Chapters Transcript Pediatric Subspecialist Shortages: Where Does Pediatric Ophthalmology Stand? Speaker: Grayson B. Ashby, MD For those of you that don't know me, my name is Grayson. I'm one of the PGY 4 residents. Based out of Rochester. And today, I'll be talking about the pediatrics of specialist shortages and discuss where pediatric ophthalmology stands, which I thought would be a timely topic as I'm in the midst of applying for a fellowship. So we can review some of the um things that have been published on this topic. At the end of this talk, participants will be able to review the current workforce trends for pediatrics of specialty care, including pediatric ophthalmology, and describe how the impact of pediatric ophthalmology workforce shortages have impacted. Children's abilities to access eye care. And lastly, we'll identify some potential solutions to the pediatric ophthalmology workforce shortage. The multiple choice question for this talk is which of the following has been associated with higher likelihood of pursuing pediatric ophthalmology in Jerusalem fellowship. A higher number of fellowship trained faculty, B. Early exposure to the field, C, higher surgical volume during residency, and D, length of subspecialty rotation during residency, or E, presence of a home fellowship program. We'll come back to that at the end. Um, so I thought I would start with going over this article that was published last summer in The New York Times. It was an opinion piece that was written by Aaron Carroll, who's a pediatrician and health services researcher at Indiana University. And in this article was published, she sort of brought to light some of the issues that have been going on for workforce shortages within pediatrics, um, and subspecialty care. Specifically, he went in to highlight some of the contributing causes, such as poor reimbursement for children due to the abundance of patients who are on Medicaid. Um, the decreasing match rate for pediatrics residents. And fellowships, and then lastly, um, some of the complexities of care that are associated with children who have complex medical needs. Um, ultimately, at the end of the article, he presented a call to action. Taking care of kids is our future, so we should really do our best to, um, to really draw attention to what's been going on for the pediatric workforce shortages. The National Academies have studied this issue in great detail, which you can see photographed here. They published a report in 2023, and In that report, they highlighted both the need for primary care within pediatrics as well as subspecialty care. And how the difficulties with access to care has been impacting children. Um, and not just children who are seeing doctors, but also some of the other folks that take care of kids, like mental health providers, allied healthcare staff that see. Primarily pediatric patients and more. Um, within that, they outlined some of the key contributing influences for those who are pursuing career in pediatrics, including some of the systemic disincentives for people who are providing care for children such as Um, the financial issues that were mentioned in the article published by Doctor Carroll, and ultimately they talk about downstream, downstream effects that this has on patients. The report at the end provides some summative recommendations within the domains that it discusses. Ultimately, with the goal of improving pediatrics workforce and then improving pediatrics' access to care. These include, um, improving the primary care subspecialty interface so that Uh, essentially, pediatricians have, um, the ability to work to the top of their medical training, uh, and provide some of the introductories of specialty care. Number 2, to reduce some of the financial barriers, um, to those pursuing careers in pediatrics, such as changing reimbursements. Or addressing um loan repayment strategies because pediatricians have a lower expected salary, again, partly due to their expected reimbursement. Number 3, to improve the pediatrics training pipeline. Um, there are multiple strategies that are presented there, including, uh, flexible fellowship training pathways or alternative residencies to allow people to self-select into areas of interest earlier on. And then one of the last recommendations was to support the pediatric physician scientist pipeline, so that ultimately research can continue to advance the care of children. Which, um, may have the, the downstream impact of um improving the access to care. One of the key things I thought was interesting from this report was that they made it very clear that just increasing the workforce alone will not solve the problem of the current, uh, shortages within. Um, pediatrics, and that we have to address some of these other issues in order to really, uh, solve the problem. So when we look at what's been happening more recently, um, there was a study that was published not too long ago that showed that the absolute number of pediatric specialists has increased from 2003 to 2019, but these increases have been relatively concentrated in a few specialties. So those specialties have reasonably good representation, but then the larger majority surrounding that have um had a a lack of growth over that time period. In addition to the growth within just a couple of specialties, there's also been a relative concentration of geography around larger urban centers. So there are large swaths of the population who have to drive a significant period