ROYAL COLLEGE OF OPHTHALMOLOGISTS' NATIONAL DATABASE STUDY OF VITREORETINAL SURGERY: Report 7, Intersurgeon Variations in Primary Rhegmatogenous Retinal Detachment Failure

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.

Outcomes of Rhegmatogenous Retinal Detachment Repair When Comparing Surgeon Continuity in a Team-Based Practice

BACKGROUND AND OBJECTIVE

To facilitate timely surgery and efficient use of operating room time, our practice uses a team-based approach so patients may undergo primary rhegmatogenous retinal detachment (RRD) surgery with a different surgeon instead of the diagnosing surgeon.

PATIENTS AND METHODS

This was a retrospective cohort study of 331 eyes that underwent RRD surgery. Patients were divided into two groups: RRD surgery performed by the diagnosing surgon, and RRD surgery performed by a different surgeon.

RESULTS

Of 331 eyes, 200 eyes (60.4%) were repaired by the diagnosing surgeon and 131 eyes (39.6%) were repaired by a different surgeon. Primary anatomic success (PAS) rates at 3 months postoperatively were equivalent between the two groups (87.0% and 87.8% in the diagnosing surgeon and different surgeon groups, respectively [P = .83]). There was no significant difference in preoperative (P = .08) or final (P = .28) visual acuity between the groups. Time between diagnosis and RRD repair was shorter in the different surgeon group (median of 1.5 days [IQR: 1.0-3.6] in the surgeon group versus 2.2 days [IQR: 0.8-5.7] in the diagnosing surgeon group) (P = .03). Logistic regression analysis gave no evidence to suggest that PAS rates depended on day of week, time of day surgery was performed, group, or the interaction between those factors (P = .93).

CONCLUSIONS

Visual and anatomic success in RRD repair are equivalent when surgery is performed by either the diagnosing surgeon or a surgical colleague because time to surgery is reduced. Neither time of day nor day of the week had any influence on the outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:560-566.].

Parsplana vitrectomy alone versus parsplana vitrectomy combined with phacoemulsification for the treatment of rhegmatogenous retinal detachment: a randomized study

BACKGROUND

To compare parsplana vitrectomy (PPV) with and without phacoemulsification to treat rhegmatogenous retinal detachment (RRD).

METHODS

Subjects aged 48-65 years with RRD in a phakic eye due to superior retinal tears with an overall extension of retinal breaks < 90° underwent to PPV alone (group A); or PPV plus phacoemulsification (phacovitrectomy, PCV, group B). Post-operative follow-up visits occurred at 1 week, 1 month (m1), 3 months (m3), and 6 months (m6) after surgery. The main outcome was the rate of retinal reattachment. Secondary outcomes included best-corrected visual acuity (BCVA), intraocular pressure (IOP), central macular thickness (CMT), and cataract progression (in the lens-sparing [PPV-alone] group).

RESULTS

In this initial phase of the study a total of 59 patients (mean age: 55 years, 59 eyes) were enrolled: 29 eyes in group A and 30 eyes in group B. Both groups had similar gas tamponade. During the follow-up there were three cases of RRD recurrence in group A and one in group B. The relative risk of recurrence in group A was 3.22 times higher but the difference was not significant (p = 0.3). The two groups were also similar in terms of BCVA and IOP variation. At m3, CMT was significantly higher in group B (p = 0.014). In group A, cataract progression was significant at m6 (p = 0.003).

CONCLUSIONS

In a cohort of RRD patients selected according to their preoperative clinical characteristics, PPV was comparable to PCV in terms of the rate of retinal reattachment after 6 months.

TRIAL REGISTRATION

ISRCTN15940019 . Date registered: 15/01/2021 (retrospectively registered).

Preoperative factors to select vitrectomy or scleral buckling for retinal detachment in microincision vitrectomy era

BACKGROUND

To determine the preoperative factors associated with selecting scleral buckling (SB) or pars plana vitrectomy (PPV) to treat rhegmatogenous retinal detachments (RRDs) in the era of microincision vitrectomy surgery.

METHODS

A nationwide, multicenter, observational study in the Japan Retinal Detachment Registry was done. From February 2016 to March 2017, 3446 cases were registered, and 3219 among them were analyzed. The factors related to the patient or surgeon were selected; the surgeon's factor included years of experience, number of cases registered, and current activity. The odds ratio (OR) for factors associated with SB or PPV was estimated by a mixed logistic regression model.

