Outcomes of Heavy Silicone Oil (Densiron) compared to Silicone Oil in primary rhegmatogenous retinal detachment: a multivariable regression model

PURPOSE

To measure the visual outcomes, proliferative vitreoretinopathy (PVR) and retinectomy rates following primary rhegmatogenous retinal detachment (RRD) repair, comparing silicone oil (SO) and heavy SO (Densiron).

METHODS

Retrospective, continuous comparative study from January 2017 to May 2021 of all primary RRD. Multivariable linear (logMAR gain) and binary-logistic (PVR-C and retinectomy rate) regression models to compare tamponade were performed. Covariates included age, gender, ocular co-morbidities, high myopia, macula-status, giant-retinal-tear (GRT), pre-op vision, PVR-C, oil type, perfluorocarbon-use, combined scleral buckle/vitrectomy, combined phaco-vitrectomy, 360-degrees-endolaser and oil duration. Cases with trauma or less than six-month follow-up were excluded.

RESULTS

A total of 259 primary RD were analysed. There were 179 SO patients and 80 Densiron patients that had six-month primary re-detachment in 18 (10.1%) and 8 (10.0%) respectively (p = 1.000). No difference in logMAR gain was detected between tamponade choice on multivariable linear regression. Subsequent glaucoma surgery was 5 (2.8%) and 4 (5.0%) for SO and Densiron patients respectively (p = 0.464). On multivariate binary-logistic regression we found no difference in development of PVR-C between oil tamponades. However, SO had significantly higher subsequent retinectomy rate compared to Densiron (odds ratio 15.3, 95% CI 1.9-125.5, p = 0.011). Duration of oil tamponade was not linked to differences in logMAR gain, PVR-C formation or increased retinectomy rate.

CONCLUSIONS

We report no difference in primary anatomical success, number of further RRD surgeries, subsequent glaucoma surgery, visual outcomes, PVR-C between both tamponades on multivariable models. Densiron oil was found to be more retinectomy sparing relative to SO.

Primary retinopexy in preventing retinal detachment in a tertiary eye hospital: a study of 1157 eyes

PURPOSE

Retinopexy is the most common vitreo-retinal procedure performed in the eye emergency department and significantly reduces the risk of a rhegmatogenous retinal detachment (RRD). There are various indications for retinopexy, with the most common being horseshoe-tears (HST). Multiple treatment techniques exist, ranging from slit-lamp laser-retinopexy, indirect laser-retinopexy or cryopexy. We report on our primary retinopexy 6-month RRD rate, repeat retinopexy rate and compare outcomes of different indications and treatment modalities.

METHODS

Retrospective consecutive case series of 1157 patients attending Birmingham and Midlands Eye Centre, UK between January 2017 and 2020.

RESULTS

The RRD rate at 6 months was 3.9%, with 19.1% requiring subsequent retinopexies. Multivariate Cox survival regression analysis showed that significant risk factors for RRD following primary retinopexy included male gender (p = 0.012), high myopia (≤ - 6.00D, p = 0.004), HST (compared to round holes, p = 0.026) and primary cryopexy (compared to slit-lamp laser, p = 0.014). HST was the most common indication for retinopexy (812 [70.2%]) in which 118 (14.5%) had multiple tears. Slit-lamp laser was used in 883 (76.3%) of cases. The rate for subsequent epiretinal membrane peel surgery was 3 (0.3%) and was higher in eyes that required multiple retinopexy procedures (p = 0.035).

CONCLUSION

With our large cohort of patients over three years, we provide additional evidence on the RRD and subsequent retinopexy rate after primary retinopexy. Further retinopexy is a common occurrence, particularly in high-risk retinal tears such as HST. Strict monitoring and prompt follow-up after retinopexy is important to prevent progression to RRD and should be of priority in the clinicians post-retinopexy management plan, particularly in those with associated risk factors.

Molecular, Viral and Clinical Features of Alcohol- and Non-Alcohol-Induced Liver Injury

Hepatic cells are sensitive to internal and external signals. Ethanol is one of the oldest and most widely used drugs in the world. The focus on the mechanistic engine of the alcohol-induced injury has been in the liver, which is responsible for the pathways of alcohol metabolism. Ethanol undergoes a phase I type of reaction, mainly catalyzed by the cytoplasmic enzyme, alcohol dehydrogenase (ADH), and by the microsomal ethanol-oxidizing system (MEOS). Reactive oxygen species (ROS) generated by cytochrome (CYP) 2E1 activity and MEOS contribute to ethanol-induced toxicity. We aimed to: (1) Describe the cellular, pathophysiological and clinical effects of alcohol misuse on the liver; (2) Select the biomarkers and analytical methods utilized by the clinical laboratory to assess alcohol exposure; (3) Provide therapeutic ideas to prevent/reduce alcohol-induced liver injury; (4) Provide up-to-date knowledge regarding the Corona virus and its affect on the liver; (5) Link rare diseases with alcohol consumption. The current review contributes to risk identification of patients with alcoholic, as well as non-alcoholic, liver disease and metabolic syndrome. Additional prevalence of ethnic, genetic, and viral vulnerabilities are presented.

