Increasing frequency of hospital admissions for retinal detachment and vitreo-retinal surgery in England 2000-2018

The necessity and role of scleral buckling for rhegmatogenous retinal detachment

PURPOSE OF REVIEW

With a decline in the use of scleral buckling for rhegmatogenous retinal detachment (RRD) repair in recent years, this review seeks to provide a summary of the most recent research findings regarding the role of scleral buckling in the repair of RRD.

RECENT FINDINGS

Many recent studies have compared visual and anatomic outcomes between scleral buckling and pars plana vitrectomy (PPV) for RRD repair. Some suggest superior outcomes with primary scleral buckling, particularly in younger, phakic patients, and in association with other risk factors that we review. Children do best with primary scleral buckling surgery. Functionally, scleral buckling may also result in lower rates of retinal displacement compared to PPV. When PPV is necessary, a supplemental buckle may benefit certain patients, while the advantage remains unclear in other clinical scenarios and necessitates further investigation.

SUMMARY

Scleral buckling is an important technique for the repair of RRD and it is crucial to continue training retina surgeons in this technique to maximize patient outcomes.

Updates on Treatment Modalities for Primary Rhegmatogenous Retinal Detachment Repair

Rhegmatogenous retinal detachment, a severe eye condition, presents anatomic separation of the neurosensory retina from its outermost layer-the retinal pigment epithelium. Early recognition of this relatively common finding and proper referral of patients to the retinal surgery department is essential in order to minimize its consequent possible severe reduction in vision. Several major surgical methods for the repair of primary rhegmatogenous retinal detachment have been in use over the last several decades, and they all aim to find and close the break in the retina that has caused the detachment. Surgery can be performed as pneumatic retinopexy, pars plana vitrectomy, and/or episcleral surgery (buckling). General surgical trends for reattaching the retina include moving from extraocular to intraocular surgery and from bigger gauge to smaller gauge via minimal invasive vitrectomy surgery (MIVS), with implementing shorter-lasting intraocular tamponades. Surgical options for rhegmatogenous retinal detachment treatment nowadays emphasize gaining retinal reattachment, preferably with one surgery and with minimum damage to the eye. The procedure should not bring secondary eye conditions and complications with severe impairment of visual acuity, and it should be performed on as much as a smaller budget, with possibly peribulbar anesthesia, enabling the patient the quickest possible recovery. It should be adjusted to the patient's condition, not to the surgeon's skills or preferences.

Clinical features of retinal detachment treated with segmental scleral buckling

PURPOSE

Our study aims to evaluate the surgical outcomes and clinical features of retinal detachment (RD) cases treated with segmental scleral buckling (SB), elucidating the role of segmental SB as a vital option in specific situations during the current era.

METHODS

We retrospectively reviewed 128 eyes with primary rhegmatogenous RD that underwent segmental scleral buckling between November 2008 and December 2020. Clinical features and success rates were recorded and analyzed.

RESULTS

A total of 128 eyes were included. The patient's ages ranged from 12 to 72 years, with a median age of 45. Most of the eyes were phakic (97%). Regarding the type of break, 47% were holes, and flap tears were found in 68 cases (53%). The break locations were superior-temporal (54%), inferior-temporal (31%), superior-nasal (9.5%), and inferior-nasal (5.5%). The length of the SB applied ranged from 3.5 to 8.0 clock hours, with a median of 6.0. Primary success was achieved in 121 eyes, and recurrence occurred in 7 eyes. All recurrent RD cases reattached after undergoing secondary VT. The causes of failure included 2 break reopens, 1 missed break, and 4 eyes with proliferative vitreoretinopathy. The single-surgery anatomic success (SSAS) rate for segmental SB was 94.5%. The final success rate was 100%.

CONCLUSIONS

For phakic, low complexity retinal detachment in our study, segmental scleral buckling emerges as a surgical option with a high primary success rate and a lower incidence of complications.

Recurrences and Macular Complications after Perfluorocarbon-Liquid-Free Vitrectomy for Primary Rhegmatogenous Retinal Detachment

INTRODUCTION

This study investigates factors associated with recurrent rhegmatogenous retinal detachment (RRD), macular complications, and visual outcomes after pars plana vitrectomy (PPV) without perfluorocarbon liquids (PFCLs) for primary RRD.

