Cole Eye Institute - Cleveland Clinic

1
Cole Eye
Institute
Outcomes | 2007

Patients First

1
Outcomes 2007
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.
Cole Eye Institute

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
2

what’s inside
Chairman’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

Chairman’s Letter
The 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
Outcomes 2007 4

Institute Overview
At 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-ofthe-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.
5
Cole Eye Institute

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
Outcomes 2007 6

Cataract Surgery
7
Complications during Cataract Surgery
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.
N = 2,412
Complications during Cataract Surgery
10000
8000
6000
4000
2000
0
Postoperative Complications
1.5% Posterior Capsule Tear
0.8% Zonular Dialysis
0.1% Iris Trauma
97.6% None
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.
N = 1,644
1.6% Cystoid Macular Edema
0.4% Epiretinal Membrane
0.1% Retinal Detachment
0.1% Vitreous Hemorrhage
97.8% None
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.
Cole Eye Institute

Difference Between Actual and Target Refractive Error
Percent
60
50
100
40
30 80
20 60
10 40
0
20
0
After cataract Text surgery, 7.5 point the Roman great majority of patients achieved a refractive outcome that was near the anticipated
refractive error. Axis labels Regardless 7.5 Bold 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.
Axis line weight = 1
Line weight for bars and pie pieces = 0.5
Use stacked bar sequence shown
Change in Visual Acuity by Ocular Comorbidity
ETDRS* Visual Acuity Score
* Early Treatment of Diabetic Retinopathy Study
100
80
60
40
20
0
2 -2 to -1 -1 to 0
Dashed line weight = 0.75 Dash 2 Gap 1
None Cornea Glaucoma Retina Uveitis Other
Text 7.5 point Roman
Axis labels 7.5 Bold
Diopters
Ocular Comorbidities
0 to +1 +1 to +2 2
Preop VA
Postop VA
The goal of Axis cataract line weight surgery = 1is
to improve visual acuity, which was accomplished in the vast majority of our
patients. The Line mean weight improvement for bars and in pie the pieces ETDRS = 0.5 visual acuity score following cataract surgery was 14.5 letters,
representing Use an stacked improvement bar sequence in vision shown 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 Dashed including line weight corneal = 0.75 disease, Dash retinal 2 Gap disease, 1 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.
Outcomes 2007 8

Cornea Surgery
Corneal 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.
Yes
No
Graft Clear at 3 Months
Percent Surgeries
100
80
60
40
20
0
Anterior
Lamellar
Posterior
Lamellar
Type of Procedure
Penetrating
Keratoplasty
9 Cole Eye Institute

4000
2000
0
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
Intraoperative
have benefited
Complications
from this procedure, with excellent visual and anatomical results.
Intraoperative Complications
N = 223
0.4% Choroidal Hemorrhage
0.4% Corneal Graft Edema
99.2% None
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.
Outcomes 2007 10

Postoperative Complications
80
60
40
20
0
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.
Change in Visual Acuity by Procedure
80
60
40
20
0
N = 222
ETDRS Visual Acuity Score
0.5% Retinal Detachment 0.5% Graft Failure
Keratoprosthesis
Text 7.5 point Roman
Axis labels 7.5 Bold
Lamellar
Keratoplasty
Type of Procedure
Penetrating
Keratoplasty
Axis line weight = 1
Line weight for bars and pie pieces = 0.5
Use stacked bar sequence shown
Dashed line weight = 0.75 Dash 2 Gap 1
0.5% Persistent Epithelial Defect
0.9% Other
97.7% None
Preop VA
Postop VA
11 Cole Eye Institute

Glaucoma Surgery
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.
Surgeries Performed in Patients with ≥ 3 Months Follow-up Data
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
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,
Outcomes 2007 12

Change in Intraocular Pressure
Intraocular Pressure (mm Hg)
40
30
20
10
0
60
50
40
30
20
10
0
Trabeculectomy Glaucoma Implant
Text 7.5 point Roman
Axis labels 7.5 Bold
Axis line weight = 1
Line weight for bars and pie pieces = 0.5
Use stacked bar sequence shown
Dashed line weight = 0.75 Dash 2 Gap 1
Visual Acuity at 3 Months
ETDRS Visual Acuity Score
60
50
40
30
20
10
0
Preop VA Postop VA
Text 7.5 point Roman
Axis labels 7.5 Bold
Axis line weight = 1
Line weight for bars and pie pieces = 0.5
Use stacked bar sequence shown
Dashed line weight = 0.75 Dash 2 Gap 1
Preop IOP
Postop IOP
13 Cole Eye Institute

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.
Intraoperative Complications
N = 443
4000
2000
0
Intraoperative Complications
Postoperative Complications
N = 443
10000
8000
6000
4000
2000
0
1.1% Button Hole
0.9% Hyphema
0.2% Choroidal Effusion
0.2% Other
Postoperative Complications
97.7% None
0.5% Hypotony
0.2% Implant Exposure
99.1% None
Outcomes 2007 14

