PurposeTo determine the financial and clinical impact of conversion from International Classification of Disease, 9th revision (ICD-9) to ICD-10 coding.DesignRetrospective, database study.Materials and methodsMonthly billing and coding data from 44,564 billable patient encounters at an academic ophthalmology practice were analyzed by subspecialty in the 1-year periods before (October 1, 2014, to September 30, 2015) and after (October 1, 2015, to September 30, 2016) conversion from ICD-9 to ICD-10.Main outcomes and measuresPrimary outcome measures were payments per visit, relative value units per visit, number of visits, and percentage of high-level visits; secondary measures were denials due to coding errors, charges denied due to coding errors, and percentage of unspecified codes used as a primary diagnosis code.ResultsConversion to ICD-10 did not significantly impact payments per visit ($306.56±$56.50 vs $321.43±$38.12, P=0.42), relative value units per visit (7.15±0.56 vs 7.13±0.84, P=0.95), mean volume of visits (1,887.08±375.02 vs 1,863.83±189.81, P=0.71), or percentage of high-level visits (29.7%±4.9%, 548 of 1,881 vs 30.0%±1.7%, 558 of 1,864, P=0.81). For every 100 visits, the number of coding-related denials increased from 0.98±0.60 to 1.84±0.31 (P<0.001), and denied charges increased from $307.42±$443.39 to $660.86±$239.47 (P=0.002). The monthly percentage of unspecified codes used increased from 25.8%±1.1% (485 of 1,881) to 35.0%±2.3% (653 of 1,864, P<0.001).ConclusionThe conversion to ICD-10 did not impact overall revenue or clinical volume in this practice setting, but coding-related denials, denied charges, and the use of unspecified codes increased significantly. We expect these denials to increase in the next year in the absence of Medicare’s 1-year grace period.

We report the first case of fatal myocarditis presenting as bilateral ptosis in a patient on combination therapy with pembrolizumab and epacadostat. An 83 year-old man with stage III high-grade urothelial carcinoma presented with acute onset droopy eyelids one month after starting pembrolizumab and epacadostat. Exam showed myogenic ptosis and ophthalmoplegia. He was later found to have acute myocarditis with complete heart block and subsequently passed away. Pembrolizumab in combination with epacadostat can induce a potentially fatal myocarditis. Although immune mediated myocarditis is a rare established side effect, more reported fatalities are needed in the literature to highlight the urgency for standardized cardiac monitoring of even asymptomatic patients to prevent fatal outcomes, as well as a consensus on treatment protocols. Cancer immunotherapy complications are not well known to ophthalmologists. This case is unique in that the presenting sign was ptosis, which prompted the patient to call his ophthalmologist first.

PurposeTo report a case of metastatic intraocular medulloepithelioma successfully treated with neoadjuvant chemotherapy, superficial parotidectomy, and enucleation.ObservationsA 5-year-old male with history of cataract surgery, glaucoma drainage device, endocyclophotocoagulation, scleral patch grafting, and chronic posterior “inflammation” in a blind left eye presented with a rapidly enlarging painful mass under the left upper eyelid. Biopsy of the conjunctival mass and fine needle aspiration of an enlarged preauricular lymph node revealed medulloepithelioma, which was also seen in the left parotid gland on positron emission tomography (PET) scan. The patient's father refused exenteration, so the patient received 3 cycles of vincristine, cisplatin, cyclophosphamide, and etoposide per a retinoblastoma protocol. Repeat magnetic resonance imaging (MRI) showed regression of ocular extension, and an enucleation was performed, histologically confirming the diagnosis of malignant, non-teratoid medulloepithelioma. The child later underwent superficial parotidectomy and received an additional round of chemotherapy. There has been no evidence of recurrence for 9 years.Conclusions and importanceThere is no standard treatment for metastatic intraocular medulloepithelioma. The neoadjuvant chemotherapy regimen used in our patient led to regression of the extrascleral extension of the tumor, allowing for enucleation rather than a more disfiguring exenteration, as well as likely improving his prognosis. We believe that it is reasonable to consider neoadjuvant chemotherapy for patients with extrascleral and/or metastatic medulloepithelioma.

Resident-performed functional upper eyelid blepharoplasty under the direct supervision of an attending is a safe and effective procedure with similar complication rate, number of revision procedures, and patient satisfaction to attending-performed functional upper eyelid blepharoplasty. Purpose: To determine the safety and efficacy of resident-performed functional upper eyelid blepharoplasty. Methods: The authors retrospectively looked at functional upper eyelid blepharoplasty surgery performed on 836 eyes of 448 patients under the supervision of one oculoplastic surgery attending at the University of California Davis Eye Center from January 1, 2013, to December 31, 2017. The primary surgeon was a resident on 427 eyes and was an attending on 409 eyes. Patients (73.5%) were female, and the mean age was 66.0 ± 10.0. All patients had at least 2 postoperative visits, and eyes that underwent other concurrent upper eyelid or brow procedures were excluded. The authors looked at major and minor complications, percentage of initially dissatisfied patients, and percentage of cases that required a revision procedure within 6 months. Chi-square tests were used for statistical analysis. Results: There were no major complications in either group. There was no difference in the rate of minor complications (10.8% vs. 7.6%, p = 0.11), percentage of patients who were initially dissatisfied with the procedure (3.5% vs. 2.0%, p = 0.17), or percentage of patients requiring a revision procedure (5.2% vs. 3.2%, p = 0.15). The most common minor complications were inclusion cysts (45, 5.4%), wound dehiscence (9, 1.1%), and hypertrophic scars (9, 1.1%), and the most common revision procedures were removal of inclusion cyst(s) (17, 2.0%) and suturing or placement of topical skin adhesive for wound dehiscence (9, 1.1%). Conclusions: Ophthalmology residents can perform functional upper eyelid blepharoplasty safely and effectively under the supervision of an attending physician.

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