Does surgical experience have an effect on the success of retinal detachment surgery?

ASSESSMENT OF SIMULATED SURGICAL DEXTERITY AFTER MODIFIABLE EXTERNAL EXPOSURES AMONG NOVICE VERSUS EXPERIENCED VITREORETINAL SURGEONS

PURPOSE

To evaluate novice and senior vitreoretinal surgeons after various exposures. Multiple comparisons ranked the importance of these exposures for surgical dexterity based on experience.

METHODS

This prospective cohort study included 15 novice and 11 senior vitreoretinal surgeons (<2 and >10 years' practice, respectively). Eyesi-simulator tasks were performed after each exposure. Day 1, placebo, 2.5 mg/kg caffeine, and 5.0 mg/kg caffeine; day 2, placebo, 0.2 mg/kg propranolol, and 0.6 mg/kg propranolol; day 3, baseline simulation, breathalyzer readings of 0.06% to 0.10% and 0.11% to 0.15% blood alcohol concentrations; day 4, baseline simulation, push-up sets with 50% and 85% repetitions maximum; and day 5, 3-hour sleep deprivation. Eyesi-generated score (0-700, worst-best), out-of-tolerance tremor (0-100, best-worst), task completion time (minutes), and intraocular pathway (in millimeters) were measured.

RESULTS

Novice surgeons performed worse after caffeine (-29.53, 95% confidence interval [CI]: -57.80 to -1.27, P = 0.041) and alcohol (-51.33, 95% CI: -80.49 to -22.16, P = 0.001) consumption. Alcohol caused longer intraocular instrument movement pathways (212.84 mm, 95% CI: 34.03-391.65 mm, P = 0.02) and greater tremor (7.72, 95% CI: 0.74-14.70, P = 0.003) among novices. Sleep deprivation negatively affected novice performance time (2.57 minutes, 95% CI: 1.09-4.05 minutes, P = 0.001) and tremor (8.62, 95% CI: 0.80-16.45, P = 0.03); however, their speed increased after propranolol (-1.43 minutes, 95% CI: -2.71 to -0.15 minutes, P = 0.029). Senior surgeons' scores deteriorated only following alcohol consumption (-47.36, 95% CI: -80.37 to -14.36, P = 0.005).

CONCLUSION

Alcohol compromised all participants despite their expertise level. Experience negated the effects of caffeine, propranolol, exercise, and sleep deprivation on surgical skills.

The Role of Preoperative Case Selection in the Training of Surgical Repair of Primary Rhegmatogenous Retinal Detachment

Purpose

To analyse single-operation anatomical success (SOAS) of primary rhegmatogenous retinal detachment (RRD) repair by junior vitreoretinal surgeons guided by preoperative individual case selection by an experienced mentor vitreoretinal surgeon.

Methods

Retrospective, single institute, observational study, included all patients who underwent standard pars plana vitrectomy (PPV) or combined encircling band (CB) and PPV and gas tamponade in the treatment of RRD from November 2021 to December 2022 were included. Preoperative selection for the surgery decision, whether standard PPV or combined CB & PPV was undertaken through the senior surgeon; according to the location and extensions of the RRD, number of retinal tears (RT) and lens status. We excluded patients with tractional retinal detachment, RD with proliferative vitreoretinopathy stage C, giant tears, trauma, previous scleral buckle, schisis RD and RD requiring silicone oil. The primary outcome measure was to evaluate the single-operation anatomic success (SOAS). Secondary outcome measures evaluated whether there was a statistical significant difference between both procedures.

Results

Eighty-two eyes were included in the study. Forty-five eyes were selected for combined CB&PPV and 37 eyes for standard PPV. SOAS was achieved in 40 eyes (88.8%) in combined group and 35 eyes (94.5%) in standard PPV group. There was no statistically significant difference in the success rate between both operations, p = 0.65.

Conclusion

Structured preoperative selection of standardized surgical techniques according to the degree of complexity of RD together with close supervision enables junior vitreoretinal surgeons in training to achieve re-attachment rates of more than 80% with both types of surgeries.

