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Lessons Learned: Wrong Intraocular Lens

Oliver D. Schein, MD, MPH,1 James T. Banta, MD,2 Teresa C. Chen, MD,3 Scott Pritzker, MBA, RN,1

Andrew P. Schachat, MD4

Objective: To report cases involving the placement of the wrong intraocular lens (IOL) at the time of cataractsurgery where human error occurred.

Design: Retrospective small case series, convenience sample.Participants: Seven surgical cases.Methods: Institutional review of errors committed and subsequent improvements to clinical protocols.Main Outcome Measures: Lessons learned and changes in procedures adapted.Results: The pathways to a wrong IOL are many but largely reflect some combination of poor surgical team

communication, transcription error, lack of preoperative clarity in surgical planning or failure to match the patient,and IOL calculation sheet with 2 unique identifiers.

Conclusions: Safety in surgery involving IOLs is enhanced both by strict procedures, such as an IOL-specific time-out, and the fostering of a surgical team culture in which all members are encouraged to voicequestions and concerns.

Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed

in this article. Ophthalmology 2012;119:20592064 2012 by the American Academy of Ophthalmology.

During the past decade, there has been an increasing na-tional focus on ensuring patient safety, fostering transpar-ency, and stimulating initiatives to minimize errors inhealthcare delivery. As a result, a proliferation of protocol,policy, and regulatory/compliance mandates have been in-stituted publicly and privately to address quality and safetyissues. In particular, preventable causes of morbidity havebeen targeted, and examples of this include surgery involvingthe wrong patient, the wrong site, and the wrong procedure. InJuly of 2004, the Joint Commission on Accreditation ofHealthcare Organizations promulgated a universal protocolin an effort to prevent such medical errors.1 This protocolprovides a consistent approach involving preoperative ver-ification, site marking, and a time-out immediately beforeincision.

Cataract surgery is the most commonly performed sur-gical procedure, and virtually all involve placement of anintraocular lens (IOL). Wrong lens implants have repeatedlybeen documented to be the highest frequency medical errorsin ophthalmic surgery. In a review of malpractice insuranceclaims and New York State Department of Health reportsthat were related to eye surgery between 1982 and 2005,wrong lens implants accounted for 63% of the cases.2 In a

multispecialty review of incorrect surgical procedures inVeterans Health Administration Medical centers between2001 and 2006, ophthalmic procedures had the highest rateof reported adverse events by surgical specialty (1.8 per10 000 cases), and approximately half of the surgical errorswere attributed to wrong implant.3 In a follow-up report onthe same population from 2006 to 2009, ophthalmic surgeryhad the second highest rate (1.06 per 10 000 cases), with themajority of errors due to wrong implants.4 In 2009, Lumand Schachat5 wrote an editorial on the quest to eliminatewrong surgery, drawing attention to the Universal Proto-col and its application to ophthalmic surgery. The American

Academy of Ophthalmology (AAO) established a wrongsite task force that made its recommendations publiclyavailable.6 This document emphasized standard processesfor marking the eye and for the time-out. The importanceof using 2 patient identifiers to cross-reference the patientand the consent was emphasized. In regard to IOL surgery,the task force emphasized the need to double-check IOLmeasurements, to ensure clarity and completeness in theordering of IOLs, and to have some form of written docu-mentation regarding the intended IOL available during thesurgery. Examples provided for doing this were writing thepatients name, eye, and IOL power on a whiteboard orhaving a copy of the operative plan taped to the operatingmicroscope. In a recent report from the United Kingdom,7

164 cases of wrong IOL implantation were enumerated viaa national incident reporting database between 2003 and2010. A reason for the error was reported for 102 of thesecases. Approximately 30% were attributed to inaccuratebiometry. The remainder was due to a variety of humanerrors, including transcription and filing errors, handwritingmisinterpretation, and other patient or eye identificationconfusions. The authors recommended against transcriptionand the use of abbreviations and whiteboards, and favored

electronic patient records, preoperative checklists, and anadequate stock of IOL ranges.

