Letters
ported complications include vitreous hemorrhage,1 venous occlusions,1 macular ischemia,3 both serous and rhegmatogenous retinal detachments,4 and neovascular glaucoma.5 Although many associated complications imply ischemiaderived pathology, we report the first case, to our knowledge, of Wyburn-Mason syndrome with peripheral retinal neovascularization and successful laser treatment. Hypothetical mechanisms include retinal ischemia from partial thromboses (secondary to increased vascular turbulence), direct compression of venous vasculature from the AVM, or a “steal” phenomenon from differential circulation to the lesion and surrounding retina.1,2 Bloom et al5 reported an AVM case of retinal ischemia, sclerotic vessels, and neovascular glaucoma noted on fluorescein angiography; tractional retinal detachment developed, implying retinal fibrovascularization. In 1989, Mansour et al6 described an isolated retinal AVM with a neovascular tuft months after an episode of retinal hemorrhage, ischemia, and vascular sheathing. Observation is usually indicated owing to the stability of these lesions.1,2 However, intra-arterial embolization has been reported for both intracranial and maxillofacial AVMs.2 In our case, treatment was pursued owing to progression into the optic chiasm and tract that threatened the contralateral eye. Unfortunately, retinal and choroidal infarction and cranial nerve palsies occurred postoperatively. Subsequent visual field testing revealed dense temporal hemianopia in the visually unimpaired eye. Spontaneous retinal and choroidal infarctions have been reported.2 In this case, however, the time course of injury suggests direct complication from embolization therapy. Conclusions | We present 2 novel complications, to our knowledge, of Wyburn-Mason syndrome: peripheral retinal ischemia and neovascularization treated successfully with laser and diffuse retinal and choroidal ischemia after intra-arterial embolization therapy. Both observations and serial ultra– wide-field imaging highlight important aspects of the vascular pathology encountered in managing patients with Wyburn-Mason syndrome. Prethy Rao, MD, MPH Benjamin J. Thomas, MD Yoshihiro Yonekawa, MD Joshua Robinson, MD Antonio Capone Jr, MD Author Affiliations: Department of Ophthalmology, Beaumont Eye Institute, Royal Oak, Michigan (Rao, Thomas, Yonekawa, Capone); Associated Retinal Consultants, Royal Oak, Michigan (Thomas, Yonekawa, Capone); Emory Eye Center, Atlanta, Georgia (Robinson). Corresponding Author: Antonio Capone Jr, MD, Associated Retinal Consultants, 3535 W 13 Mile Rd, Ste 344, Royal Oak, MI 48073 (acaponejr @arcpc.net). Published Online: April 23, 2015. doi:10.1001/jamaophthalmol.2015.0716. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Schmidt D, Pache M, Schumacher M. The congenital unilateral retinocephalic vascular malformation syndrome (Bonnet-Dechaume-Blanc syndrome or 854
Wyburn-Mason syndrome): review of the literature. Surv Ophthalmol. 2008;53 (3):227-249. 2. Dayani PN, Sadun AA. A case report of Wyburn-Mason syndrome and review of the literature. Neuroradiology. 2007;49(5):445-456. 3. Panagiotidis D, Karagiannis D, Tsoumpris I. Spontaneous development of macular ischemia in a case of racemose hemangioma. Clin Ophthalmol. 2011;5: 931-932. 4. Onder HI, Alisan S, Tunc M. Serous retinal detachment and cystoid macular edema in a patient with Wyburn-Mason syndrome. Semin Ophthalmol. 2015;30 (2):154-156. 5. Bloom PA, Laidlaw A, Easty DL. Spontaneous development of retinal ischaemia and rubeosis in eyes with retinal racemose angioma. Br J Ophthalmol. 1993;77(2):124-125. 6. Mansour AM, Wells CG, Jampol LM, Kalina RE. Ocular complications of arteriovenous communications of the retina. Arch Ophthalmol. 1989;107(2): 232-236.