RESULTS

SB was selected in 24.2% (779/3219), PPV was in 71.5% (2238/3219), and PPV+SB was in 6.3% (202/3219). Multivariate analysis showed that age [< 70 years old, OR 4.27, 95% confidence interval (CI) 2.34-7.79, P < 0.001], visual acuity [1.0+ (OR 7.41, 95% CI 3.47-15.82, P < 0.001)], pseudo-phakia (OR 4.83, 95%CI 2.11-10.56, P < 0.001), retinal tear (OR 6.92, 95% CI 4.83-9.92, P < 0.001), breaks at/near the vitreous base (OR 8.07, 95% CI 3.50-18.62, P < 0.001), 90+° retinal tear (OR 108.24, 95% CI 7.44-1574.34, P < 0.001), and number of breaks 4+ (OR 3.15, 95% CI 1.95-5.09, P < 0.001), were significantly associated with selecting PPV over SB. The surgeons' activity defined as the number of cases experienced during the registry period was related to the selection of PPV (OR 3.83, 95% CI 2.11-6.93, P < 0.001).

CONCLUSIONS

The choice of PPV for the RRD was associated not only with patients' preoperative factors but also the surgeon's activity. Active surgeons selected PPV more than SB.

Evolving trends in strabismus following retinal surgery: is there still a role for botulinum toxin?

Purpose Ocular motility disturbances following retinal detachment surgery are well documented, resulting in ocular misalignment and disabling diplopia. Interestingly, there has been a downward trend over the last decade across the United Kingdom with the evolution of refined vitrectomy techniques and instrumentation. We aim to report our updated experience on factors influencing botulinum toxin outcomes in view of the trend toward vitrectomy. Methods The Moorfields strabismus service carried out a follow-up retrospective study of all subjects that received botulinum toxin for retinal surgery-related strabismus at our center over an eleven-year period. All new onset constant or intermittent strabismus following retinal detachment surgery were included. Botulinum toxin response was stratified to good and poor. Results 32 patients fulfilled our criteria, with a mean follow-up of 20 months. The majority were vitrectomised eyes (62%), presented with diplopia (60%) and exotropia (66%). All isolated and combined vertical deviations (18%) were noted among cryobuckled eyes only. Baseline largest mean horizontal deviation was 49 and 51 prism diopters (PD) among the good and poor responders, respectively. A statistically and clinically significant reduction in the horizontal angle of deviation was noted among the good (p < .0001) responders, requiring a mean of six injections, in comparison to the poor responders (p = .03). Of the good responders, five patients (16%) with decompensated phorias regained fusion control. A small number of complications (15%) were noted, the most marked being intractable diplopia in a good responder (3%) with failure to fuse. Conclusions Botulinum toxin is a useful treatment modality, particularly when surgical options are limited. It can restore binocularity in patients with preexisting fusion potential. Ocular cosmesis can be achieved but requires ongoing injections. Barriers to fusion restoration include multiple retinal surgeries, persistent macula pathology and central-peripheral retinal rivalry. This highlights the need for rigorous baseline macula assessment to allow a tailored approach when considering botulinum toxin therapy for strabismus.

Japan-Retinal Detachment Registry Report I: preoperative findings in eyes with primary retinal detachment

PURPOSE

To report the demographics and clinical characteristics of patients with a primary retinal detachment (RD).

DESIGN

Prospective cohort study by a registry design.

PARTICIPANTS

Patients with RD treated at vitreoretinal sub-specialty institutions in Japan from February 2016 to March 2017.

METHODS

Descriptive statistics for the primary RD, and multivariable ordered logistic regression and multiple linear regression analyses were performed.

RESULTS

3178 eyes of 3178 cases were analyzed. The interval from onset to surgery was significantly shorter in patients in the 40-year age group than in other age groups except for the 50-year age group (P<0.05, Steel-Dwass test). The proportion of complex cases was significantly higher in the 10-year, 70-year, and 80+ year age groups than in the 40 and 50-year age groups (P<0.05, Steel-Dwass test). The size of RD was significantly associated with the male sex (odds ratio, 1.29; 95% confidence interval [CI], 1.07 to 1.56; P=0.0085) and the interval from onset to surgery (odds ratio, 1.03 95% CI, 1.01 to 1.04; P=0.0014). Low IOPs in eyes with RD were significantly associated with an older age (-0.24 mmHg/10 years, 95% CI, -0.32 to -0.16], P<0.0001) and larger RD area (-0.91 mmHg/quadrant, 95% CI, [-1.06 to -0.76], P <0.0001).

CONCLUSION

Profile and clinical characteristics of patients with a primary RD were not exactly the same as previous reports. A preoperative low IOP was associated with several ocular factors while the area of RD was associated not only with ocular but with social factors as well.

Intraoperative OCT-Assisted Retinal Detachment Repair in the DISCOVER Study: Impact and Outcomes

PURPOSE

The purpose of this study is to evaluate intraoperative OCT (iOCT) utility and outcomes during retinal detachment (RD) repair.