The following cases illustrate how initial errors, evenoccurring before the day of surgery, can result in a cascadeof events culminating in a wrong IOL implant. These casesoccurred between 2006 and 2011, over a period of time inwhich there was considerable evolution nationally in prac-tice related to universal protocols in general and cataractsurgery specifically. It is well recognized that there aremany different reasons for IOL errors, including some thatreflect limitations in our measurements and equations insubsets of patients with very long or short eyes or after

2059 2012 by the American Academy of Ophthalmology ISSN 0161-6420/12/$see front matterPublished by Elsevier Inc. http://dx.doi.org/10.1016/j.ophtha.2012.04.011

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refractive surgery.8 The focus of this report, however, re-lates to IOL implantation that is wrong as the result ofhuman or system error.

Materials and Methods

An informal consortium of faculty responsible for quality and

safety programs at their respective institutions was formed todiscuss areas of common interest and concern. These facultyidentified 7 cases related to the implantation of a wrong IOL thatresulted in a formal review or root cause analysis (RCA). Althoughthe exact format of the RCA varied by institution, all shared theuse of a multidisciplinary team approach to document the event,explore multiple possible contributing causes, and outline specificplans to reduce the likelihood of recurrence. These cases, theirreview, and resulting changes in clinical policy were summarized.

Results

Case 1

A surgeon consulted the printed IOL calculation sheet in the chartjust before patient transport into the operating room (OR). Thesurgeon reviewed the calculations, circled the desired IOL, andbrought that IOL into the OR. Uncomplicated surgery was per-formed, the circulating nurse confirmed that the IOL selectedmatched the one circled on the printout (correct brand, model, andpower), and the patient was transported to the recovery room.While completing the postoperative paperwork, the surgeon notedthat the patients chart had 2 separate IOL calculation printouts,and the one from which the patients IOL was chosen was theincorrect one. It belonged to another patient and had been misfiled.The surgeon immediately informed the patient of the error, broughtthe patient back to the OR, and safely exchanged the IOL for thecorrect power. The patient did well postoperatively. An RCA was

undertaken that concluded the error had largely occurred becausethe IOL printout had not been matched to the patient by name. Apolicy to do so was then instituted.

Case 2

A patient with a common last name presented to the clinic forconsideration of cataract surgery in his right eye. He was a highmyope who had previously undergone cataract surgery in the lefteye elsewhere and had purposely been left with approximately 4diopters (D) of myopia in that eye. The surgeon received the IOLcalculations back from the ophthalmic technician soon after thepatient had left the clinic. These calculations had been centered ona target of plano. The surgeon recalled that the intended target forthe right eye was approximately 3 D of myopia and asked anothertechnician to repeat the calculations with a target of3 D. Thetechnician went directly to the IOL Master (Carl Zeiss, Inc,Oberkochen, Germany), pulled the name off the pick list pro-vided by that instruments software, performed the calculation, andplaced the printed output in the chart. Several weeks later, thepatient underwent uncomplicated cataract surgery, and the IOLpower was verified by a clinical fellow and a circulating nurse,both of whom compared the name on the patients consent formwith that on the IOL calculation sheet. In addition, just beforeinsertion of the IOL, the circulating nurse read aloud the patientsname and the IOL selected from the IOL printout, and the attend-ing surgeon affirmed his agreement. On the first postoperative day,the patients eye was found to be anatomically intact, but the vision

was limited to counting fingers. On further evaluation, the pa-tient was found to have approximately 10 D of myopia. The chartwas reviewed, and it was discovered that the second IOL calcula-tion that had been requested with a target of 3 D of myopiacontained the name of another patient with the same last name andan almost identical first name. The patient was promptly informedof the error, and 24 hours later an IOL exchange was performedwithout complication, and the patient did well. An analysis of thecase reached what had become an obvious conclusionthe IOL

printout must be matched to the patient with 2 identifiers, such asname and date of birth or medical record number.

Case 3

A patient with cataract and corneal astigmatism was scheduled forimplantation of a toric IOL. An Alcon SN6AT6, 6.5 D lens (AlconInc, Hnenberg, Switzerland) was ordered. The packing slip con-firmed the order was for an SN6AT6, 6.5 D lens. In the OR, duringthe time-out preceding implantation, the circulator read aloud thelabel on the IOL box, indicating an SN60AT, 6.5 D lens. Thesurgeon, after looking at the chart, indicated correct, and thatIOL was implanted. Postoperatively, although the patient did welland was pleased with his vision, it was discovered that the patient

had not received the intended toric IOL, but instead, the sphericalSN60AT IOL. The patient was informed, and the additional chargefor that IOL was refunded. Despite the satisfactory clinical out-come, a wrong implant had been used. On review of the case,several factors were recognized as contributory to this error. First,the similarity in lens model names facilitated the confusion. Sec-ond, it was recognized that it is preferable for the surgeon to repeatback to the circulator the desired IOL specifications, not simply torespond yes, correct. Third, an alert on the OR schedule, indi-cating the plan for a nonstandard IOL (e.g., toric, multifocal)would be helpful.