METHODS

A longitudinal cohort study included consecutive patients with RRD who underwent PFCL-free PPV. Postoperative visual acuity and spectral-domain optical coherence tomography findings [cystoid macular edema (CME), epiretinal membrane (ERM), ellipsoid zone/interdigitation zone (EZ/IZ) damage] were collected. Logistic regression and linear mixed models analyzed rates and risk factors for RRD recurrence, CME, ERM, EZ/IZ damage, and visual acuity at 12 months.

RESULTS

346 eyes with RRD were studied. Single-operation success rates were 96% and 93% for uncomplicated (n = 274 eyes) and complicated (n = 72 eyes) RRD, respectively. Factors associated with RRD recurrence were posterior retinal breaks [odds ratio (OR) = 10.7 compared to peripheral retinal breaks, p = 0.008], silicone oil tamponade (OR = 5.66 compared to gas, p = 0.01), and sectorial laser retinopexy (OR = 4.34 compared to 360° laser retinopexy, p = 0.007). The prevalence of CME, ERM, and EZ/IZ damage at 12 months was 10%, 9%, and 6%, respectively. Eyes with EZ/IZ defects had worse postoperative visual acuity in both uncomplicated and complicated RRD. Proliferative vitreoretinopathy (OR = 2.95, p = 0.03) and silicone oil tamponade (OR = 3.70 compared to gas, p = 0.05) were associated with EZ/IZ damage.

CONCLUSIONS

PFCL-free PPV demonstrated satisfactory single-operation success rates for uncomplicated and complicated RRD, with a low prevalence of macular complications. Analyzing factors associated with RRD recurrence can provide provisional recommendations for PFCL-free approaches in the absence of randomized trials.

Postprocedural Disorders of Eye and Adnexa Admissions Profile

Purpose

The aim of this study was to examine hospitalisation profiles related to postprocedural disorders of eye and adnexa in England and Wales.

Patients and Methods

This was an ecological study using publicly available data extracted from the "Hospital Episode Statistics (HES) database" in England and the "Patient Episode Database for Wales (PEDW)" for the period between April 1999 and April 2020. Diagnostic code for postprocedural disorders of eye and adnexa (H59) was used to identify hospital admission. We used the chi-squared test to assess the difference between the hospital admission rates between 1999 and 2020.

Results

Hospital admission rate decreased by 6.3% [from 4.98 (95% CI 4.79-5.17) in 1999 to 4.67 (95% CI 4.50-4.84) in 2020 per 100,000 persons, trend test, p<0.05]. The most common hospital admissions causes were other postprocedural disorders of eye and adnexa "Chorioretinal scars after surgery for detachment." The age group 75 years and above accounted for 44.3% of the total number of admissions. Hospital admission rate among females decreased by 30.2% [from 5.90 (95% CI 5.61-6.19) in 1999 to 4.12 (95% CI 3.89-4.35) in 2020 per 100,000 persons]. Hospital admission rate among males increased by 30.2% [from 4.02 (95% CI 3.77-4.26) in 1999 to 5.23 (95% CI 4.97-5.49) in 2020 per 100,000 persons].

Conclusion

This study revealed that hospital admission rates for postprocedural disorders of the eye and adnexa decreased over the course of the study period. Eye and adnexa disorders accounted for the preponderance of hospital admissions among the elderly. Further research is required to identify risk factors that can be avoided.

The Cost of Standard and Complex Pars Plana Vitrectomy for Retinal Detachment Repair Exceeds Its Reimbursement

OBJECTIVE

To measure the total costs and reimbursements associated with standard and complex pars plana vitrectomy using time-driven activity-based costing (TDABC).

DESIGN

Economic analysis at a single academic institution.

SUBJECTS

Patients who underwent standard or complex pars plana vitrectomy (PPV; Current Procedural Terminology codes 67108 and 67113) at the University of Michigan in the calendar year 2021.

METHODS

Process flow mapping for standard and complex PPVs was used to determine the operative components. The internal anesthesia record system was used to calculate time estimates, and financial calculations were constructed from published literature and internal sources. A TDABC analysis was used to determine the costs of standard and complex PPVs. Average reimbursement was based on Medicare rates.

MAIN OUTCOME MEASURES

The primary outcomes were the total costs for standard and complex PPVs and the resulting net margin at current Medicare reimbursement levels. The secondary outcomes were the differential in surgical times, costs, and margin for standard and complex PPV.