to get in to see a pediatric subspecialist. Uh, the undersupply of pediatrics or specialists we've seen more recently is expected to worsen by 2040, and the geographic disparities, including, including the urban-rural divide is expected to get worse. In addition to, um, there's expected to be a widening of the disparity in the American South and the American West. And one of the things I thought was interesting is that, uh, in addition to the overall growth of pediatrics or specialists not keeping up with the population growth, there's also been a change over the last uh couple of decades in Physicians either having increased non-clinical care time or a number of people pursuing part-time work in pediatrics rather than full-time work. So that also has been thought to potentially exacerbate this undersupply. Uh, and there's this interesting interactive model that's been published on the American Board of Pediatrics website, which you can see screenshotted to the right. And it allows you to play with a bunch of what if scenarios for, you know, if we do this versus that, how will that change the expected supply of uh pediatrics and specialists over the next 20 years. And it's kind of small, but you can see, uh, in the top right, the, the key to the graph here. The bottommost line is the orange line, and that would be what would happen if we just increased the number of fellows who are training in pediatrics, and has a modest increase above the baseline compared to what's expected over the next two decades. But if you don't make any changes to the number of fellows, and you just increase the clinical clinical work equivalent, so how much each pediatrician is working by 7%, you can see there's a significantly larger jump. Um, compared to just increasing the number of fellows. And of course, if you do both of those things, you get an even greater effect. So just drawing attention to some of the different ways in which the workforce could be changed over time. Um, I mentioned before that the concentration of growth within pediatric subspecialty care has been within a few subspecialties. Um, and this was a survey that was put out by the Children's Hospital Association of some of their member hospitals looking at Of all the job postings they had, which were the specialties that had job postings that lasted for longer than 12 months, and you can see this list here. Some of these things are um somewhat expected based on some of the shortages that have been published in the literature, like developmental pediatrics or genetics or child neurology. Those all have had kind of long-standing issues with uh workforce. But interestingly, you can see buried here in the middle that ophthalmology is also on that list. And also of note, if you look through the whole list, ophthalmology is the only surgical specialty that's represented in this list of vacancies with lasting longer than 12 months. And when we look at how that might impact um patient care, um, by not being able to fill these positions, this is a graph of expected wait times from 2019 to 2022 for children who have a new consult that was placed to see a variety of subspecialists. This is based out of uh the Children's Specialty Care Coalition in California. And you can see across the board that um there's a wide range of expected wait times to see folks. And based on the last slide, some things are not surprising, like developmental and behavioral pediatrics has quite a long waitlist, same with genetics. But you can see here is where we live, in ophthalmology. Back in 2019, it took just over a month and a half to get in to see a pediatric ophthalmologist when a new consult was placed. But in just three years, that time has nearly doubled, and now it's almost 80 days to get in to see a pediatric ophthalmologist. So, clearly, um, the workforce shortages are having an impact, not just on patients' ability to access care. Uh, to come in just for a simple eye exam. And there was a paper that was published recently in JAMA Ophthalmology that looked at Um, how is the access to pediatric eye cares across the US? Um, this is kind of a piggyback study that was built off of a previously very similar study. This study included pediatric ophthalmologists and optometrists, whereas one before was just ophthalmologists, but they found that the distribution of eye care for kids across the US was as pictured below. Uh, 90% of counties across the US do not have access to a pediatric eye care provider, which was minimally changed compared to the study just of ophthalmologists only, indicating that pediatric ophthalmologists and pediatric optometrists are pretty much co-locating across the US rather than kind of expanding the access to care, as one might hope. Um, there's roughly, as they reported, roughly 1 ophthalmologist for every 80,000 children across the US. But this data is quite skewed because in some of the larger population areas where, uh, you can see the darker shading on this graph. Um, that, uh, that ratio could be as high as like 150, 1 ophthalmologist for every 50,000 children. But then some of the less densely populated areas, that number obviously goes up quite high. Um, there is a separate study published that showed that for children who live around those areas where they have good access to pediatric ophthalmologists, they unsurprisingly had, um, better outcomes when it came to strabismus and amblyopia, which is not surprising that when you can actually get in to see the doctor, you tend to do