Case 4

A patient underwent uncomplicated cataract surgery and was

found to have blurry vision in the operated eye postoperatively.Manifest refraction revealed approximately 2.5 D of hyperopia.Investigation revealed that the surgeon had mistakenly chosen thepower of the lens from the column designated for the anteriorchamber IOL (ACIOL) when a posterior chamber IOL (PCIOL)had been intended. Further investigation revealed that the positionof the PCIOL and ACIOL lens power options on the IOL mea-surement printout had been switched from their traditional posi-tions on the IOL printout, although both columns were clearlymarked. The patient underwent an uneventful IOL exchange anddid well. An RCA was performed that led to the institution of anew IOL-specific time-out before insertion of the IOL duringsurgery. The IOL calculation sheet is now matched to the patientby name and date of birth by the circulating nurse. The surgeon isthen required to review the IOL calculation sheet and confirm theIOL style and power to be implanted before the implant is openedfor the scrub technician to load.

Case 5

A patient was scheduled for cataract surgery. The surgeon re-quested a 14.5 D PCIOL on an IOL order form. The order formwas faxed to the ambulatory surgical center, and the nurse whopulled the lens was unsure whether the note read 14.5 or 17.5 D.She guessed it was 17.5 D but never mentioned her uncertainty tothe surgeon or any other staff member until questioned later.During the time-out before lens implantation, the nurse read thelens order aloud, calling for a 17.5 D lens, and the surgeon

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confirmed by looking at the IOL packaging (not at the originalorder form) that this was correct. On dictating the case, the surgeonnoted that the IOL power used was significantly different from thatpreviously implanted in the fellow eye. On review of the chart, hesaw that a 17.5 D lens had been implanted instead of the intended14.5 D lens. The patient was notified immediately, and the decisionwas made to wait and see if she tolerated the unintended mono-vision. In fact, the anisometropia was minimal, and the patient washappy with her vision postoperatively, declining further interven-tion. An RCA was performed and led to a change in the IOL-specific time-out before insertion of the IOL during surgery.Subsequent to this case, the IOL policy was amended to requirethat the IOL calculation sheet be matched to the patient by nameand date of birth by the circulating nurse. The surgeon is thenrequired to review the IOL calculation sheet and confirm the IOLstyle and power to be implanted before the implant is opened forthe scrub technician to load.

Case 6

In preparation for surgery, a surgeon ordered 4 separate IOLs.Before the patient was transported into the OR, the surgeon se-lected a monofocal spherical IOL and placed that IOL on aseparated stand in the OR. The other 3 IOLs that had been ordered,one of which was a toric IOL, were placed on a shelf in the OR.Uncomplicated surgery was performed, and the patient was trans-ported to the recovery room. When examining the patient onpostoperative day 1, the surgeon noticed that a toric IOL had beenimplanted instead of the intended spherical IOL. The surgeonimmediately informed the patient of the error, and the patientunderwent uncomplicated surgery to rotate the toric lens into theoptimal position. The patient did well postoperatively. An RCAwas undertaken that concluded the error had occurred becausethere was no verification between the nurse and the surgeonregarding which was the intended IOL. The circulating nurse hadtaken the toric IOL from the shelf, unaware that the surgeon had

already placed the intended IOL on a separate stand. A newprocess was then instituted requiring the surgeon and nurse tocheck IOL printouts together and mutually confirm the intendedIOL before the surgery. That process also requires, once thepreferred IOL has been chosen, that all other IOLs are removedfrom the OR.