RESULTS

Over the 2021 calendar year, a total of 270 standard and 142 complex PPVs were included in the analysis. Complex PPVs were associated with significantly increased anesthesia time (52.28 minutes; P < 0.001), operating room time (51.28 minutes; P < 0.0001), surgery time (43.64 minutes; P < 0.0001), and postoperative time (25.95 minutes; P < 0.0001). The total day-of-surgery costs were $5154.59 and $7852.38 for standard and complex PPVs, respectively. Postoperative visits incurred an additional cost of $327.84 and $353.86 for standard and complex PPV, respectively. The institution-specific facility payments were $4505.50 and $4935.14 for standard and complex PPV, respectively. Standard PPV yielded a net negative margin of -$976.93, whereas complex PPV yielded a net negative margin of -$3271.10.

CONCLUSIONS

This analysis demonstrated that Medicare reimbursement is inadequate in covering the costs of PPV for retinal detachment, with a particularly large negative margin for more complex cases. These findings demonstrate that additional steps may be necessary to mitigate adverse economic incentives so that patients continue to have timely access to care to achieve optimal visual outcomes after retinal detachment.

FINANCIAL DISCLOSURE(S)

The authors have no proprietary or commercial interest in any materials discussed in this article.

Hospitalisation Trends for Choroid and Retina Diseases in the Past 20 Years: An Ecological Study in Australia

Background

Choroidal and retinal disorders significantly contribute to vision impairment, often necessitating hospitalization for the purposes of diagnosis, treatment, and continued care. The aim of this study was to examine hospitalisation trends of choroid and retina diseases in the past 20 years in Australia.

Methods

This was an ecological study that used publically available data in Australia from 1998 to 2021. The National Hospital Morbidity Database (NHMD) is an online database that was used to collect the data for this study. We used the chi-squared test to assess the difference between the hospitalisation rates between 1998 and 2021.

Results

During the study period, hospital admission rate for choroid and retina diseases increased by 13.21-fold [from 29.54 (95% CI 28.77-30.32) in 1998 to 419.70 (95% CI 417.21-422.20) in 2021 per 100,000 persons, p<0.001]. Same-day hospital admission patients accounted for 90.3% of the total number of episodes. Rates of same-day hospital admission increased by 37.70-fold [from 9.24 (95% CI 8.81-9.68) in 1998 to 357.78 (95% CI 355.48-360.09) in 2021 per 100,000 persons]. Rates of overnight-stay hospital admission decreased by 19.3% [from 20.34 (95% CI 19.69-20.98) in 1998 to 16.41 (95% CI 15.91-16.90) in 2021 per 100,000 persons]. Females contributed to 54.6% of the total number of hospital admission. Admission rate among females increased by 16.01-fold [from 23.68 (95% CI 22.70-24.66) in 1998 to 402.78 (95% CI 399.33-406.22) in 2021 per 100,000 persons]. Admission rate among males increased by 8.69-fold [from 35.57 (95% CI 34.36-36.78) in 1998 to 344.80 (95% CI 341.58-348.02) in 2021 per 100,000 persons].

Conclusion

In this ecological investigation, we found that the admission rate for choroid and retina disorders increased dramatically. The preponderance of these admissions were made up of females and elderly patients. Future research is required to identify additional risk factors for disorders of this type.

Are Retinal Detachments Becoming More Frequent? Data from 2 University Eye Clinics and Literature Review

There have been marked increases in the numbers of patients with retinal detachments at individual centres in recent years and this is supported by the subjective impression of many experts. We therefore surveyed the literature on changes in the incidence of retinal detachments worldwide. This revealed quite significant methodological differences between the studies, so that it was difficult to achieve a conclusive comparison of the development of the incidence of retinal detachment. Despite these limitations, all data from recent studies suggest an increase in the number of retinal detachments. The incidence of retinal detachment in the western world currently seems to be more than 20 cases per 100,000 person-years, which is significantly higher than described in earlier decades. It can be assumed that an increase in the number of individuals with myopia, a demographic increase in patients of the typical age group for retinal detachment and an increasing number of cataract surgeries, especially in younger patients, are responsible for the rising incidence of retinal detachment.

A Comparative Study of Traditional Scleral Buckling to a New Technique: Guarded Light Pipe with Heads-Up Three-Dimensional Visualization

Purpose

The guarded light pipe is a recently described alternative endoillumination technique to chandelier illumination. We sought to compare the outcomes of scleral buckling (SB) under indirect ophthalmoscopy (ID) to heads-up three-dimensional visualization with a guarded light pipe (3DGLP).

