1. Training: Undergrad: Goshen College Medical School: Indiana University Medical School Residency: Indiana University Work Experience: Private practice St. Joseph, MI with Great Lakes Eye Care, 1997 - present Harlan, KY 1995 – 1997 Alaska summer emergency ophthalmologist 1994 Wife: Shelley and 4 kids Missions: Honduras, Nicaragua, Ecuador Serves: Administrator of Mission Eyes Network COS Board member

2. Stan Pletcher, MD Great Lakes Eye Care

3. ICEH (International Centre for Eye Health) Publisher of Community Eye Health London, England www.iceh.org.uk WHO (World Health Organization) Vision 2020 Global initiative for the Elimination of Avoidable Blindness http://whqlibdoc.who.int/hq/1997/WHO_PBL_97.61_Rev.1.pdf Geneva, Switzerland www.who.int

4. 1988 World population 5.1 billion Age 65 and up 320 million Number of blind 37 million Global cataract operations 5 million/yr World population 6.7 billion Age 65 and up 500 million Number of blind 45 million (2004) Global cataract operations 15 million/yr 2008

5. 45 million blind (<3/60 in best eye) 37 million from eye disease 8 million from refractive error 17 million from cataract

7. CountryCSR (Operations/million/year) United States5500 Western Europe and Japan4000 IndiaWas 1500 – now 3000 Russia1500 Africa300 China280

8. How do we measure outcomes? Measured in Visual acuity Quality of life Economic rehabilitation Monitoring Visual acuity alone Quick, standardized, already part of procedure May not be sensitive enough to measure function Monitoring visual function, quality and economic rehab lengthy process more difficult to standardize

9. Skills of surgeon Surgical technique Patient factors and preop disease Facilities and equipment and environment Post operative care Availability of optical correction

10. Fear of surgery High cost Poor visual results or outcomes Lack of eye surgeon Good Outcomes Motivate others to have surgery Knowing cause of poor outcomes can help improve outcomes

11. GoodVa 20/20 to 20/60 Borderline Va 20/80 to 20/200 PoorVa 20/400 or worse

12. > 95% have IOLs inserted at surgery > 90% have good outcome (20/20 to 20/60) < 5% with poor outcome (<20/200)

13. Affect demand of cataract surgery Recommend simple method to monitor & evaluate outcomes Purpose: Identify causes of poor outcomes Address causes – to improve outcomes Improve outcomes to increase cat sx output

14. 4 S’s Selection Surgical complications Spectacles Sequelae Most common Operative complications Lack of spectacles

15. How many actively doing mission ophthalmology monitor and track your outcomes? At one day At 4 weeks At one year

17. Having surgeons monitor outcomes will improve outcomes Better results reduce fear and motivate patients for surgery Monitoring is not to compare surgeons or centers – but for self review

18. Case selection Surgical skills Procedure type Facilities Postop followup Other factors

19. Manual Tally Sheet Computerized package

20. Preop, Operative and Postop data CSR (cataract surgery record) – for one patient Tally sheet – for summary of all patients Record causes of poor outcomes Selection Surgery Spectacles Sequelae

24. Capsulorhexis extended Capsule ruture Without vit loss With vit loss Damage to iris Iris prolapse or dehiscense Zonular dehiscence Without vit loss With vit loss Suprachoroidal hemorrhage Descemet’s Tear

25. Check Snellen acuity < 20/200 then do pinhole < 20/200 with pinhole, then examine for cause Record data Discharge patient

26. Operative complications – total and type At Discharge: % of good, borderline, and poor outcomes Cause of poor outcomes At 4 weeks % of good, borderline and poor outcomes Cause of poor outcomes

28. Proportion of cases w/ IOLs (>95%) % complications < 10% PC rupture < 5% and vit loss < 5% Discharge >50% good presenting Va and < 10% poor Va 4 Weeks >80% good uncorrected Va and <5% poor Va >90% good corrected Va and <5% poor Va

29. Surgeon must see and review results Have a scheduled meeting with team Quarterly, semi-annually, yearly

30. Available online for free Adv Reporting is automatic – easy to update Choose text or graphic outcome display On demand report available to surgeon Can compare more variables easier (techniques, astigmatism, refractive surprises, diabetics) Disadv Cost and complexity of starting

31. Commitment to education (CME) Collaboration and innovation Discipline to team and process Biometry is essential Equipment Volume and experience Monitoring of outcomes M & M meetings (involve the whole team) Leadership

32. Responding to local needs or request Long term commitment Repeated visits Involvement of local community Commitment to transfer of skills Using appropriate technology and materials Fostering sharing of experience and ideas