better. Um, these workforce issues tend to end up turning into equity issues because when this study looked at, um, a variety of factors for the areas that have less access to, um, pediatric eye care, they found that the areas that are most underserved also tend to face other systemic barriers with access to care, like lower median household income, lower expected education, more difficulties with access to transport, and other things that would, again, get into the way of having good outcomes as far as their eye care. Now, one of the reasons that's been kind of long talked about uh for why pediatric ophthalmology has such a workforce shortage is that it has, um, for the last couple of decades had A relatively low match rate for people who are entering the field. This was a graph from 2000 to 2015 that looked at the rates, the match rate for a variety of surgical fellowships within ophthalmology. And found that essentially almost every year for the past 15 years, pediatric ophthalmologists or business had the lowest match rate of any fellowship, and this was a statistically significant finding. Of note, this published match rate here does not include the number of positions who are filled through post-match vacancies, but that may represent, um, the initial match rate may represent kind of the number of people who are anticipated to go into the field to practice long term rather than just using that, um, fellowship for a, a separate purpose. Some of the other interesting things that have been discussed as far as the pediatric ophthalmology match rate include the larger proportion of international medical graduates relative to some of the other subspecialties. Um, and in fact, more recently, there's been more IMGs who've been pursuing pediatric fellowship than US applicants. Um, this may also contribute to some of the workforce issues because international medical graduates may be less likely to stay in the US to practice after they're done with their training. Or they may be using one of the pediatric ophthalmology fellowship as one of their um fellowship opportunities to continue with their licensure in the US. So by the time they're done with all their training, they may practice very little pediatrics, if at all. Um, also, I know, I, the interesting thing here is that this doesn't include some of the primarily non-surgical subspecialties like uveitis or neuro-ophthalmology. Um, those specialties tended to be lower in match rate even than pediatrics, but this is just a study looking at the, the primarily surgical subspecialties. Um, so when you think about pediatric ophthalmology, and you compare it to that list I showed earlier of all the, the specialties that have vacancies longer than 12 months, um, I mentioned that that was the only surgical subspecialty on the list. Um, and so the group out of Boston actually looked at, you know, is pediatric ophthalmology fellowship any different from pediatrics fellowships and some of the other house of surgery, um, disciplines? And on the left, you can see, um, compared to neurosurgery, ENT, orthopedics, or urology, the match rate was approximately the same. There's no statistically significant difference between those five fields at about anywhere between 65 to 80%. Um, but general surgery tended to be the outlier. It had nearly a 100% match rate for their fellowship positions. But if you compare the match rate to the, the graph on the left, the graph on the left shows Um, on the bottom, the number of fellowship positions per 100 graduating residents. And so it was thought that the high match rate is perhaps not um related to a difference in interest, but rather due to a relative scarcity of the number of programs who provide training compared to some of the other disciplines within the house of surgery. Um, but as I mentioned, ophthalmology is the only specialty that, um, the only surgical specialty on this list. I had vacancies for longer than 12 months. Um, and one of the difficult things when looking at some of the workforce issues within the field of pediatrics is that oftentimes, some of the surgical, um, subspecialties are studied separately. The American Board of Pediatrics typically covers almost every medical specialty, um, within the pediatrics. But they may or may not include some of the surgical specialties depending on what they're looking at. Um, and that may be due to the fact that we have different supervising bodies or perhaps there's Um, a perceived difference in the way that we train or the way that our incentives are structured. Um, so it's just something to note, um, as we think about kind of the workforce issues. There have been several studies of residents who've, uh, in ophthalmology who pursued fellowships, basically looking at either what made you pursue pediatrics or what made you not go into pediatrics and to choose a different fellowship. And uh the number one cited reason for why people didn't pursue a pediatric scholarship is just a lack of clinical interest. And that is a relatively consistent finding regardless of what field you're looking at, that clinical interest is one of the number one drivers for why people choose, um, additional subspecialty training, which is closely followed by um the expected job market within that field. And I, I put here the perceived lower earnings within pediatric ophthalmology because there have been kind of some talks and stuff that's been published that the expected salary that's kind of put out on the internet for what would be