Oculoplastic Surgery
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.
Distribution of Oculoplastic Surgeries
N = 792
18.3% Lacrimal
10.5% Orbital
71.2% Eyelid
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.
Postoperative Complications of Eyelid Surgery
5.5% Need Revision
0.9% Need Reoperation
4.5% Worsened Dry Eye
0.9% Other
88.2% None
15 Cole Eye Institute

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 Eyelid Symmetry
N = 564
3.4% Good
96.6% Excellent
Postoperative Complications of Lacrimal Surgery
N = 49
4.1% Need Revision
4.1% Need Reoperation
2.0% Other
Other, 2.0%
N = 49
Lacrimal surgery outcome measures included intraoperative complications None, 89.8% 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.
89.8% None
Outcomes 2007 16

Ocular Oncology Surgery
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.
Treatment of Uveal Melanoma
N = 71
Treatment of Recurrent 11% Uveal Enucleation Melanoma
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 Recurrent Uveal Melanoma
N = 5
40%
Plaque
Radiotherapy
89% Plaque Radiotherapy
60% Enucleation
17 Cole Eye Institute

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
Outcomes 2007 18

Refractive Surgery
100
Outcomes 80 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) 60 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
40
is the proportion of patients whose final refractive error falls within ± 0.5 diopters of the
intended 20 result.
Below 0are
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 PRK
Vision Correction after IntraLASIK and PRK
Low Myopia Low Myopia (0 (0 to to ≤3 -3 Diopters Sphere, Sphere, ≤ 0.5 D ≤ Cylinder) 0.5 D Cylinder)
Percent
100
80
60
40
20
0
0.5 D
Text 7.5 point Roman
Axis labels 7.5 Bold
3 months N = 137
12 months N = 36
20/15 20/20 20/40
Vision Correction Vision after Correction IntraLASIK after IntraLASIK and and PRK
Moderate Myopic Astigmatism (-3 to -6 Diopters Sphere ≥ 0.75 D Cylinder)
Moderate Myopic Axis line weight Astigmatism = 1 (-3 to -6 Diopters Sphere,
Line weight for bars and pie pieces = 0.5
≥0.75 D Cylinder)
Percent
100
80
60
40
20
0
Use stacked bar sequence shown
3 months N = 141
Dashed line weight = 0.75 Dash 2 12 Gap months 1 N = 73
0.5 D
Text 7.5 point Roman
Axis labels 7.5 Bold
20/15 20/20 20/40
19
Axis line weight = 1
Line weight for bars and pie pieces = 0.5
Cole Eye Institute
100
80
60
40
20
0

Greater than 80 percent of myopic eyes achieved uncorrected visual acuity of 20/20 or better, and about 95 percent had a refractive 0 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 High Myopia (> after -6 Diopters IntraLASIK Sphere ≥ and 0.75 D PRK Cylinder)
High Myopia (>-6 Diopters Sphere, ≥ 0.75 D Cylinder)
Percent
100
80
60
40
20
0
Vision Correction after IntraLASIK and PRK
Use stacked bar sequence shown
Hyperopia (0 to +6 Diopters Sphere, All Eyes)
Percent
100
80
60
40
20
0
0.5 D
Text 7.5 point Roman
Axis labels 7.5 Bold
Axis line weight = 1
Line weight for bars and pie pieces = 0.5
Dashed line weight = 0.75 Dash 2 Gap 1
0.5 D
Vision Correction after IntraLASIK and PRK
3 months N = 41
12 months N = 19
20/15 20/20 20/40
3 months N = 26
20/15 20/20 20/40
Outcomes 2007 20
100
80
60
40
20

Vitreoretinal Surgery
60
50
The vitreoretinal department at the Cole Eye Institute 40 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
30
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. 20
10
From January 2006 through September 2007, the 0team
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.
Change in Visual Acuity
ETDRS Visual Acuity Score
60
50
40
30
20
10
0
Preop VA Postop VA
Text 7.5 point Roman
Vision Improved Axis labels by 7.5 > 14 Bold ETDRS Letters by Indication for Surgery
Change in Visual Acuity by Indication for Surgery
Axis line weight = 1
Line weight for bars and pie pieces = 0.5
ETDRS Score
Use stacked bar sequence shown
80
Preop Dashed VA line weight = 0.75 Dash 2 Gap 1
Postop VA
60
40
20
0
Macular
Hole
Rhegmatogenous
Retinal
Detachment
Diabetic
Vitrectomy
Indication for Surgery
Epiretinal
Membrane
Dissection
21 Cole Eye Institute

30
During the above mentioned time period, the vitreoretinal 20 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
10
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 0 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
ETDRS Score
60
50
40
30
20
10
Text 7.5 point Roman
Vision Improved Axis labels by > 7.5 14 Bold ETDRS Letters by Indication for Surgery
Vision Improved by > 14 ETDRS Letters by Indication for Surgery
Axis line weight = 1
Line weight for bars and pie pieces = 0.5
ETDRS Score
Use stacked bar sequence shown
80
Preop Dashed VA line weight = 0.75 Dash 2 Gap 1
Postop VA
60
40
20
0
0
60
50
40
Macular
Hole
Vision Improved by > 14 ETDRS Letters
Yes No
Rhegmatogenous
Retinal
Detachment
Diabetic
Vitrectomy
Indication for Surgery
Epiretinal
Membrane
Dissection
Outcomes 2007 Text 7.5 point Roman
Axis labels 7.5 Bold
22