Case 7

Just before a patients cataract surgery, the circulating nurse re-viewed the IOL that had been delivered to the OR for that patient.She noticed that a 5 D lens had been delivered to the OR,whereas the surgeon had ordered a 5 D lens. When the nurse

verified with the surgeon that the 5 D lens was indeed theintended lens, the correct 5 D was brought to the OR. Uncom-plicated surgery was performed, and the correct IOL was im-planted. An RCA, undertaken to investigate this near miss,concluded that the wrong IOL had been delivered to the ORbecause the staff member selecting the IOL had misread the IOLboxs label. The minus sign in front of the 5 D power was in asmaller font than used to specify the IOL power and had beenoverlooked. A letter was then written to the company that producesand packages the IOL chosen, suggesting a modification to thelabel that would highlight the presence of the minus sign bychanging the font or color. The company responded affirmativelyand subsequently improved the packaging in that regard.

Discussion

In the United States, more than 3 million cataract surgeriesare performed annually, and almost all involve the selectionand placement of an IOL. With such an enormous denom-inator, it is not surprising that IOL cataract surgery isassociated with the greatest number of surgical confu-sions in ophthalmology2 or that ophthalmology has been

disproportionately represented in raw counts of adverseevents occurring in ORs.3 There are more opportunities tochoose a wrong IOL than there are to make analogouserrors for any other implanted device. This is a simplefunction of the volume of cases performed and the largenumber of potential IOL choices that reflect the range ofdioptric powers and lens designs available. The advent ofmultifocal and toric IOLs has both increased the options wecan offer patients and our opportunity for error. Othercommonly implanted devices (e.g., orthopedic, vascularstents) are produced in far fewer versions. The true rate ofwrong IOL implantation is unknown. Because of differ-ences in case definition, ascertainment, and time surveyed,

we do not have an accurate pooled rate of wrong IOLimplantation across our institutions. However, if the rate ofwrong IOL due to error in selection were on the order of 1per 10 000 (99.99% accuracy), as implied by Neily et al,3

this would yield approximately 200 such cases annually inthe United States.

The institutions represented by the authors of this articlehave made significant efforts during the past 5 years tominimize such errors. Although none of the IOL errorsreported in this article resulted in permanent patient harm,that potential exists. Furthermore, IOL errors underminepatient confidence in the surgeon or institution and may bea source of considerable distress for both patient and sur-geon, not to mention a potential source of litigation. Theregulatory requirements for reporting IOL errors vary sig-nificantly by state and may also vary on the basis of thepractice setting in which the IOL surgery occurred (e.g.,whether the surgery was performed in a hospital OR or aphysician office setting). In some states, the implantation ofa wrong IOL is considered wrong site surgery, no differ-ent than if the wrong eye, limb, or lung had been operated.Such states require reporting of IOL errors to various reg-ulatory agencies, which may result in a range of conse-quences to the reporting institution or surgeon, even includ-ing fines and community service. Just as for the reportingrequirements, the potential consequences of reporting IOLerrors are state-specific and vary tremendously. The errors,

and often information about steps taken to reduce thechance of recurrence, were disclosed by the surgeon to eachpatient included in this report, in keeping with the disclo-sure and apology movement in risk management.

Cases 1 and 2 both involved having the incorrect IOLprintout sheet present in the OR. Both cases would likelyhave been prevented with time-out procedures that matchthe IOL printout to the consent form with 2 patient identi-fiers, such as name and date of birth. The AAO task forcestipulates the use of 2 patient identifiers to prevent wrongsite or wrong patient surgery but does not specifically indi-cate that the IOL printout itself be reconciled to the patient

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or patient consent form using the same 2 identifier standard.We highly recommend this practice. In addition, it would behelpful if 2 patient identifiers were required to access apatients IOL data from the IOL calculation database. Thiswould reduce the possibility of printing out the incorrectpatients data, especially in cases where there are similar oreven identical names involved. Case 3 would likely havebeen prevented if the surgeon had taken a greater role in

confirming the IOL before initiation of the surgery. If thesurgeon were consciously planning for a toric IOL, the axisof astigmatism would need to have been marked and theIOL axis aligned appropriately. The AAO checklist recom-mending that the written surgical plan be visible to thesurgeon intraoperatively would have been helpful. Case 4highlights the importance of having at least 2 people, typi-cally the surgeon and circulating nurse, review the IOLprintout form and the intended IOL together. The power ofthe ACIOLs and PCIOLs was confused because this stepwas not taken, and the likelihood of surgeon error wascompounded because of the inadvertent change in the rou-tine format for the IOL printout at that institution. Case 5