Environmental Effect of Fluorinated Gases in Vitreoretinal Surgery: A Multicenter Study of 4,877 Patients

PURPOSE

To investigate the direct contribution to carbon emissions of fluorinated gases used in all vitreoretinal (VR) procedures utilizing gas tamponade and assess the respective carbon footprint of the three different gas delivery systems.

DESIGN

A multicenter, retrospective, environmental impact study.

METHODS

All VR procedures using fluorinated gases between 2017 to 2020 at the Manchester Royal Eye Hospital (MREH) and Birmingham and Midland Eye Centre (BMEC) (the second and third largest VR centers in the UK), and between 2019 to 2020 at the University Hospitals Coventry and Warwickshire (UHCW) were included. CO2 equivalent mass (CO2EM) was calculated from the mass of each gas used, according to the Intergovernmental Panel on Climate Change.

RESULTS

A total of 4877 (1883 SF6 [38.6%], 2096 C2F6 [43.0%], and 897 C3F8 [18.4%]) procedures were analyzed. UHCW and BMEC utilized single-use 30 mL and 75 mL cannisters, respectively. MREH used four cylinders of each gas over 4 years (2 kg SF6, 1 kg C2F6, 1 kg C3F8). Mean CO2EM per patient was: MREH 111.8 kg, BMEC 7.5 kg, and UHCW 2.7 kg. For MREH and BMEC, the CO2EM was 73.4 metric tons annually (if all cases were performed with i) 30 mL: 3.7 tons and ii) cylinders: 148.0 tons, x 40-fold difference), equating to 599,400 (30,500-1.2 million) km travelled by a passenger car. The current use of SF6 in VR surgery accounts for 0.11% of total SF6 use; if 30 mL cylinders were exclusively used in the UK, this could be lowered to 0.01%.

CONCLUSIONS

This study highlights the significant waste associated with large gas cylinders and demonstrated that 30 mL cannisters can lead to a marked reduction in carbon emissions, even after accounting for the increased carbon footprint involved in their manufacture and disposal.

Environmental effect of air versus gas tamponade in the management of rhegmatogenous retinal detachment VR surgery: A multicentre study of 3,239 patients

Purpose

To report the potential reduction of carbon emissions by utilising air-tamponade (AT), where possible, instead of fluorinated gases in the management of rhegmatogenous retinal detachment (RRD). We compared the carbon CO₂ emissions produced at two large tertiary referral vitreoretinal (VR) centres where RRD are exclusively repaired using fluorinated gases to a tertiary VR mass of each gas used according to the Intergovernmental Panel on Climate Change.

Materials and methods

Retrospective, continuous, comparative multicentre study of all procedures using fluorinated gases between 01/01/17-31/12/20 at the Manchester Royal Eye Hospital (MREH) and Birmingham and Midland Eye Centre (BMEC), and between 01/01/19-31/12/2020 at the University Hospitals Coventry and Warwickshire (UHCW).

Results

We report on 3,239 (SF₆:1,415 [43.7%], C₂F₆:1,235 [38.1%], C₃F₈:541 [16.7%], Air:48 [1.5%]) procedures. UHCW and BMEC utilise single use 30ml and 75ml cannisters, respectively and MREH use multi-use gas cylinders. UHCW used AT in 48 (70%) of RRD repairs. Mean equivalent mass CO₂/patient was MREH:115.9kg, BMEC:7.9kg and UHCW:1.9kg. If assuming all centres used 30ml cannisters, the mean equivalent mass CO₂/patient was MREH:3.5 kg, BMEC:3.1kg and UHCW:1.9kg. AT enabled UHCW to greatly reduce the need for the most environmentally damaging SF₆ gas, leading to lower CO₂ emissions by 47.0% and 41.1% compared to MREH and BMEC, respectively.

Conclusion

We demonstrate how AT vs. the fluorinated gases can reduce in carbon footprint in the management of RRD. Further studies are required to determine the most ‘environment-friendly’ intraocular tamponade without compromising patient outcomes centre that also routinely employs AT in selected RRD cases.