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).
Intraoperative Complications
N=1,010
Percent
100
80
60
40
20
0
Macular
Hole
Rhegmatogenous
Retinal
Detachment
Indication for Surgery
Postoperative Complications
N=1,010
Percent
100
80
60
40
20
0
Macular
Hole
Rhegmatogenous
Retinal
Detachment
Diabetic
Vitrectomy
Diabetic
Vitrectomy
Indication for Surgery
Epiretinal
Membrane
Epiretinal
Membrane
None
Hyphema
Vitreous Hemorrage
Iatrogenic Break
Choroidal Hemorrhage
Other
None
Hyphema
Vitreous Hemorrage
Iatrogenic Break
Choroidal Hemorrhage
Other
23 Cole Eye Institute

0
Strabismus Surgery
20
10
Adult Strabismus Cases
Number of Surgeries
50
40
30
20
80
10
60
0
40
20
0
Esotropia Exotropia Dissociated
Vertical
Deviations
Text 7.5 point Roman
Axis labels 7.5 Bold
IVth Nerve
Palsy
Diagnosis
VIth Nerve Hypertropia Thyroid
Palsy
Eye
Disease
Axis line weight = 1
Line weight for bars and pie pieces = 0.5
Pediatric Strabismus Cases
Use stacked bar sequence shown
Number of Surgeries
Dashed line weight = 0.75 Dash 2 Gap 1
80
60
40
20
0
Esotropia Exotropia IVth Nerve
Palsy
Text 7.5 point Roman
Axis labels 7.5 Bold
Dissociated
Vertical
Deviations
Diagnosis
Axis line weight = 1
Line weight for bars and pie pieces = 0.5
Use stacked bar sequence shown
VIth Nerve Hypertropia Nystagmus
Palsy
Dashed line weight = 0.75 Dash 2 Gap 1
Outcomes 2007 24

Surgical Outcome for Adults
N=151
19% Poor (Overcorrected
or undercorrected)
Surgical Outcome for Children
N=97
6% Poor (Overcorrected
or undercorrected)
Surgical Outcome for Adults
Surgical Outcome for Children
81% Good (Diplopia disappeared
and/or anomalous head
position resolved)
94% Good (Deviation < 10 prism
diopters in primary position
and/or anomalous head
position resolved)
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.
25 Cole Eye Institute

Patient Experience
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.
Overall Rating of Care 2007
Overall Rating of Provider Care 2007
Would Recommend Provider 2007
Percent
100
80
60
40
20
0
Percent
100
80
60
40
20
0
Percent
100
80
60
40
20
0
Excellent
Excellent
Extremely
Likely
N=1,622
Very Good Good Fair Poor
N=1,621
Very Good Good Fair Poor
Very
Likely
Somewhat
Likely
Somewhat
Unlikely
N=1,579
Very
Unlikely
Outcomes 2007 26

Innovations
Retinopathy 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.
27
“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).
Cole Eye Institute

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 Repair
Müller 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 muscleconjunctiva
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.
Outcomes 2007 28

Advanced Corneal Imaging Sheds Light on Refractive
Shift After DSAEK
Surgeons 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.
29
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.
Cole Eye Institute

New Knowledge
For a complete list of
Cole Eye Institute 2007
publications go to
www.clevelandclinic.org/
quality/outcomes
Journal Articles
Ambrosio 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 highspeed
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.
Outcomes 2007 30

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 firstyear
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.
31
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.
Cole Eye Institute

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 stiffperson
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.
Outcomes 2007 32

Book Chapters
Bollinger 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.
33
Cole Eye Institute

Staff Listing
Chairman
Hilel 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
Glaucoma
Edward J. Rockwood, MD
Scott D. Smith, MD, MPH
Keratorefractive Surgery
Ronald R. Krueger, MD
Steven E. Wilson, MD
Neuro-Ophthalmology
Gregory S. Kosmorsky, DO
Lisa D. Lystad, MD
Vitreo-Retinal
Froncie 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/Strabismus
Andreas Marcotty, MD
Elias I. Traboulsi, MD
Oculoplastics
Julian D. Perry, MD
Oncology/Eye Tumors
Arun D. Singh, MD
Outcomes 2007 34

Uveitis
Careen 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
35
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 Anesthesiology
Armin 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
Cole Eye Institute

Contact Information Institute Locations
General 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 Information
General 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 medicalconcierge@ccf.org
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
Outcomes 2007 36

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.
37
eCleveland Clinic
eCleveland 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.
DrConnect
Online 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 drconnect@ccf.org.
MyConsult
MyConsult 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 eclevelandclinic@ccf.org or call 800.223.2273,
ext 43223.
Cole Eye Institute

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