expected for a pediatric ophthalmologists is perhaps lower reported than that which has been surveyed from the members of uh kind of the governing board for pediatric ophthalmology. So it's possible that as people are making their fellowship decisions, they're using this um Uh, unrepresentative data to make a decision. Uh, and perhaps it's not actually accurate. There's also uh an expected higher clinic to surgery ratio, meaning that um people have to see more patients in clinic in order to convert to surgical cases relative to some of their adult counterparts. But um this is um somewhat variable depending on What types of surgeries that um people are willing and able to do after fellowship. So that's something that can change depending on how your training goes. Uh, the clinical complexity is what I should say, um, because as children are having longer life expectancy with the advances in medical care over the last couple of decades. Children are becoming more complex. They're having issues that require multidisciplinary care. And so folks are perhaps less interested in trying to work within a team on that front. And then lastly, this is what I think most people think when they're going into taking care of kids, is that this is what their day is going to look like uh from day to day, which, to be fair, does happen and is a fair point. But isn't perhaps representative of what every patient will be like. Now, the workforce issues within pediatric ophthalmology um is not something that's just been talked about amongst pediatricians and amongst the pediatric ophthalmologists. It's actually made its way to the American Academy of Ophthalmology. And this was um a screenshot of the 2023 issues that had brought to the council advisory Committee. Um, for the AAO and you can see here, there were 10, um, 10 recommendations that were sent in in 2023, and two out of the top 10 were related to pediatric ophthalmology workforce issues, one of which was just talking about kind of the issue abroad, and then the other was to address Uh, issues related to reimbursement for Medicaid, which is one of the, what people, um, will cite as being one of the primary drivers for this issue. Um, so there have been a couple of recruitment strategies that have been published again, based on some of the survey data of residents, and they found that early exposure to the field and strong faculty membership within the field was associated with residents more likely to pursue pediatric ophthalmology fellowship. And a higher surgical volume during their pediatric ophthalmology rotation was associated with. Um, pursuing fellowship in the field. Um, one quick side note on that would be that there was a study, again, published by the Boston Group that looked at, um, resident case logs over the last decade from 2010 to 2020, and they looked at the major categories, which would be cataract surgery, uh, strabismus, oculoplastics, cornea, etc. And they found that strabismus surgery was the only major category. Of surgical procedures that went down over that time period, um, compared to some of their counterparts. So it seems that residents are performing less surgery with the last, uh, less divisive surgery, I should say, over the last decade compared to others. Uh, and that may be impacting in part their ability to pursue. Or their interest to pursue pediatrics fellowship. Uh, and then one of the other things that was kind of published would be that we could prioritize matching residents with an expressed interest in pediatrics to departments with larger faculty or with a home fellowship program. Um, there have been studies that have shown that most people who know they want to go into pediatrics, uh, I think it's like 50% of them know that before they even hit residency. And so if you're able to identify that in people early, you may be able to match them with departments who have larger faculties or with a home fellowship program, which gives them kind of the um access to people who are passionate about teaching or research that might foster a career early. And um people who go to programs with more pediatrics faculty or with a home fellowship are more likely to pursue pediatrics scholarship. So if we're able to get these people to places where they might have their interests fostered even further, that might help, um, help the workforce pipeline. And I just put some things here. Lots of people are thinking about this issue, and they've been kind of several unique strategies to try and get around this. I put some screenshots here. Apost has been offering scholarships for 4th year medical students who want to pursue pediatric ophthalmology so that they can do away rotations and get connected with mentors in the field. There are other fellowships that are providing alternative fellowship plans, like this one is from the University of Wisconsin in Madison, and they offer a hybrid fellowship where you still get to do some comprehensive practice, but also learn pediatric ophthalmology. So I think I looked into their website, it's like 15% comp time to do general adult comprehensive ophthalmology. So that your skills don't atrophy over your of fellowship training. And then there have even been people who have proposed things like a medical ophthalmology fellowship for non-ophthalmology residents to do essentially everything that you would do within pediatric ophthalmology outside of operate, and that could be available to pediatrics residents or, uh, you know, like child neurology