Vitreoretinal specialists compared with residents on outcomes of primary laser retinopexy in preventing retinal detachment in 958 eyes

Objective

Retinal tears are the most common vitreoretinal (VR) emergency and retinopexy aims to reduce the risk of rhegmatogenous retinal detachment (RRD). Currently retinal laser is a required competence by the Royal College of Ophthalmologists for residents. We report 6-month detachment rate and repeat retinopexy rate of VR specialists compared with residents.

Methods and analysis

A retrospective, consecutive study of 958 eyes undergoing primary laser retinopexy (slit lamp or indirect laser) from January 2017–2020 was divided into training level by operator: specialty training (ST) 2–3, ST4–5, ST6–7 and VR specialists.

Results

We report an overall 6-month RRD rate in 32/958 (3.3%) (ST2–3: 9/221 (4.1%), ST4–5: 15/373 (4.0%), ST6–7: 2/72 (2.8%) and VR specialists: 6/292 (2.1%)). We additionally report a repeat retinopexy rate of 189/958 (19.7%), (ST2–3: 44/221 (19.9%), ST4–5: 80/373 (21.4%), ST6–7: 16/72 (22.8%) and VR specialists: 49/292 (16.8%)]). Multivariable Cox survival regression analysis showed significant risk factors for developing RRD include male gender (p=0.018), high myopia (≤−6.00 Dioptres, p=0.004), ST2–3 (p=0.022) and ST4–5 (p=0.040) (relative to VR specialists) and by ST6–7, no significance was found (p=0.151). Significantly higher repeat retinopexy rates were associated with horseshoe tears (relative to round holes, p<0.001) and high myopia (p=0.026) with no difference between different training levels.

Conclusion

There was a decreasing trend in RRD rate following primary retinopexy with increase in training. Although junior residents had a higher RRD rate than VR specialists, it was still favourable relative to other large case series. While there was no difference in subsequent laser retinopexy rate between training levels, the retreatment rate was associated with the type of tear and high myopia.

Retinal Detachment Repair With Vitrectomy: Air Tamponade Integration to a Vitreoretinal Service, Comparison With Gas Tamponade, and Literature Review

BACKGROUND AND OBJECTIVE

Rhegmatogenous retinal detachment (RRD) repair by pars plana vitrectomy and gas tamponade (GT) has significant clinical and quality-of-life impacts compared with repair by short-acting air tamponade (AT). With AT, most authors minimize cryotherapy because of prolonged chorioretinal scar formation and use perfluorocarbon to maximize subretinal fluid drainage; this deviates from traditional technique, which discourages popularization of AT.

PATIENTS AND METHODS

Prospective 12-month study from January to December 2019 of all primary macula-on RRD cases. Patients fulfilling the inclusion criteria for the Pneumatic Retinopexy Versus Vitrectomy for Retinal Detachment Trial received AT and otherwise were assigned to receive GT.

RESULTS

Forty-six patients were enrolled: 22 (48%) receiving AT and 24 (52%) receiving GT. The primary success rate of AT was 21 (95%) and the primary success rate of GT was 23 (96%), with 100% final success. Cryopexy was used in 64% of AT cases and 58% of GT cases. Cataract surgery was required less when AT was used (1 [6%]) than when GT was used (3 [21%]). AT was used in 48% of primary macula-on RRD and 27% of all primary RRD cases.

CONCLUSIONS

AT has visual and anatomical outcomes comparable to those of GT with conventional vitrectomy techniques, with faster postoperative rehabilitation enabling a swift return to normal daily activities. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:87-95.].

Effect of demographics and ethnicity on laser retinopexy in preventing retinal detachment in a tertiary eye hospital in 812 eyes

PURPOSE

To investigate different baseline characteristics, clinical indications, repeat retinopexy rate, and 6-month detachment rate of primary laser retinopexy across different ethnicities.

METHOD

Retrospective, single-centre, consecutive comparative study, looking at all patients who had primary laser retinopexy between January 2017 and 2020. Multivariate Cox survival [reporting hazard ratio (HR)] and binary logistic regression (reporting odds ratio) analyses were performed to investigate differences between ethnicities with age, gender, operator level (vitreoretinal or general ophthalmologist) and high myopia status (≤-6.0 Dioptres) as covariates.