illustrates the potential consequences of a transcription er-ror. In this case, a 4 was mistaken for a 7, and thepotential for error was compounded by the reluctance of thenurse to disclose her uncertainty. A goal of all surgicalteams should be to create an environment where all mem-bers of the team are comfortable in voicing uncertainty andcontributing to a culture of safety. In regard to transcriptionerrors, these can be best minimized by avoiding transcrip-tion whenever possible. Transcription occurs most fre-quently in settings where surgeons or their surrogates tran-scribe onto order forms a desired IOL. An alternative is tocircle and initial the intended IOL on a copy of the IOLprintout. Transcription occurs by necessity when the axiallength is measured using an ultrasound technique and thevalue then manually entered into an IOL calculator. Like-wise, transcription of keratometric values is usually neces-sary to perform the calculations needed to select a toric IOL.In such settings where transcription is practiced, the surgeonand staff should make efforts to confirm that the transcrip-tion was accurately performed. Case 6 is another example offailure to involve a direct communication between the sur-geon and the circulating nurse regarding a confirmation ofthe intended IOL. It also highlights the enhanced potentialfor error when multiple IOLs are in the OR simultaneously.Finally, case 7 was a near miss. A 10 D error in IOLchoice was averted by an alert nurse, again demonstratingthe notion that a surgeon and nurse team trump either alone.

This case also illustrates, as does case 3, that packaging andlabeling are important. This has long been recognized as apotential problem in other settings. For example, manyophthalmologists are aware of patients who have confusedtheir artificial tears or contact lens lubricants with productsdesigned for ear care or even with adhesives such as super-glue. Industry can play a greater role in promoting safety bymaking greater and more logical distinctions between themodel numbers of its IOL designs.

The cases reported occurred at 4 large ophthalmic train-ing institutions over a 5-year period. Each institution facesa common challenge that is also shared by many others:

how to institutionalize a culture of safety that will applyequally to part- and full-time faculty and to residents andfellows in training. That challenge is in turn magnified bythe relative rarity of errors and the multiplicity of paths thatmay lead to the error. Although not an exhaustive list, it iscritical to recognize the multitude of potential causes forIOL selection errors, such as the following:

1. An IOL calculation sheet for a different patientwith a similar or same name is in the medicalrecord.

2. The previous patients IOL is inserted.3. The IOL power for the wrong eye is inserted.4. The wrong IOL A-constant or formula is used in

IOL calculations.5. The surgeon misreads intended IOL power (e.g.,

28.0 instead of 23.0).6. The power for an ACIOL is selected instead of the

intended PCIOL power.7. The wrong IOL model is picked from IOL calcu-

lation sheet.8. The axial length is confused with the IOL power on

the printout.9. The wrong IOL is chosen when multiple IOL types

are present in the OR.10. A minus is confused with a plus in choosing the

target refraction or IOL power.11. A transcription error is made when transferring

data for keratometry or axial length data into IOLcalculation software.

12. The patient specifically requests myopia or mono-vision, but the surgeon targets emmetropia.

13. The patient requested (and paid for) a different typeof premium IOL than implanted.

14. The patient did not want a toric or presbyopia-

correcting IOL, but one was implanted, or viceversa.

15. The requested special-order IOL was not availablein the OR after lens extraction.

Although it is acknowledged that the most critical mo-ments in preventing IOL error occur in the OR, it hasbecome equally apparent that the path to IOL error oftenbegins earlier. Errors, once committed, may be propagateddownstream and may be more difficult to detect than toprevent in the first instance. Quality-control efforts mustbegin at the time of initial measurement and decision forsurgery. Because of some variability in practice and patient

flow in clinics, preoperative holding areas, and staffing,there is not a single, rigid plan that is optimal for everysetting. However, we were able to identify a set of commonelements that we believe will minimize IOL errors. Thesemay be summarized as follows:

A surgical plan regarding the type of IOL (e.g., spher-ical, toric, presbyopia correcting) and general refrac-tive target (e.g., better for distance or near) should bedocumented in the medical record.

The intended IOL, in particular any special-order IOL,should be verified to be present in the OR before thepatient is taken to the OR.

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A patient label that contains name, medical recordnumber, and date of birth is present on every IOLcalculation printout. Each technician performing IOLcalculations should use 2 patient identifiers (name andeither date of birth or medical history number) tomatch the name on the IOL calculation printout to thatof the specific patient. If additional calculations on apatient are subsequently requested, 2 patient identifiers

are used to confirm that the correct patient has beenaccessed from the IOL database.