Severe Conjunctival Reaction Following Attempted Corneal Tattooing Corneal tattooing is considered to be a simple and safe outpatient procedure for unsightly leukomatous opacities. Very rarely, serious untoward complications may occur and may warrant additional medical and surgical management. We report a case of severe chemical injury following corneal tattooing and describe our strategy to treat it. Report of a Case | A man in his late 20s with a unilateral corneal opacity in his long-standing blind left eye of 20 years’ duration approached us seeking an alternate cosmetic improvement to colored contact lenses, which he was using for more than 2 years and to which he had become increasingly intolerant. He gave a history of penetrating trauma to his left eye in childhood that was surgically managed then but had no vision thereafter. Visual acuity was 20/20 OD and no light perception OS. On slitlamp examination, the anterior segment of his right eye was normal and the left eye showed a large leukomatous corneal opacity involving the whole cornea with band-shaped keratopathy and exotropia. The conjunctiva and the tear film of both eyes were normal. He was advised to undergo a tattooing procedure for his left corneal opacity to improve cosmesis. Surgery was planned as per our regular protocol to paint the leukomatous opacity with alternating cotton-tipped applicators soaked in 2% platinum chloride and 2% hydrazine hydrate solutions, after epithelial debridement, under topical anesthesia using proparacaine hydrochloride, 0.5%, eyedrops. No additional agents like disinfectants or UV light were used. After application of the first soaks of both reagents, the usual feature of mild pigmentary deposition with microbubble formation was noticed. In addition, significant blanching of the superior conjunctival vessels was noticed initially, which progressed circumferentially. The patient did not note pain. Surgery was immediately stopped. Immediate, copious irrigation with normal saline was maintained for 10 minutes. Since the procedure was performed under topical anesthesia and because of the liquid nature of the reagents, a spillover of the dye into the conjunctiva could not be effectively ruled out. A bandage contact lens was placed after application of a single drop of moxifloxacin hydrochloride, 0.5%, eyedrops.
JAMA Ophthalmology July 2015 Volume 133, Number 7 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
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Letters
Figure 1. Clinical Photographs Depicting the Ischemic, Thickened, and Puckered Conjunctiva and Minimally Stained Cornea on Postoperative Day 1 A
B
A, Superior half. B, Temporal and inferior quadrants.
Figure 2. Clinical Photograph Following Surgery and Histopathological Examination A
B
A, Clinical photograph following surgical excision of the ischemic conjunctival tissue and amniotic membrane transplantation. B, Histopathological examination of the excised tissue showing acanthotic squamous epithelium with areas of epithelial diffuse vascular ectasia (hematoxylin-eosin, original magnification ×40).
On follow-up the next day, the patient presented with mild eyelid edema and moderate pain. A 360° limbal ischemia was noted. The conjunctiva was puckered with marked areas of localized thickening and patchy pigmentation, extending almost 4 to 5 mm from the limbus (Figure 1). Minimal staining of the cornea with a large epithelial defect was present. A diagnosis of severe acute chemical conjunctivitis was made. Copious irrigation with normal saline was again carried out for 20 minutes and the patient was treated with a combination of gatifloxacin, 0.3%, and dexamethasone sodium phosphate, 0.1%, eyedrops 4 times daily along with systemic ascorbic acid (2 g/d). He was seen subsequently on alternate days. Since the ischemic conjunctiva was becoming thicker and the patient noted increasing irritation, surgical excision of the involved conjunctiva with amniotic membrane transplantation was performed (Figure 2A). The patient was subsequently treated with a combination of gatifloxacin, 0.3%, and dexamethasone sodium phosphate, 0.1%, eyedrops 4 times daily for 3 additional weeks, by which time he had obtained symptomatic relief. Histopathological examination with hematoxylin-eosin staining of the excised tissue revealed acanthotic squamous epithelium with areas of epithelial diffuse vascular ectasia (Figure 2B). Discussion | Corneal tattooing is a simple, useful treatment strategy for unsightly corneal opacities in eyes without visual potential, especially those that are intolerant to cosmetic contact lenses.1 jamaophthalmology.com
Our patient developed an unexpected severe toxic reaction in the conjunctiva following the dye application on the cornea with possible spillover of the dye into the conjunctiva. Even though complications such as corneal melting,2 granulomatous keratitis,3 persistent epithelial defects, ulceration, and iridocyclitis have been reported in the literature,4,5 intraoperative toxic conjunctivitis of this magnitude has not been reported to our knowledge. Of interest is the fact that the reagents used were in recommended concentrations and none of the previous patients treated using the same buffer stock had any such reaction. Hence, intraoperative medication error is unlikely. Sayali Pradhan, MD, FICO Manoranjan Das, MD Arun Kumar Panigrahi, MD N. Venkatesh Prajna, MD, FRCS Author Affiliations: Cornea Services, Aravind Eye Hospital, Madurai, India. Corresponding Author: N. Venkatesh Prajna, MD, FRCS, Cornea Services, Aravind Eye Hospital, 1, Anna Nagar, Madurai, Tamil Nadu 625 020, India (prajna @aravind.org). Published Online: April 30, 2015. doi:10.1001/jamaophthalmol.2015.0934. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Pitz S, Jahn R, Frisch L, Duis A, Pfeiffer N. Corneal tattooing: an alternative treatment for disfiguring corneal scars. Br J Ophthalmol. 2002;86(4):397-399. 2. Al-Mezaine HS. Corneal stromal melting after corneal tattooing with platinum chloride. Saudi J Ophthalmol. 2007;21(2):124-126. (Reprinted) JAMA Ophthalmology July 2015 Volume 133, Number 7
Copyright 2015 American Medical Association. All rights reserved.
