-the-art digital information systems to offer several services, including remote second medical opinions to patients around the world; personalized medical record access for patients; patient treatment progress for referring physicians (see below); and imaging interpretations by our subspecialty trained radiologists. For more information, please visit eclevelandclinic.org.

DrConnectOnline Access to Your Patient’s Treatment Progress

Whether you are referring from near or far, DrConnect can streamline communication from Cleveland Clinic physicians to your office. This online tool offers you secure access to your patient’s treatment progress at Cleveland Clinic. With one-click convenience, you can track your patient’s care using the secure DrConnect website. To establish a DrConnect account, visit eclevelandclinic.org or email [email protected].

MyConsultMyConsult Remote Second Medical Opinion is a secure online service providing specialist consultations and remote second opinions for more than 600 life-threatening and life-altering diagnoses. The MyConsult service is particularly valuable for people who wish to avoid the time and expense of travel. For more information, visit eclevelandclinic.org/myconsult, email [email protected] or call 800.223.2273, ext 43223.

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9500 Euclid Avenue, Cleveland, OH, 44195

© The Cleveland Clinic Foundation 2008

Cleveland Clinic is a nonprofit multispecialty academic medical center. Founded in 1921, it is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds, an education institute and a research institute.

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Please visit us on the Web at clevelandclinic.org.

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