If the difference in axial length between the 2 eyes is0.3 mm, we recommend that this difference be rec-onciled clinically by the surgeon or the measurementrepeated.

If the axial length is measured by ultrasonography, orcorneal power measured manually and then tran-scribed into an IOL calculation software, the datatranscribed should be subsequently confirmed by atechnician or the surgeon. The use of IOL order formsthat require manual transcription from the IOL print-out should be minimized.

If the IOL calculations are missing on the day ofsurgery, they should be transmitted to the OR properlylabeled with name, date of birth, and medical recordnumber before the patient enters the OR.

IOL verification on the day of surgery: The circu-lating nurse reviews the patient chart with the sur-geon and confirms that the IOL calculation sheetmatches the patient by name and date of birth ormedical record number and that the IOL model anddiopter power circled on the printout sheet andsigned or initialed by the surgeon has been broughtinto the OR. Only the IOL for that one patient isbrought into the OR.

The time-out in the OR that confirms the correctpatient, procedure, and site occurs before the firstincision. For patients who will be receiving an IOL, all4 institutions participating in this review concur thatan IOL-specific time-out is a necessity. However,there is variability across the institutions as to whenthis should take place. At one of our institutions, theIOL verification occurs as an integral component ofthe initial time-out before the first incision, and theintended IOL in its sterile package is typically placedon the Mayo stand in real time. That institutions logicfor its timing is that if a concern regarding the IOL isto be discovered, it would rather see that conflict

resolved before the incision, rather than have to do soin the middle of surgery. At the other institutions, aseparate IOL time-out is held just before the insertion,with the logic that the closer in time the IOL time-outis to the actual insertion, the better. For all 4 institu-tions, the components of the verification include amatching (visual and auditory) of the patients nameand date of birth (or medical record number) as re-corded on the consent form with that on the label of theIOL printout. If a change in IOL is requested intraop-eratively, the surgeon and circulating nurse will repeatthe IOL verification procedure.

Only the IOL for the patient currently undergoingsurgery is present in the OR; any unused IOL isremoved from the OR after each case.

Reducing the rate of IOL errors requires a team ap-proach that involves the efforts and concentration ofophthalmic technicians, surgical schedulers, operativenursing staff, and surgeons. In the future, human error

might be further reduced by the introduction of electronicsystems, such as bar coding or the use of radio frequencyidentification,9 which might even be linked to patientspecific biometry and electronic medical records. Ofcourse, the use of electronic records may pose otherchallenges yet to be fully appreciated. For example, anerror once in an electronic system can easily be propa-gated downstream. At present, there is growing evidencethat the use of surgical safety checklists10,11 may improvesurgical quality and safety. In the setting of cataractsurgery, such a checklist should contain detailed andspecific information related to the intended IOL. The lastmoment before IOL implantation in the OR is crucial, but

often is not the optimal time to prevent errors whose rootsbegin elsewhere, such as transcription errors occurring inclinic or at scheduling. Improving processes and theiraccuracy before the day of surgery will reduce errors.However, the final verification steps on the day of surgerywill always remain paramount as the last, if not the best,way to prevent the implantation of a wrong IOL.

In conclusion, the risk of implanting the wrong IOL asthe result of human or system error has decreased overrecent years. The AAOs 2008 operative checklist was amajor milestone in this evolution. We have tried to offersome additional refinements to such processes, recogniz-ing and hoping that these too will be supplanted by stillmore effective mechanisms in the future.

References

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Footnotes and Financial DisclosuresOriginally received: March 26, 2012.

Final revision: April 12, 2012.

Accepted: April 13, 2012.

Available online: June 14, 2012. Manuscript no. 2012-440.

1 Wilmer Eye Institute, Johns Hopkins University School of Medicine,

Baltimore, Maryland.

2 Bascom Palmer Eye Institute, University of Miami School of Medicine,

Miami, Florida.

3 Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston,

Massachusetts.4 Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.

Financial Disclosure(s):

The author(s) have no proprietary or commercial interest in any materials

discussed in this article.

Correspondence:

Oliver D. Schein, MD, MPH, 600 N. Wolfe Street, Wilmer 116, Baltimore,

MD 21287. E-mail: oschein@jhmi.edu.

Ophthalmology Volume 119, Number 10, October 2012

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