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855
Letters
3. Sharma A, Gupta P, Dogra MR, Hidayat AA, Gupta A. Granulomatous keratitis following corneal tattooing. Indian J Ophthalmol. 2003;51(3):265-267. 4. van der Velden/Samderubun EM, Kok JH. Dermatography as a modern treatment for coloring leucoma corneae. Cornea. 1994;13(4):349-353. 5. Panda A, Mohan M, Chawdhary S. Corneal tattooing: experiences with “lamellar pocket procedure.” Indian J Ophthalmol. 1984;32(5):408-411.
COMMENT & RESPONSE
Effect of Conversion to Immediate Sequential Cataract Surgery on Ambulatory Surgery Centers in the United States in the Cost-Analysis Model To the Editor An additional comment on the cost-analysis model comparing immediate sequential cataract surgery (ISCS) with delayed sequential cataract surgery (DSCS) in the United States from the societal and physician perspectives would be beneficial.1,2 Physicians were shown to have a decline in physician practice–derived income with a conversion to ISCS. 2 Because many physicians have an ownership stake in ambulatory surgery centers (ASCs), an additional negative impact on physicians’ incomes could occur if ASCs experience a decline in profitability from ISCS conversion. The cost-analysis model was updated to examine the financial impact of ISCS conversion on ASCs. The update used Medicare cataract surgery volume estimates, 1 Medic are 2012 ASC c ataract surgery fees ($874.59), and estimates of expense differences between ISCS and DSCS for a West Tennessee multispecialty ASC using the previous model’s data1,2 along with data obtained from the ASC. A 75% ISCS eligibility base case level was used.1,2 Eight DSCS cataract operations and 10 ISCS cataract operations per 4.5-hour half day were based on literature
data.3 The 2012 surgical supply costs of DSCS and ISCS were compared using a microcosting method. Analysis of operating room (OR) personnel costs used a 1- and 2-OR scenario for DSCS and a 1-OR scenario for ISCS. A minimum and maximum cost method was used for preoperative, postoperative, and medical record personnel costs. In the base case, the ASC had a $168 358.58 decline in revenue. A potential expense reduction of $16 891.86 to $36 404.98 using the minimum method or $30 288.17 to $49 801.29 using the maximum method did not offset this revenue loss. The cataract surgery supply cost reductions ($6.41/eye) and medical record cost reductions were minimal for ISCS. Total preoperative, postoperative, and OR personnel cost reductions were $19.96 to $45.30 per eye using the minimum method and $32.56 to $57.90 per eye using the maximum method and accounted for most ISCS cost reductions. Fixed costs were equivalent for ISCS and DSCS. A net margin loss of $118 557.29 to $151 466.71 occurred. No adjustment was made for increased OR availability with ISCS; however, significant additional surgical volume, if available, could potentially offset this margin loss. The ISCS eligibility level sensitivity analysis results are summarized in the Table. With conversion to ISCS, ASCs will have a profit margin decrease. This will affect ASC physician owners’ incomes negatively, in addition to the negative financial impact on their practice incomes from ISCS conversion. Our current reimbursement system’s dual negative financial impact could increase the risk of gaming, supplier-induced demand, and physician resistance to ISCS with financial considerations trumping patient benefits. Sean T. Neel, MD, MSc
Table. Base Case and Sensitivity Analysis of Revenue Lost, Potential Expense Reductions (Minimum and Maximum Methods), and Net Margin Gain or Loss With Conversion to ISCS From DSCSa ISCS Eligibility Measure
25%
50%
Base Case, 75%
100%
Revenue, $ DSCS
223 895.04
449 539.26
673 434.30
899 078.52
ISCS
167 921.28
337 154.45
505 075.73
674 308.89
Change with ISCS
−55 973.76
−112 384.82
−168 358.58
−224 769.63
Abbreviations: DSCS, delayed sequential cataract surgery; ISCS, immediate sequential cataract surgery; OR, operating room. a
Results may vary slightly secondary to rounding.