RESULTS

We report on 812 patients in three ethnicities: Black [69 (8.5%)], South Asian [SA, 156 (19.2%)] and White [587 (72.3%)] with overall 6-month detachment rate of 31 (3.8%). Rate for subsequent retinopexies was Black: 12 (17.4%), SA: 15 (9.6%) and White: 131 (22.3%), p = 0.002. Multivariate Cox survival regression analysis found no difference in detachment rate between ethnicities. South Asian (SA) had lower repeat retinopexy rate than White patients [HR, 0.40 (95% confidence interval [CI], 0.22-0.71, p = 0.002)]. Multivariate binary logistic regression found that Black and SA patients compared with White, have the following: (i) higher proportion of round holes relative to horseshoe tears [OR, 2.31 (95% CI, 1.19-4.49, p = 0.014) and OR, 2.06 (95% CI, 1.25-3.40), p = 0.004, respectively] and (ii) higher proportion of high myopia [OR, 2.99 (95% CI, 1.20-7.46, p = 0.019) and OR, 2.35 (95% CI, 1.11-4.96), p = 0.025, respectively]. Ethnic minorities were younger than White patients: SA [43, interquartile range (IQR), 28-61], Black (49, IQR, 35-57) and White (61, IQR, 54-67 years, p < 0.001) and had more indirect and 360 retinopexy compared with slit lamp (p < 0.001).

CONCLUSION

We demonstrate a significant difference in baseline characteristics, retinal tear morphology and treatment course between the ethnic groups. Further studies are necessary to investigate the genetic and biological differences that may influence these variations and may help to allow for more targeted health care.

Effect of deprivation and ethnicity on primary macula-on retinal detachment repair success rate and clinical outcomes: A study of 568 patients

PURPOSE

Socio-economic deprivation and ethnic variation have been frequently linked to poorer health outcomes. We collected a large series of primary macula-on rhegmatogenous retinal detachment (RRD) cases and analysed the effect of socio-economic deprivation and ethnicity on both six-month retinal re-detachment rate and visual outcomes.

MATERIALS AND METHODS

Retrospective consecutive case series of 568 patients attending Birmingham and Midlands Eye Centre from January 2017-2020. Multiple Indices of Deprivation (IMD) deciles were used for deprivation status and split to two groups: IMD-A (Decile 1-5) and IMD-B (Decile 6-10). The two largest subgroups of ethnicities were compared, White and South Asians (SA).

RESULTS

We report an overall retinal re-detachment rate of 8.5%. IMD-A re-detached significantly more than IMD-B (11.2% vs 6.0% respectively, p = 0.034). No statistical significance was found between White and SA re-detachment rate (9.1% and 5.6% respectively, p = 0.604). SA median age significantly lower at 49 years (IQR: 37-61) compared to White patients at 57 years (IQR: 50-65) (p = <0.001). IMD-A median age of 55 years (IQR: 46-64) was significantly lower to IMD-B median age of 58 years (IQR: 51-65) (p = 0.011). No differences in final visual outcomes were detected across all groups.

CONCLUSION

We demonstrated an increased retinal re-detachment rate in our more deprived patients according to IMD and a younger cohort of SA compared to White ethnicity. Further prospective studies are required to demonstrate the link between socio-economic deprivation and surgical success.

816 Managing Acute Appendicitis During the First Wave of the COVID-19 Pandemic: A Single-Centre Retrospective Study

Introduction

The COVID-19 pandemic provoked a change to normal surgical practice and led to a higher proportion of acute appendicitis (AA) patients being treated conservatively with antibiotics. We aim to analyse patients presenting with AA during the first wave of the pandemic, comparing surgically and conservatively managed patients.

Method

All patients presenting to our centre with AA between March and July 2020 were included. Six-month follow-up data was collected retrospectively using electronic records. Patients were categorised into surgically and conservatively managed groups. The primary outcome was the complication rate (post-operative complications vs failure of antibiotic treatment) and the secondary outcome was length of hospital stay.

Results

Fifty-seven patients (n = 57) were admitted with AA, 45.6% (n = 26) managed conservatively compared to 54.4% (n = 31) treated surgically. Higher complication rates were observed amongst the conservatively managed group, although not statistically significant (16% vs 35%; p = 0.131). There was no significant difference in length of hospital stay observed between the two groups (surgical: median, 2; interquartile range, 2-3 vs conservative: median, 3; interquartile range, 2-4). White cell count (WCC) and Alvarado score were higher on admission in the surgical group with statistical significance (p = 0.012 and p = 0.028 respectively).

Conclusions

Stratification criteria, such as Alvarado score and WCC may identify patients more suitable for conservative management. Longer term follow-up will be carried out, which may alter complication rates in either group. We suggest all patients treated conservatively should undergo computerised tomography (CT) to exclude complicated appendicitis. Further UK-based studies will add to the evidence-base surrounding management of AA during the COVID-19 pandemic.