residents or something like that. Um, which all interesting, but perhaps don't get to the heart of the issue. So in conclusion, uh, the pediatric workforce issues will require multifaceted efforts in order to address both the current problem and the expected problems to come. And pediatric ophthalmology is not alone in its workforce issues, but it may be unique compared to some of the other surgical services based on some of the data that's been put out there, um, as far as our issues and filling positions. And when we think about um people who might be entering the workforce pipeline, having an interest in the, the substance substance of the, the issue is key for fellowship, but there are opportunities that we have along the way to further encourage trainees to pursue um fellowship training. So things that we could consider kind of systemically in addition to just fostering the interest that's already there. So when we go back to our multiple choice question, which of the following has been associated with higher likelihood of pursuing fellowship in pediatric ophthalmology and strabismus? It's actually all of the above except for length of subspecialty rotation during residency, which um based on some of the published data did not have any effect. And with that, I'd be happy to take a couple of questions before we turn it over to Michelle. Uh, sure, Doctor Scott. That was a great talk. Did they, when you in your research, do you find, do they talk about one of the reasons why maybe they're, um, things are clustering in bigger cities is because of the way ped pediatricians are trained, uh, um, presently, uh, because, um, back when I was younger, um, pediatricians. Didn't have strict lines on outpatient clinic practices and inpatient uh uh uh practices, and they also did some neonatal and now they. They don't, uh, they're pretty much, uh, people coming out of the pediatric uh uh um uh residency don't, aren't able to really feel comfortable taking care of newborn, newborns, and, and they don't really like inpatient practices. And so because of the Medicare reimbursement, we're finding in La Crosse we can't get new people because one, it isn't practical to have that division because there isn't enough volume. Uh, um, and so it, it makes it difficult, and I'm wondering if are they thinking about addressing that and trying to get their residents, uh, their graduates more well rounded. Thanks. Yeah, to your point about why people tend to cluster around larger geographic areas, um, some of that is just, uh, you know, it's not unique to pediatrics, um, whether that be pediatric ophthalmology or pediatrics at large. It's just like physicians tend to cluster, uh, in larger population areas. So that's not really an unexpected finding. Um, but to your point, I think there are other things that might contribute systemically to why people concentrate in areas, especially when you think about subspecialty care. A lot of times people who are in subspecialty care may work in larger group practices, which, um, just for condensation of resources, as you mentioned, they tend to be in larger population areas. And so to go out and hang a shingle in the middle of nowhere as a single um sub-specialist without a good referral network or without access to ancillary testing if you need it, like imaging, or, um, you know, or even a surgical center for our case, like you, you tend to have to cluster in areas where you have enough of those resources in place to have a financially viable practice. Especially when you consider the fact that Medicaid reimbursement is so poor at baseline, that if you don't, um, help your overhead cost for some of those other problems, you're, you're probably not going to be able to have a practice for long. Um, others have talked about, you know, potentially putting into effect like a, what they call a wheel and spoke model where you have a home base and then you travel out to other areas. But that is not exactly, um, An attractive option for some people. They don't want to spend 2 hours a day on the road, you know, a couple of times a week to go to rural sites. Um, so it's a problem that, uh, people have thought, oh, can something like telemedicine help us? But I don't know that anyone has an answer for it as of yet. Real quickly, because I know we're short of time, just a few comments. Number one is, thank you for sharing. You know, this is a sort of topic that gets a lot of press on the APOs board and on, uh, you know, state academies and other, other settings. Um, number one, it, it does affect residents. Some, some people wonder if we're selecting medical students and even residents that are a little bit different than the way we selected them 20 years ago in terms of. What their CV is supposed to look like and that may be affecting the number of people going into it. Number 2, it does talk about it, it is important to think about residency exposure during, you know, during the, the how the residencies are created to give early exposure. Um, you also talked about the Knights Templar is the one who, um, supports, uh, residents going or medical students going to a post meeting or, I mean going to other rotations, but they also, um, to the tune of $100,000 send, um, individuals if for with research or interest in going to the. Post mating. So we're trying to find all these creative, um, options to getting early exposure, but I just, I thank you for, for the topic, and I, and one last comment on advocacy. It's so important to consider and