b
Minimum revenue offset method includes the reduction from performing more cases with ISCS (10 cases) than with DSCS (8 cases).
c
Expense reductions include preoperative, postoperative, and OR personnel; all supplies; and medical record personnel costs.
d
Maximum revenue offset method additionally includes a reduction in the number of preoperative and postoperative personnel as well as a 33% reduction in medical record personnel costs. One OR was used for ISCS; 1 or 2 ORs were used for DSCS as many physicians go back and forth between rooms.
Minimum revenue offset methodb Total expense reduction, $c 1 OR 2 ORs
5616.00
11 275.87
16 891.86
22 041.48
12 103.47
24 301.50
36 404.98
48 092.75
Net margin change with ISCS conversion, $ 1 OR
−50 357.76
−101 108.95
−151 466.71
−202 728.15
2 ORs
−43 870.29
−88 083.31
−131 953.60
−176 676.88
Maximum revenue offset methodd Total expense reduction, $c 1 OR
13 550.79
21 952.04
30 288.17
38 689.43
2 ORs
20 038.27
34 977.68
49 801.29
64 740.70
1 OR
−42 422.97
−90 432.77
−138 070.40
−186 080.20
2 ORs
−35 935.49
−77 407.13
−118 557.29
−160 028.93
Net margin change with ISCS conversion, $
856
JAMA Ophthalmology July 2015 Volume 133, Number 7 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Universite Laval User on 11/03/2015
jamaophthalmology.com
ported complications include vitreous hemorrhage,1 venous occlusions,1 macular ischemia,3 both serous and rhegmatogenous retinal detachments,4 and neovascular glaucoma.5 Although many associated complications imply ischemiaderived pathology, we report the first case, to our knowledge, of Wyburn-Mason syndrome with peripheral retinal neovascularization and successful laser treatment. Hypothetical mechanisms include retinal ischemia from partial thromboses (secondary to increased vascular turbulence), direct compression of venous vasculature from the AVM, or a “steal” phenomenon from differential circulation to the lesion and surrounding retina.1,2 Bloom et al5 reported an AVM case of retinal ischemia, sclerotic vessels, and neovascular glaucoma noted on fluorescein angiography; tractional retinal detachment developed, implying retinal fibrovascularization. In 1989, Mansour et al6 described an isolated retinal AVM with a neovascular tuft months after an episode of retinal hemorrhage, ischemia, and vascular sheathing. Observation is usually indicated owing to the stability of these lesions.1,2 However, intra-arterial embolization has been reported for both intracranial and maxillofacial AVMs.2 In our case, treatment was pursued owing to progression into the optic chiasm and tract that threatened the contralateral eye. Unfortunately, retinal and choroidal infarction and cranial nerve palsies occurred postoperatively. Subsequent visual field testing revealed dense temporal hemianopia in the visually unimpaired eye. Spontaneous retinal and choroidal infarctions have been reported.2 In this case, however, the time course of injury suggests direct complication from embolization therapy. Conclusions | We present 2 novel complications, to our knowledge, of Wyburn-Mason syndrome: peripheral retinal ischemia and neovascularization treated successfully with laser and diffuse retinal and choroidal ischemia after intra-arterial embolization therapy. Both observations and serial ultra– wide-field imaging highlight important aspects of the vascular pathology encountered in managing patients with Wyburn-Mason syndrome. Prethy Rao, MD, MPH Benjamin J. Thomas, MD Yoshihiro Yonekawa, MD Joshua Robinson, MD Antonio Capone Jr, MD Author Affiliations: Department of Ophthalmology, Beaumont Eye Institute, Royal Oak, Michigan (Rao, Thomas, Yonekawa, Capone); Associated Retinal Consultants, Royal Oak, Michigan (Thomas, Yonekawa, Capone); Emory Eye Center, Atlanta, Georgia (Robinson). Corresponding Author: Antonio Capone Jr, MD, Associated Retinal Consultants, 3535 W 13 Mile Rd, Ste 344, Royal Oak, MI 48073 (acaponejr @arcpc.net). Published Online: April 23, 2015. doi:10.1001/jamaophthalmol.2015.0716. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Schmidt D, Pache M, Schumacher M. The congenital unilateral retinocephalic vascular malformation syndrome (Bonnet-Dechaume-Blanc syndrome or 854