Refractive Outcomes of Phacovitrectomy in Retinal Detachment Compared to Phacoemulsification Alone Using Swept-Source OCT Biometry

BACKGROUND AND OBJECTIVE

To assess the refractive outcomes in patients who underwent combined phacovitrectomy for retinal detachment compared to phacoemulsification and intraocular lens (IOL) implant utilizing newer swept-source optical-coherence-tomography (SS-OCT) biometry and determine the requirement of an adjustment factor for superior predicted refractive outcomes.

PATIENTS AND METHODS

Retrospective study of 95 eyes: 52 eyes that underwent phacovitrectomy and 43 eyes with phacoemulsification only that served as the control group. Mean refractive error (ME) and mean absolute error (MAE) were used to compare the groups.

RESULTS

No statistically significant postoperative refractive shift was found between phacoemulsification and phacovitrectomy eyes for (1) ME (0.05 D [± 0.51 diopters (D)] and (0.03 [± 0.73 D], respectively; P = .348), (2) MAE (0.41 D ± 0.29 D and 0.60 ± 0.44 D, respectively), or (3) MAE of the control compared to macula-on/off eyes (P = .160 and P = .078, respectively).

CONCLUSION

The authors do not recommend an adjustment factor for IOL selection when utilizing SS-OCT biometry, as it provided refractive outcomes superior to those found in previous studies utilizing a partial coherence interferometry system. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:432-437.].

The impact of the COVID-19 pandemic on microbial keratitis presentation patterns

BACKGROUND

Microbial keratitis (MK) is the most common non-surgical ophthalmic emergency, and can rapidly progress, causing irreversible sight-loss. This study explored whether the COVID-19 (C19) national lockdown impacted upon the clinical presentation and outcomes of MK at a UK tertiary-care centre.

METHODS

Medical records were retrospectively reviewed for all patients with presumed MK requiring corneal scrapes, presenting between 23rd March and 30th June in 2020 (Y2020), and the equivalent time windows in 2017, 2018 and 2019 (pre-C19).

RESULTS

In total, 181 and 49 patients presented during the pre-C19 and Y2020 periods, respectively. In Y2020, concurrent ocular trauma (16.3% vs. 5.5%, p = 0.030) and immunosuppression use (12.2% vs 1.7%, p = 0.004) were more prevalent. Despite proportionately fewer ward admissions during the pandemic (8.2% vs 32.6%, p<0.001), no differences were observed in baseline demographics; presenting visual acuity (VA; median 0.6 vs 0.6 LogMAR, p = 0.785); ulcer area (4.0 vs 3.0mm2, p = 0.520); or final VA (0.30 vs 0.30 LogMAR, p = 0.990). Whilst the overall rates of culture positivity were similar in Y2020 and pre-C19 (49.0% vs. 54.7%, p = 0.520), there were differences in the cultures isolated, with a lower rate of poly-microbial cultures in Y2020 (8.3% vs. 31.3%, p = 0.022).

CONCLUSIONS

Patient characteristics, MK severity and final visual outcomes did not appear to be affected in the first UK lockdown, despite fewer patients being admitted for care. Concurrent trauma and systemic immunosuppression use were greater than in previous years. The difference in spectra of isolated organisms may relate to behavioural changes, such as increased hand hygiene.

ASSESSING REFRACTIVE OUTCOMES AND ACCURACY OF BIOMETRY IN PHACOVITRECTOMY AND SEQUENTIAL OPERATIONS IN PATIENTS WITH RETINAL DETACHMENT COMPARED WITH ROUTINE CATARACT SURGERY

PURPOSE

To compare refractive outcomes and accuracy of modern optical biometry, swept-source optical coherence tomography, ultrasound biometry, and effect of the macula status in rhegmatogenous retinal detachment managed with either combined phacovitrectomy or sequential vitrectomy and cataract surgery compared with a control, phacoemulsification alone.

METHODS

Retrospective, comparative, consecutive study of 154 eyes; Group 1 underwent phacovitrectomy (n: 70), Group 2 underwent vitrectomy with subsequent cataract surgery (n: 41), and Group 3 underwent cataract surgery alone (n: 43).

RESULTS

No difference in the mean absolute error was found between Group 2 (0.41 ± 0.56) and Group 3 (0.41 ± 0.29); both were superior to Group 1 (0.74 ± 0.57). Between Group 1 and Group 2, no statistically significant difference in the mean absolute error was found between macula-on subgroups (P = 0.057), but this was statistically significant between macula-off subgroups (P = 0.009). Subgroup analysis by biometry showed that the difference in the mean absolute error between macula-off optical biometry Group 1 and Group 2 against our control, Group 3, were not significant (P = 0.078 and P = 0.119, respectively); the mean absolute error was significantly different when considering macula-off ultrasound biometry cases (P < 0.001 and P = 0.038, respectively).