support that way. APOS has been looking at developing its own pack, but I don't know that that's going to happen in large part because there's such bigger fish to fry on the national level. It's hard to get a bandwidth to changes. Um, academically. So, um, more to come. I think we have to go to the end of the next topic, but I do thank you for presenting this important topic. Yeah, thanks for your, uh, input, Doctor Bo and. I appreciate it. I will turn things over to Michelle. Um, I'm Michelle. I'm a 4th-year med student here at Mayo and I'll be presenting on glaucoma progression development following secondary intraocular lens surgery. Um, our mentor for this project was Doctor Starr. Our learning objectives for this presentation are to describe rates of glaucoma progression after secondary intraocular lens or SIOL implantation, to recognize risk factors associated with glaucoma progression after SIO implantation, and to determine the relative glaucoma risk associated with various SIOL implantation techniques. Um, I have no disclosures. Um, moving on to our multiple choice question, which secondary intraocular lens implantation technique has higher risk of glaucoma progression? Is it A, anterior chamber IOL, B scleral sutured IOL, C, the Yamane technique, um, which is a, a, a type of um scleral fixated IOL, um, or D, no difference in risk between techniques. We should be able to answer this by the end of this presentation. I want to start off with the case because I think it illustrates why it was important to look into the subject. We had a 71-year-old female with cataract surgery done in the 1990s. She presented to Mayo in February 2018 for a dislocated IOL of the right eye. Relevantly, she does have this history of retinal detachment in 1991 and is now status post cryo and laser in that eye. Upon pre-op evaluation, her IOP was 16, cup disc ratio was normal at 0.3, and visual acuity was 2125. So ultimately, she underwent removal of her IOL, a PPV, and scleral sutured intraocular lens implantation of the right eye. Notably, this was a combined surgery performed by a retina surgeon and an anterior segment surgeon. But unfortunately at post-op month 4, her IOP had increased to 38 and Timolol was started at this time. Um, we'll kind of return back to this at the end. So some background on this topic, uh, multiple techniques have been developed to treat patients with insufficient capsular support. Um, some examples are anterior chamber IOLs, iris fixated IOLs, scleral fixated IOLLs. Um, in this study, we'll look specifically at the Yamane technique, uh, scleral sutured IOLs, and sulcus implantation. However, a few studies have really shown superiority of one technique over the other, and so, as a result, preferred implantation technique is often based on the individual surgeon's preference and and experience, patient characteristics and rate of complications. So specifically regarding glaucoma progression, there is still limited data on that. The purpose of our study was to investigate glaucoma progression in patients receiving SIOL based on surgical approach, including scleral sutured IOL, uh, scleral fixated IOL, anterior chamber IOL, and sulcus implantation. This was a retrospective cohort study including adult patients who received SIOL implantation at Mayo across all three sites between 2014 to 2022. Patients were identified using the OPUS tool, and the most significant exclusion criteria were that they had inadequate follow-up, so less than 6 months of follow-up, and if they had a simultaneous glaucoma surgery at the time of their SIL implantation, they were also excluded. Um, now, to define glaucoma progression, ideally we would have used visual field testing and RNFL, but unfortunately that data wasn't readily available for most of our patients, so we ended up defining. Glaucoma progression kind of in line with previous retrospective studies that looked into this topic. And so we define glaucoma progression as either patients receiving a new glaucoma diagnosis from an ophthalmologist or glaucoma specialist, um, either having to undergo a procedure for IOP control or having um elevation of IOP at least 24 millimeters of mercury or at least 5 above baseline requiring the addition of glaucoma medications with use at at least 6 months post-op. Of course, we collected relevant data including demographics, prior ocular history, indications for Sile implantation procedure technique, and relevant glaucoma follow-up data. Um, and we performed the, the appropriate statistical tests, including, um, univariable and multivariable analysis to determine the effect of possible risk factors associated with glaucoma progression. So moving on to our results, we ended up including 440 eyes in the study, including 195 um scleral sutured IOL eyes, 51 um sclero fixated or the Yamani technique, um, eyes, 91 eyes that underwent ACIOL or anterior chamber IOL, 101 eyes that underwent um implantation to the sulcus, um, and one each of glued and iris fixated IOL. Here are some of their um demographics. Um, they were older patients, of course. Mean age of surgery was 71.3 years, but I want to point your attention specifically upon um this row here. Uh, more patients in the Yamane group, uh, had a greater proportion. of eyes in the Yamani group had prior history of glaucoma going into the surgery, which will be relevant later, but in general there were 144 eyes or 32.7% of all eyes that had prior history of glaucoma prior to their SIL surgery. As for indications