Wyburn-Mason syndrome): review of the literature. Surv Ophthalmol. 2008;53 (3):227-249. 2. Dayani PN, Sadun AA. A case report of Wyburn-Mason syndrome and review of the literature. Neuroradiology. 2007;49(5):445-456. 3. Panagiotidis D, Karagiannis D, Tsoumpris I. Spontaneous development of macular ischemia in a case of racemose hemangioma. Clin Ophthalmol. 2011;5: 931-932. 4. Onder HI, Alisan S, Tunc M. Serous retinal detachment and cystoid macular edema in a patient with Wyburn-Mason syndrome. Semin Ophthalmol. 2015;30 (2):154-156. 5. Bloom PA, Laidlaw A, Easty DL. Spontaneous development of retinal ischaemia and rubeosis in eyes with retinal racemose angioma. Br J Ophthalmol. 1993;77(2):124-125. 6. Mansour AM, Wells CG, Jampol LM, Kalina RE. Ocular complications of arteriovenous communications of the retina. Arch Ophthalmol. 1989;107(2): 232-236.
Severe Conjunctival Reaction Following Attempted Corneal Tattooing Corneal tattooing is considered to be a simple and safe outpatient procedure for unsightly leukomatous opacities. Very rarely, serious untoward complications may occur and may warrant additional medical and surgical management. We report a case of severe chemical injury following corneal tattooing and describe our strategy to treat it. Report of a Case | A man in his late 20s with a unilateral corneal opacity in his long-standing blind left eye of 20 years’ duration approached us seeking an alternate cosmetic improvement to colored contact lenses, which he was using for more than 2 years and to which he had become increasingly intolerant. He gave a history of penetrating trauma to his left eye in childhood that was surgically managed then but had no vision thereafter. Visual acuity was 20/20 OD and no light perception OS. On slitlamp examination, the anterior segment of his right eye was normal and the left eye showed a large leukomatous corneal opacity involving the whole cornea with band-shaped keratopathy and exotropia. The conjunctiva and the tear film of both eyes were normal. He was advised to undergo a tattooing procedure for his left corneal opacity to improve cosmesis. Surgery was planned as per our regular protocol to paint the leukomatous opacity with alternating cotton-tipped applicators soaked in 2% platinum chloride and 2% hydrazine hydrate solutions, after epithelial debridement, under topical anesthesia using proparacaine hydrochloride, 0.5%, eyedrops. No additional agents like disinfectants or UV light were used. After application of the first soaks of both reagents, the usual feature of mild pigmentary deposition with microbubble formation was noticed. In addition, significant blanching of the superior conjunctival vessels was noticed initially, which progressed circumferentially. The patient did not note pain. Surgery was immediately stopped. Immediate, copious irrigation with normal saline was maintained for 10 minutes. Since the procedure was performed under topical anesthesia and because of the liquid nature of the reagents, a spillover of the dye into the conjunctiva could not be effectively ruled out. A bandage contact lens was placed after application of a single drop of moxifloxacin hydrochloride, 0.5%, eyedrops.
JAMA Ophthalmology July 2015 Volume 133, Number 7 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
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Letters
Figure 1. Clinical Photographs Depicting the Ischemic, Thickened, and Puckered Conjunctiva and Minimally Stained Cornea on Postoperative Day 1 A
B
A, Superior half. B, Temporal and inferior quadrants.
Figure 2. Clinical Photograph Following Surgery and Histopathological Examination A
B
A, Clinical photograph following surgical excision of the ischemic conjunctival tissue and amniotic membrane transplantation. B, Histopathological examination of the excised tissue showing acanthotic squamous epithelium with areas of epithelial diffuse vascular ectasia (hematoxylin-eosin, original magnification ×40).