CONCLUSION

All three groups had comparable refractive outcomes when using optical biometry. However, phacovitrectomy macula-off cases had inferior refractive outcomes when the ultrasound biometry had to be used. In macula-off rhegmatogenous retinal detachment, when optical biometry is not reliable, it is preferable to perform sequential surgery rather than phacovitrectomy.

Surgical Versus Conservative Management of Acute Appendicitis During the COVID-19 Pandemic: A Single-Centre Retrospective Study

Introduction The COVID-19 pandemic provoked a change to normal surgical practice in the United Kingdom and led to an increase in acute appendicitis (AA) patients being treated conservatively with antibiotics. We aim to analyse the management of patients presenting with AA to our institution during the first wave of the pandemic, comparing surgically and conservatively managed patients. Method All patients presenting to our centre with AA between March and July 2020 were included. Six-month follow-up data were collected retrospectively using electronic records. Patients were categorised into surgically and conservatively managed groups. The primary outcome was the complication rate (post-operative complications vs failure of antibiotic treatment) and the secondary outcomes were length of hospital stay and Alvarado score. Results  Fifty-seven patients (n=57) were admitted with AA, 45.6% (n=26) managed conservatively compared to 54.4% (n=31) treated surgically. Higher complication rates were observed amongst the conservatively managed group, although not found to be statistically significant (16% vs 35%; p=0.131). There was no significant difference in length of hospital stay observed between the two groups (surgical: median, 2; interquartile range, 2-3 vs conservative: median, 3; interquartile range, 2-4). White cell count (WCC) and Alvarado score were higher on admission in the surgical group with statistical significance (p=0.012 and p=0.028, respectively). Conclusions COVID-19 has led to a significant cohort of conservatively managed AA patients in the United Kingdom. We propose a stratification pathway based on clinical severity, Alvarado score and imaging to facilitate safe selection for conservative management of AA, in order to reduce failure of treatment rates in this patient group. Further UK-based studies will add to the evidence-based surrounding safe management of AA with conservative treatment.

The impact of COVID-19 on primary retinopexy in preventing retinal detachment in a tertiary eye hospital emergency department

PURPOSE

To review the effect of COVID-19 on rhegmatogenous retinal detachment (RRD) rate following primary retinopexy.

METHODS

Retrospective consecutive case series of 183 patients attending Birmingham and Midlands Eye Centre undergoing primary retinopexy (cryotherapy and laser) between March 23rd to June 30th in 2019 (Group 1) and 2020 (Group 2).

RESULTS

In total we reviewed 183 retinopexies, 122 in Group 1 and 61 in Group 2, a reduction of 50%. In Group 2 compared to Group 1, we showed a significant difference in characteristics of patients having primary retinopexy with an increase in proportion of male patients from 50 (41.0%) to 39 (63.9%) (p = 0.005), increase in high myopes from 1 (0.8%) to 4 (6.6%) (p = 0.043), more slit lamp laser retinopexy from 83 (68.0%) to 52 (85.2%) (p = 0.013) and less cryopexy from 21 (17.2%) to 2 (3.3%) (p = 0.008). In Group 2, primary retinopexy resulted in significantly more 3-month RRD rate 1 (0.8%) to 5 (8.2%) (p = 0.016). There were no changes in number of patients requiring further retinopexy (p = 1.000).

CONCLUSION

This study demonstrates a reduction of primary retinopexy, an increased risk for RRD following primary retinopexy and a significant shift in type of primary retinopexy performed, demographics, operator and change in characteristics of type of retinal break observed during this pandemic. This study contributes to the growing literature of the secondary effects of the COVID-19 pandemic on other aspects of healthcare that is not just limited to the virus itself.

Vitrectomy with air tamponade and cryotherapy for retinal detachment repair without perfluorocarbon use: A UK 12-month prospective case series

INTRODUCTION

Rhegmatogenous retinal detachment (RRD) is commonly managed by pars plana vitrectomy (PPV). Gas tamponade has significant clinical and quality of life factors that affect the patient. Using shorter acting air tamponade, intuitively leads to surgical concern for higher rate of primary detachment. To circumvent this, surgeons advocate the use of perfluorocarbon to maximise sub-retinal-fluid drainage when using air tamponade and/or avoid using cryotherapy due to longer duration for scar formation relative to laser. These steps are a deviation from traditional technique for otherwise routine primary RRD repair and discourages popularisation of using air tamponade despite the benefits to patients.