for SIO implantation, um, the majority of patients underwent the surgery due to IOL subluxation, and we also marked, um, which surgeries, uh, had simultaneous PPV, and we found that a little over half of patients underwent simultaneous PPV during their SIOL implantation. For post-op results, um, we had 191 eyes in total. That's 43.4% of all eyes have a post-op glaucoma diagnosis. Now this included patients who, you know, went into the surgery with glaucoma, and so, um, specifically, there were 50 new cases of glaucoma after their surgery. We did look into mean IOP and cup disc ratios, like combining or comparing them pre-op to post-op, and There were a few statistically significant results, but we felt that these differences were likely not large enough to be clinically significant. Um, as for glaucoma development, we end up having 42 eyes. Um, that's 9.5% of all eyes have to undergo, uh, some kind of glaucoma treatment procedure post-op. Um, and ultimately, we had 144 eyes, that's 32.7% of all eyes meet our criteria for glaucoma progression. We perform univariable and multivariable analysis, um, and this is the multivariable analysis that's adjusted for the variables below. Um, but these are risk factors potentially associated with glaucoma progression, and we found that specifically history of glaucoma and history of CME were positively associated with glaucoma progression, whereas simultaneous PPV was not associated with glaucoma progression. We also compared the different implantation techniques and found that neither was more associated with glaucoma progression, and this held true even in sub analyses that kind of compared each technique to the other. And just to visualize some of those results, there's, these are Kaplan markers for glaucoma progression. Here on the left, you can clearly see that patients with a history of glaucoma were more likely to have glaucoma progression, whereas on the right, the different implantation techniques were pretty comparable to each other. It might look like the Yamane technique has kind of a higher risk of glaucoma progression, but that's why it's important to note that a higher proportion of patients going into the study had history of glaucoma prior to their surgery. Um, and this kind of, uh, difference, um, went away when we, when we, um, performed the multivariable analysis that adjusted for history of glaucoma. Moving on to our discussion. So as I've kind of mentioned, previous studies have not really reached a consensus on the superiority of one SIOL implantation technique over the other. Um, there was a report by AAO that reviewed 45 articles on IOL implantation techniques in the absence of cellular support, and, um, that study reported postoperative glaucoma rates between 0 to 27.9%. Interestingly enough, the highest rate came from an SSIOL study, a scleral sutured IOL study, but um when they looked individually at studies that compared SSIOL directly to ACIOL, they found comparable rates of glaucoma between the two. I just wanted to touch upon sulcus fixated IOL because a single-piece IOL in that context has been previously linked to secondary pigmentary glaucoma and thus is no longer recommended. So this glaucoma risk has been greatly mitigated with the utilization of three-piece IOL, at least one implanting into the ciliary sulcus. And our study, of course, found no difference in glaucoma progression between SSIOL, Yane, ACIOL, and sulcus fixation techniques. Overall, we had 144 eyes in our study experienced glaucoma progression postoperatively at a mean time of 15.6 months after surgery. Um, and we wanted to look specifically at eyes without history of glaucoma as well. And in this, um, group, there were 76 eyes. That's, um, a little more than a quarter of eyes without history of glaucoma experienced some kind of glaucoma progression postoperatively. Of those, they had 50 eyes that received. A novel glaucoma diagnosis. I want to mention this because although of course rate of progression is lower than that of eyes with a history of glaucoma, um, I think it shows how important it is for these eyes without history of glaucoma to still be monitored for elevated IOP and other signs of glaucoma after their SIOL surgery. For risk factors, we found that history of glaucoma and history of CME were risk factors for glaucoma progression, and we hypothesize here that the effects of steroids, inflammation, perhaps obstruction of the trabecular meshwork by degenerated RBCs, and an absence of a lens to scavenge free radicals may be contributing. We also looked specifically at PPV because previous studies have estimated incidence of glaucoma following PPV to be between 7.9 to 20%. Um, the Pan-American Collaborative Retina Study Group uh concluded in their study that uncomplicated PPV does increase IOP and the proposed mechanism there is that this decreased oxygen tension gradient in the vitreous chamber after PPV results in an inability to reduce. Oxygen derivatives from the cornea and retina. Of course, there are other studies published in the literature that have concluded that PPV does not increase IOP, and our study results kind of fall more in line with those latter studies. That, that being said, I think more investigation is necessary to clarify this risk. Of course, we had study limitations. This was a retrospective study design, as I kind of mentioned earlier. Um, we had to use secondary uh measures for glaucoma progression as most patients didn't receive regular visual field testing or