DESIGN

The Determination of Feasibility of Intraoperative Spectral-Domain Microscope Combined/Integrated OCT Visualization during En Face Retinal and Ophthalmic Surgery (DISCOVER) intraoperative OCT study is a prospective Institutional Review Board-approved study.

PARTICIPANTS

Participants in the DISCOVER study undergoing surgical repair for RD.

METHODS

This was a post hoc analysis of eyes in the DISCOVER study undergoing surgical repair for RDs. Inclusion criteria included iOCT after perfluorocarbon liquid placement and at least 6 months follow-up. Exclusion criteria included severe retinal pathology unrelated to RD. Surgeons completed standardized questionnaires after each case evaluating the iOCT instrument's utility. Functional and surgical outcome data were collected at the latest available time point between 6 and 12 months. Outcomes were evaluated in 2 groups: uncomplicated primary and complex cases.

MAIN OUTCOME MEASURES

Intraoperative OCT utility, single-surgery success, and visual acuity outcomes.

RESULTS

A total of 103 eyes were included in this study: 51 uncomplicated primary and 52 complex cases. Intraoperative OCT provided valuable information in 36% of cases. In 12% of cases, iOCT data directly altered surgical decision making. There was a significantly higher rate of valuable iOCT feedback in complex cases compared with primary cases (50% vs. 22%, P < 0.01). Among primary cases, 48 (94%) had successful single surgery repair with a mean postoperative visual acuity of 20/47 compared with the complex group's 75% single surgery success (n=39) and mean postoperative visual acuity of 20/92.

CONCLUSIONS

This study affirms the potential impact of iOCT in assisting select cases of RD repair, particularly with complex pathology. The single surgery success rate was good with more than 80% of cases successfully repaired with 1 surgery.

Does the scleral encircling band provide a protective effect against the progression of diabetic retinopathy?

AIM

To evaluate the effect of scleral encircling bands on the development and progression of diabetic retinopathy (DR) in diabetic patients.

METHODS

The medical records of diabetic patients who underwent unilateral retinal detachment (RD) surgery using scleral buckle and encircling band were reviewed retrospectively. Both eyes of patients were included in the study: one eye in each patient had a scleral buckle with encircling band (the operated eye) and the other one is the non-operated eye. The demographic characters, duration of diabetes and period between surgery and the last recall visit were retrieved from each patient. All the cases underwent fundus photo and fluorescein angiography (when indicated) to confirm the DR staging.

RESULTS

Totally 25 patients fulfilled the inclusion and the exclusion criteria were become eligible for the study. A total of 50 eyes of 25 patients were enrolled in this analysis. The mean period of time passed from surgery with encircling band and the last reassessment visit was 12.5±2y. Even though DR could develop in the operated eyes, it was at a less degree of severity compared to the non-operated eyes of same patients (P=0.027).

CONCLUSION

Scleral encircling bands have protective effects against the development and progression of DR.

Rhegmatogenous retinal detachments: primary reattachment rates and visual outcomes over a 4-year period

BACKGROUND AND AIMS

To describe rhegmatogenous retinal detachment surgery in a Dublin tertiary referral centre over a 4-year period and to examine factors predictive of surgical and anatomical success.

METHODS

A retrospective study was performed by reviewing the surgical log and the charts of patients who underwent a primary retinal detachment repair in a specialist centre over a 4-year period between 2012 and 2015. We excluded exudative and tractional cases. Multiple parameters were recorded including macular status, visual acuity, type of procedure, complications and visual and anatomical outcomes at 6 months post operation. Primary reattachment rate was calculated alongside change in visual acuity. Chi-square testing and analysis of variance were utilized to determine the effect which lens status, macular status, extent of breaks and type of procedure had on outcome and visual success.

RESULTS

A total of 613 primary rhegmatogenous retinal detachment repairs were performed over the 4-year period. Our primary reattachment rate was calculated to be 88.58% (annual range 85.25-91.30%) with a perioperative complication rate of 2.94%. We noted a statistical significant improvement in VA with a median logMAR VA of 1.0 at presentation to 0.5 at 6 months post procedure. Macular status (chi-square test p = 0.15, X² = 2.072) and lens status (chi-square test p = 0.2974, X² = 1.086) had no statistical effect on the final anatomical outcome. However, eyes with giant retinal tears were more likely to redetach than those without (chi-square test p = 0.0069, X² = 7.3). There was no statistical significant difference in the proportion of eyes achieving visual success by surgery category (one-way ANOVA analysis p = 0.501).

CONCLUSIONS

This is the first study of its kind in Ireland and will help surgeons benchmark their results against international standards in the future. Accurate recording of logMAR acuity and intraoperative complications is imperative to assist with prospective studies.