Methods

A retrospective comparative study was performed, including 47 eyes that underwent SB for rhegmatogenous retinal detachment (RRD) repair with either traditional ID (n = 31) or 3DGLP (n = 16).

Results

The single surgery anatomic success rate was 87.0% in the ID group and 87.5% in the 3DGLP group. The final anatomic success rate was 100% in both groups. The median (interquartile range) post-operative logMAR was 0.10 (0.0–0.20) in the ID group and 0.08 (0.02–0.69) in the 3DGLP group (p = 0.51). The median operative time was 107 (94–123) minutes in the ID group and 100 (90–111) minutes in the 3DGLP group (p = 0.25). Among eyes that underwent subretinal fluid drainage, the operative time was significantly longer in the ID group compared to the 3DGLP group, 113 (100–135) minutes vs 93 (85–111) minutes (p = 0.035). There were no post-operative complications in the ID group and one complication of self-resolving vitreous hemorrhage associated with a malfunctioning cryoprobe in the 3DGLP group (p = 0.34). There were no cases of post-operative cataract progression in either group.

Conclusion

Compared to traditional SB, 3DGLP improves ergonomics and educational value with similar anatomical, visual, intra and post-operative outcomes and may result in shorter operative time in cases requiring subretinal fluid drainage.

The Scottish RD survey 10 years on: the increasing incidence of retinal detachments

BACKGROUND

The Scottish RD Survey reported an incidence of 12.05/100,000/yr in 2009. Data published from Denmark recently confirmed a 50% increase in RD presentations over the last 16 years. We set out to repeat the Scottish RD survey to determine if a similar trend has been observed in Scotland.

METHODS

All 16 Scottish VR surgeons, who make up the collaboration of Scottish VR Surgeons (SCVRs) were asked to prospectively record all primary RDs presenting from 12th August 2019 to 11th August 2020. For consistency, the case definitions were the same as for the 2009 Scottish RD Survey. Basic demographic and clinical features were recorded. Age specific incidence was calculated from mid-year population estimates for 2019 obtained from the National Records of Scotland.

RESULTS

There were 875 RRDs recorded, which gives an updated incidence of 16.02/100,000/year in Scotland. 62.8% occurred in males and the greatest increases were seen in males aged 50-59 (p = 0.0094), 60-69 (p = 0.0395) and females aged 40-49 (p = 0.0312) and 50-59 (p = 0.0024). The proportion of pseudophakic RRDs in this study is 29.4% (253/860). Compared to the 21.6% in the 2010 study, this represents a 28% increase (χ² = 11.03, p = 0.0009). The proportion of macula-off RRDs remained generally stable at 58%.

CONCLUSION

Our study confirms that RRD is becoming more common in the UK, reflecting almost identical findings from Denmark. This trend is in part due to increasing myopia, increasing pseudophakia, and possibly other factors. This should be considered when planning VR services and allocating resources in the future.

Emergent Ophthalmic Disease Knowledge among Non-Ophthalmologist Healthcare Professionals in the Western Region of Saudi Arabia: Cross-Sectional Study

Background:

Patients with emergent ophthalmic diseases are likely to be examined by healthcare providers before an ophthalmologist, so it is essential that nonspecialists have adequate knowledge for recognition and preliminary diagnosis.

Objectives:

To assess knowledge of retinal detachment, acute angle-closure glaucoma, temporal arteritis, and central retinal artery occlusion among non-ophthalmologist healthcare professionals.

Methods:

We conducted an observational cross-sectional study of 351 healthcare workers, including medical residents, nurses, pharmacists, and optometrists, in western Saudi Arabia using a self-report questionnaire.

Results:

Total knowledge scores were 75.21% for retinal detachment and 74.9% for acute angle-closure glaucoma, but only 44.15% for temporal arteritis and 41.88% for central retinal artery occlusion. Stepwise logistic regression revealed that level of education was the most significant factor influencing knowledge of different eye diseases.

Conclusion:

Ophthalmologists are encouraged to promote greater awareness and provide other healthcare professionals with the knowledge required to recognize emergent eye diseases for early detection.

More Needs to Be Done During the Informed Consent Process

Retinal detachment is an emergency commonly encountered in ophthalmic practice. In this article, a reflection about the ethical implications surrounding the informed consent process of retinal detachment repair is presented. We look at how premade informed consent forms allow for a better patient understanding of their condition, the procedure they are due to undergo, their postoperative course, and the potential complications they might face, hence potentially improving the overall outcome.