OCT nerve and RNFL. Can't discount the effects of inner surgeon variability. We included procedures performed by 19 ophthalmologists, and along those lines there might have been a learning curve that affected the results of the study. The sclero sutured IOL technique was only first described in 2012, and the Yamane technique was described even more recently in 2017. Um, there might, there was a lack of standardized follow-up, so it's certainly possible that patients who returned to clinic may have had more complications in the first place, which would mean that, that our, um, rate of glaucoma, uh, progression is overestimated. Um, and we're also unable to comment on iris fixated IOL or glued IOL techniques as we only had one eye in each group. Going back to our multiple choice question, which uh SIOL implantation technique has higher risk of glaucoma progression, and of course, our results show that it's, no difference in risk between techniques. Kind of returning back to that case with our 71-year-old lady who had elevated IOP after her SIOL surgery. She was ultimately diagnosed with open angle glaucoma in the post-op period. Her cup disc ratio over time worsened to 0.8, and she had mild VF progression, which I'll show you in a second. Um, but upon last follow-up, she had pretty good IOP control, at least on lietenoprost, and her VA was 21, 2025. Um, so showing you those visual fields here in 2019 versus 2024. Um, notably, they're a little bit harder to interpret because of her history of retinal detachment and the surgeries or the treatment associated with that, but I think you can see that mild progression there, and her OCT in 2024 showed this pretty highly variable RNFL on the right with large peripapillary atrophy. So just to conclude, um, we saw glaucoma progression in 32.7% of all eyes and 25.7% of eyes without prior glaucoma history following secondary IOL implantation. Our risk factors uh for glaucoma progression were history of glaucoma and history of CME, um, but there were no differences in risk of glaucoma progression, at least when comparing surgical technique or PPB status. Of course, I wanted to thank um Doctor Starr for this project, but also um our residents, Dr. Kenny Wong and Doctor Ronnie Hassoon, um, along with my classmate Kunan Sharma, who, who greatly helped this project, and special thanks to CCATs for their statistical support as well. Any questions? Oh, it was nicely done, Michelle. Um, I think that You know, it's kind of the starting point anytime we do a retrospective. Um, obviously big limitations in this is, you know severely limited, as you said, there's not a lot of information in the literature, and so I think this is maybe, you know, something we can do to kind of get the ball rolling. I'm looking at this a little bit in better detail, you know, maybe like how Doctor Isi getsCR NFLs Matt Colles and things like that. We should be looking at some of this stuff before pre and post-op, you know, to see what we're really doing to these patients. Um. But no, nicely done. And, you know, this, this will be impressed soon, which is really exciting and, you know, looking forward to kind of um pushing this forward. Thanks, Doctor Starr. I, I have, I have a question. Um, so did, in your analysis, did, did you account for, um, patients that had pseudoexfoliation syndrome? They, they may not have had glaucoma at the time of lens exchange or secondary implantation, but that would be one question. The second question is, did you sift out the patients that received per periocular triamcinolone? Because, um, I know at least one retina surgeon would routinely do that at the end of every case, whereas my cases, um, I don't routinely do it, so there's gonna be variability there, so. Thanks for that input. I think for that second question, we didn't specifically look into whether um triamcinolone was used during um uh or, you know, perioperatively, and so I think that would be something worth looking into. Um, as for your second question, um, I don't know if we have the, I don't think we have the data here, but in the actual paper we do specify um kind of different types of glaucoma that they, you know, or and different risk factors that these patients had going into surgery. And so we did mark patients with pseudoexfoliation syndrome and in our unit variable analysis did end up looking at all of those different um like ocular risk factors, and it didn't significantly affect the results of the study. But we do have that data. Including axial length, including pseudo foliage and with or without glaucoma. We have a lot, we had over 200 metadata points, um, to examine in the study. Um, it's a great point, Sanjay, about perioerative time set alone. For our diagnosis, we wanted patients with greater than 6 months of IOP elevation. So yeah, certainly if you got Kenalog right away, you may have a short-term IOP plan. Um, but it was likely not sustained, and so our diagnosis was based on during the 6 months of IOP elevation. Any other questions? There's one question in the chat from Doctor Khana. Let's see. And thank you, Kenny for answering as well. Yes, we did not have data readily available on history of myopia, um. And I think Kenny answer it here, um. There were ACIOL, uh. Several, you know, I think a little bit of half did half a simultaneous PPV but we didn't do a specific sub-analysis on whether AL uh On ACIL patients, whether PPV was more associated with glaucoma progression there. Published September 29, 2025 Created by