METHOD

Prospective 12-month, single centre, single surgeon, consecutive study from January to December 2019. Inclusion criteria was as per based on the pneumatic retinopexy versus vitrectomy for retinal detachment: (i) single retinal break or group of breaks, no larger than 1-clock-hour (30°), in detached retina; (ii) all breaks in detached retina lie above the 8 to 4 o'clock meridian; and (iii) breaks or lattice degeneration in attached retina at any location. We excluded PVR formation and RRD in the inferior 4 o'clock hours.

RESULTS

We report primary and final success rate of 96% and 100%, respectively in 23 eyes (22 macular-on and one macular-off) with RRD eyes in a 12-month period. Cryopexy was utilised in 65% patients and in isolation in 23% with no perfluorocarbon use in all eyes.

CONCLUSION

We show cryotherapy can be used safely in AT-RRD without PFCL in RRD fulfilling PIVOT trial criteria with minimal cataract formation and IOP spikes and faster post-operative visual rehabilitation.

Calculating the economic burden of presumed microbial keratitis admissions at a tertiary referral centre in the UK

Purpose

Microbial keratitis (MK) is the most common non-surgical ophthalmic emergency admission in the UK. However, few prospective health-economic studies of MK have been performed, and no specific healthcare resources group (HRG) code exists. This study is designed to determine the feasibility of a data collection tool derived from the microbiology ophthalmology group (MOG) clinical record form, to enable quantification of direct costs of inpatient care, as well as prospective capture of epidemiological data relating to outcomes of MK.

Methods

Clinical, demographic and economic data were collected retrospectively between January and December 2013 for 101 consecutive patients admitted with MK, using an adaption of the MOG toolset. The direct cost of admission (COA) was calculated using national reference costs and compared to actual income to generate profit/deficit profiles for individual patients. Indices of multiple deprivation were used to assess effect of deprivation on the COA.

Results

The total income generated through discharge coding was £252,116, compared to a COA of £357,075, yielding a deficit of £104,960 (median: £754 per patient). The cost deficit increased significantly with length of stay (LOS, p < 0.001), whilst patients with short LOS were income generators; cost neutrality occurred at 4.8 days. Greater socioeconomic deprivation was also associated with a significantly higher cost deficit.

Conclusion

LOS is the key driver for COA of care for MK admissions. Protocols should encourage discharge of patients who are able to self-administer treatment after the sterilisation phase. The MOG-derived data collection toolset captures pertinent clinical data for quantification of COA. Further development into a multiuser and multisite platform is required for robust prospective testing, together with expansion to capture indirect costs of disease burden, including impact of treatment, visual morbidity and quality of life.

Restructuring emergency eye services during COVID-19 in a tertiary referral centre

BACKGROUND/AIMS

Maintaining emergency eye services is crucial during the COVID-19 pandemic. This article describes the introduction of a new restructured referral pathway to reduce the burden on healthcare providers and create a safe environment.

METHODS

During January and February 2020 (group 1), all appointments were face-to-face with a walk-in eye casualty. The first audit cycle comprised all patients in group 1. The primary audit criteria were discharge rates, referral to subspeciality and reattendance. In April 2020, a remodelled system was implemented in which walk-in attendance ceased and was replaced with telephone triage coupled with digital imaging via NHS email for remote clinical review. Patients requiring further assessment following this triage were invited in for face-to-face appointments. A reaudit was conducted during April-July 2020 (group 2) following implementation of these COVID-19 protocol changes.

RESULTS

In group 1, 2868 appointments (100.0%) were face-to-face and in group 2 4870 (100.0%) appointments were telephone consults that resulted in 2639 (54.2%) face-to-face appointments. The rate of discharge in the first cycle and second cycle were 55.3% and 76.9% respectively (P<0.0001). Furthermore 2298 (47.2%) patients were able to be discharged following telephone consultation in group 2.

CONCLUSIONS

Using this telephone and digital imaging review triage system, the authors have demonstrated a significant reduction in the need for face-to-face reviews. The reduction in avoidable patient face-to-face reviews allows the system to move from saturated to sustainable while increasing accessibility to services for patients who may not be able to present for face-to-face review. This complete audit cycle successfully charts interventions that maximise accessibility, reduce unnecessary hospital visits and deliver safe and prompt management during the pandemic.

Using the West Midlands CONCERT to characterise regional incidence of acute-onset post cataract surgery endophthalmitis

BACKGROUND

Whilst research and innovation is embedded within the UK's National Health Service (NHS) constitution, Doctors-in-training have little opportunity to contribute to designing, leading and recruiting into clinical trials or cohort studies. We formed the West Midlands Collaborative Ophthalmology Network for Clinical Effectiveness & Research by Trainees (The West Midlands CONCERT) and undertook a characterisation of post cataract surgery endophthalmitis as a proof-of-concept study to test the feasibility of the CONCERT model.