On follow-up the next day, the patient presented with mild eyelid edema and moderate pain. A 360° limbal ischemia was noted. The conjunctiva was puckered with marked areas of localized thickening and patchy pigmentation, extending almost 4 to 5 mm from the limbus (Figure 1). Minimal staining of the cornea with a large epithelial defect was present. A diagnosis of severe acute chemical conjunctivitis was made. Copious irrigation with normal saline was again carried out for 20 minutes and the patient was treated with a combination of gatifloxacin, 0.3%, and dexamethasone sodium phosphate, 0.1%, eyedrops 4 times daily along with systemic ascorbic acid (2 g/d). He was seen subsequently on alternate days. Since the ischemic conjunctiva was becoming thicker and the patient noted increasing irritation, surgical excision of the involved conjunctiva with amniotic membrane transplantation was performed (Figure 2A). The patient was subsequently treated with a combination of gatifloxacin, 0.3%, and dexamethasone sodium phosphate, 0.1%, eyedrops 4 times daily for 3 additional weeks, by which time he had obtained symptomatic relief. Histopathological examination with hematoxylin-eosin staining of the excised tissue revealed acanthotic squamous epithelium with areas of epithelial diffuse vascular ectasia (Figure 2B). Discussion | Corneal tattooing is a simple, useful treatment strategy for unsightly corneal opacities in eyes without visual potential, especially those that are intolerant to cosmetic contact lenses.1 jamaophthalmology.com
Our patient developed an unexpected severe toxic reaction in the conjunctiva following the dye application on the cornea with possible spillover of the dye into the conjunctiva. Even though complications such as corneal melting,2 granulomatous keratitis,3 persistent epithelial defects, ulceration, and iridocyclitis have been reported in the literature,4,5 intraoperative toxic conjunctivitis of this magnitude has not been reported to our knowledge. Of interest is the fact that the reagents used were in recommended concentrations and none of the previous patients treated using the same buffer stock had any such reaction. Hence, intraoperative medication error is unlikely. Sayali Pradhan, MD, FICO Manoranjan Das, MD Arun Kumar Panigrahi, MD N. Venkatesh Prajna, MD, FRCS Author Affiliations: Cornea Services, Aravind Eye Hospital, Madurai, India. Corresponding Author: N. Venkatesh Prajna, MD, FRCS, Cornea Services, Aravind Eye Hospital, 1, Anna Nagar, Madurai, Tamil Nadu 625 020, India (prajna @aravind.org). Published Online: April 30, 2015. doi:10.1001/jamaophthalmol.2015.0934. Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Pitz S, Jahn R, Frisch L, Duis A, Pfeiffer N. Corneal tattooing: an alternative treatment for disfiguring corneal scars. Br J Ophthalmol. 2002;86(4):397-399. 2. Al-Mezaine HS. Corneal stromal melting after corneal tattooing with platinum chloride. Saudi J Ophthalmol. 2007;21(2):124-126. (Reprinted) JAMA Ophthalmology July 2015 Volume 133, Number 7
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Universite Laval User on 11/03/2015
855
Letters
3. Sharma A, Gupta P, Dogra MR, Hidayat AA, Gupta A. Granulomatous keratitis following corneal tattooing. Indian J Ophthalmol. 2003;51(3):265-267. 4. van der Velden/Samderubun EM, Kok JH. Dermatography as a modern treatment for coloring leucoma corneae. Cornea. 1994;13(4):349-353. 5. Panda A, Mohan M, Chawdhary S. Corneal tattooing: experiences with “lamellar pocket procedure.” Indian J Ophthalmol. 1984;32(5):408-411.
COMMENT & RESPONSE
Effect of Conversion to Immediate Sequential Cataract Surgery on Ambulatory Surgery Centers in the United States in the Cost-Analysis Model To the Editor An additional comment on the cost-analysis model comparing immediate sequential cataract surgery (ISCS) with delayed sequential cataract surgery (DSCS) in the United States from the societal and physician perspectives would be beneficial.1,2 Physicians were shown to have a decline in physician practice–derived income with a conversion to ISCS. 2 Because many physicians have an ownership stake in ambulatory surgery centers (ASCs), an additional negative impact on physicians’ incomes could occur if ASCs experience a decline in profitability from ISCS conversion. The cost-analysis model was updated to examine the financial impact of ISCS conversion on ASCs. The update used Medicare cataract surgery volume estimates, 1 Medic are 2012 ASC c ataract surgery fees ($874.59), and estimates of expense differences between ISCS and DSCS for a West Tennessee multispecialty ASC using the previous model’s data1,2 along with data obtained from the ASC. A 75% ISCS eligibility base case level was used.1,2 Eight DSCS cataract operations and 10 ISCS cataract operations per 4.5-hour half day were based on literature
data.3 The 2012 surgical supply costs of DSCS and ISCS were compared using a microcosting method. Analysis of operating room (OR) personnel costs used a 1- and 2-OR scenario for DSCS and a 1-OR scenario for ISCS. A minimum and maximum cost method was used for preoperative, postoperative, and medical record personnel costs. In the base case, the ASC had a $168 358.58 decline in revenue. A potential expense reduction of $16 891.86 to $36 404.98 using the minimum method or $30 288.17 to $49 801.29 using the maximum method did not offset this revenue loss. The cataract surgery supply cost reductions ($6.41/eye) and medical record cost reductions were minimal for ISCS. Total preoperative, postoperative, and OR personnel cost reductions were $19.96 to $45.30 per eye using the minimum method and $32.56 to $57.90 per eye using the maximum method and accounted for most ISCS cost reductions. Fixed costs were equivalent for ISCS and DSCS. A net margin loss of $118 557.29 to $151 466.71 occurred. No adjustment was made for increased OR availability with ISCS; however, significant additional surgical volume, if available, could potentially offset this margin loss. The ISCS eligibility level sensitivity analysis results are summarized in the Table. With conversion to ISCS, ASCs will have a profit margin decrease. This will affect ASC physician owners’ incomes negatively, in addition to the negative financial impact on their practice incomes from ISCS conversion. Our current reimbursement system’s dual negative financial impact could increase the risk of gaming, supplier-induced demand, and physician resistance to ISCS with financial considerations trumping patient benefits. Sean T. Neel, MD, MSc
Table. Base Case and Sensitivity Analysis of Revenue Lost, Potential Expense Reductions (Minimum and Maximum Methods), and Net Margin Gain or Loss With Conversion to ISCS From DSCSa ISCS Eligibility Measure
25%
50%
Base Case, 75%
100%
Revenue, $ DSCS
223 895.04
449 539.26
673 434.30
899 078.52
ISCS
167 921.28
337 154.45
505 075.73
674 308.89
Change with ISCS
−55 973.76
−112 384.82
−168 358.58
−224 769.63
Abbreviations: DSCS, delayed sequential cataract surgery; ISCS, immediate sequential cataract surgery; OR, operating room. a
Results may vary slightly secondary to rounding.
b
Minimum revenue offset method includes the reduction from performing more cases with ISCS (10 cases) than with DSCS (8 cases).
c
Expense reductions include preoperative, postoperative, and OR personnel; all supplies; and medical record personnel costs.
d
Maximum revenue offset method additionally includes a reduction in the number of preoperative and postoperative personnel as well as a 33% reduction in medical record personnel costs. One OR was used for ISCS; 1 or 2 ORs were used for DSCS as many physicians go back and forth between rooms.
Minimum revenue offset methodb Total expense reduction, $c 1 OR 2 ORs
5616.00
11 275.87
16 891.86
22 041.48
12 103.47
24 301.50
36 404.98
48 092.75
Net margin change with ISCS conversion, $ 1 OR
−50 357.76
−101 108.95
−151 466.71
−202 728.15
2 ORs
−43 870.29
−88 083.31
−131 953.60
−176 676.88
Maximum revenue offset methodd Total expense reduction, $c 1 OR
13 550.79
21 952.04
30 288.17
38 689.43
2 ORs
20 038.27
34 977.68
49 801.29
64 740.70
1 OR
−42 422.97
−90 432.77
−138 070.40
−186 080.20
2 ORs
−35 935.49
−77 407.13
−118 557.29
−160 028.93
Net margin change with ISCS conversion, $
856
JAMA Ophthalmology July 2015 Volume 133, Number 7 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archopht.jamanetwork.com/ by a Universite Laval User on 11/03/2015
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