METHODS

Doctors-in-training formed a collaborative working group to test the concept of delivering a pan-regional clinical effectiveness study across multiple hospital sites by performing retrospective analyses of post cataract endophthalmitis over a 6-year period.

RESULTS

Overall, 157,653 cataract surgeries were performed by participating centres accredited to deliver the Royal College of Ophthalmologists training curriculum. Thirty-eight cases of post cataract endophthalmitis were identified, giving an incidence of 2.41 per 10,000 cases (0.0241%). A further 15 endophthalmitis cases presented who had surgery in non-training centres, giving a total of 53 cases. The most common organisms were S. epidermidis (14 (51.9%)) and P. aeruginosa (5 (18.5%)). Anterior-chamber and vitreous sampling yielded positive culture in 33.3% (6/18) and 50.9% (27/53), respectively. At 6 months follow-up, 19 (51.4%) patients achieved visual acuities of ≤0.5 LogMAR. Repeat intravitreal injections (11 (20.8%)) and vitrectomy (n = 22 (41.5%)) were not associated with better outcomes.

CONCLUSIONS

Using post cataract endophthalmitis as a pilot cohort, this study highlights the feasibility of using the CONCERT model for studies across multiple sites. A UK-CONCERT could provide a powerful infrastructure enabling characterisation of patient cohorts and a platform for high-quality interventional studies, improving patient care.

Redeployment of ophthalmologists in the United Kingdom during the Coronavirus Disease Pandemic

BACKGROUND

During the current coronavirus (COVID-19) pandemic, some ophthalmologists across the United Kingdom (UK) have been redeployed to areas of need across the National Health Service (NHS). This survey was performed to assess aspects of this process including training & education, tasks expected, availability of personal protection equipment (PPE) used and the overall anxiety of ophthalmologists around their redeployment.

METHOD

Online anonymous survey around the existing guidance on safe redeployment of secondary care NHS staff and PPE use by NHS England and Public Health England respectively. The survey was open to all ophthalmologists across the UK irrespective of their redeployment status.

FINDINGS

145 surveys were completed and returned during a 2-week period between 17th April 2020 and 1st May 2020, when 52% of ophthalmologists were redeployed. The majority of this group consisted of ophthalmologists in training (79%). 81% of those redeployed were assigned to areas of the hospital where patients with confirmed Coronavirus disease were being treated as inpatients. There was a statistically significant improvement in anxiety level following redeployment which was mainly attributed to the support received by staff within the redeployed area. 71% of the redeployed group were found to have sufficient PPE was provided for the area they worked in.

INTERPRETATION

This is the first national survey performed on redeployment of ophthalmologists in the UK. The study showed that ophthalmologists across all grades were able to contribute in most aspects of patient care. Anxiety of redeployment was reduced by prior training and good support in the redeployment area.

Optical coherence tomography of cutaneous lupus erythematosus correlates with histopathology

Diagnosis of cutaneous forms of lupus erythematosus (LE), including chronic discoid LE (CDLE) and subacute cutaneous LE (SCLE), is usually based on characteristic clinical and histopathological findings. We aimed to visualize morphological changes in lesions of cutaneous LE using optical coherence tomography (OCT), and to correlate the OCT findings with histopathology. Six patients with CDLE and five patients with SCLE were investigated. Prior to skin biopsy, OCT assessment was performed on previously marked lesions. The images of OCT and corresponding histology were evaluated side-by-side on the PC screen. The thickening and disruption of the entrance signal in OCT images correlated with the hyperkeratosis which was observed in the histological sections. Atrophy of the epidermis, which was demonstrated by histology, could also be detected in the OCT pictures showing a thinned layer below the entrance signals. On OCT, a patchy reduction of reflectivity was observed in the upper dermis corresponding to dense patchy, partly lichenoid, lymphocytic infiltrates and oedema of the upper dermis. Furthermore, OCT images displayed increased signal-free cavities which histopathologically corresponded to dilated vessels in the upper dermis. All OCT parameters studied significantly (P < 0.05) correlated with histopathological features as indicated by coefficients of correlation ranging from 0.55 to 0.94. OCT enables to demonstrate micromorphological changes in cutaneous LE which correlate with histopathological findings. Nevertheless, the current technique does not allow one to visualize definite diagnostic features of cutaneous LE. However, OCT may be a promising method for objective monitoring of LE activity and treatment effects over time in vivo