Weight-adjusted caffeine and β-blocker use in novice versus senior retina surgeons: a self-controlled study of simulated performance

BACKGROUND/OBJECTIVES

Tremor and expertise are potentially influenced variables in vitreoretinal surgery. We investigated whether surgeon experience impacts the association of microsurgical performance with caffeine and β-blockers weight-adjusted intake.

SUBJECTS/METHODS

Novice and senior surgeons (<2 and >10 practice years, respectively) were recruited in this self-controlled, cross-sectional study. A simulator's task sequence was repeated over 2 days, 30 min after the following exposures: day 1, placebo, 2.5 mg/kg caffeine, 5.0 mg/kg caffeine, and 0.6 mg/kg propranolol; and day 2, placebo, 0.2 mg/kg propranolol, 0.6 mg/kg propranolol, and 5.0 mg/kg caffeine. Outcomes were total score (0-700, worst-best), simulation time (minutes), intraocular trajectory (centimeters), and tremor-specific score (0-100, worst-best).

RESULTS

We recruited 15 novices (9 men [60%], 1.33 ± 0.49 practice years) and 11 seniors (8 men [72.7%], 16.00 ± 4.24 practice years). Novices performed worse after 2.5 mg/kg caffeine and improved following 0.2 mg/kg propranolol in total score (557 vs. 617, p = 0.009), trajectory (229.86 vs. 208.07, p = 0.048), time (14.9 vs. 12.7, p = 0.048), and tremor-score (55 vs. 75, p = 0.009). Surgical performance improved with propranolol post-caffeine but remained worse than 0.2 mg/kg propranolol in total score (570 vs. 617, p = 0.014), trajectory (226.59 vs. 208.07, p = 0.033), and tremor-score (50 vs. 75, p = 0.029). Seniors' tremor-score was lower after 2.5 mg/kg caffeine compared to 0.2 mg/kg propranolol (8 vs. 37, p = 0.015). Tremor-score following propranolol post-caffeine remained inferior to 0.6 mg/kg propranolol alone (17 vs. 38, p = 0.012).

CONCLUSION

While caffeine and propranolol were associated with performance changes among novices, only tremor was affected in seniors, without dexterity changes. The pharmacologic exposure impact on surgical dexterity seems to be offset by increased experience.

Incidence of early complications requiring treatment plan changes after vitreoretinal surgery: a single-center study in South Korea

BACKGROUND

Information regarding incidence of treatment plan changes may be useful when discussing postoperative treatment plans for patients. Moreover, it may help establish a standardized postoperative treatment plan. This study aimed to evaluate the incidence of early complications requiring treatment plan changes in patients following vitreoretinal surgery and investigate its risk factors.

METHODS

This single-center retrospective study included 465 patients who had undergone vitreoretinal surgery. The reasons, incidence, and timing of treatment plan changes within 14 days of surgery were identified. Potential factors associated with the changes, such as patient demographics, surgeon's experience, diagnoses, and type of surgery were also analyzed.

RESULTS

The treatment plan was changed in 76 patients (16.3%) at a mean of 4.0 ± 3.2 days after vitreoretinal surgery. The reasons for the plan changes were increased intraocular pressure (IIOP) in 66(86.8%), intraocular inflammation in 2(2.6%), corneal edema in 3(3.9%), leakage from the sclerotomy wound in 3(3.9%) patients, and combined IIOP and intraocular inflammation in 2(2.6%). The date of discharge was postponed because of treatment plan changes in 17 patients (22.4%). The incidence of plan changes was higher in patients who underwent gas or oil tamponade (P < 0.001) and those who underwent surgery performed by less experienced surgeons (P = 0.034).

CONCLUSIONS

Treatment plan was changed in 16.3% of patients after vitreoretinal surgery. The risk of treatment plan changes was associated with the surgeon's experience in vitreoretinal surgery and the type of surgery. These results should be considered when establishing standardized care plans for patients who require vitreoretinal surgery.

The Learning Curve of Surgery of Diabetic Tractional Retinal Detachment-A Retrospective, Comparative Study

Background and Objectives: There are few data in the literature concerning the learning curve of tractional retinal detachment (TRD) surgery. We have analyzed the experience gained by a vitreoretinal surgeon over 10 years. Materials and Methods: A retrospective, comparative study of 34 TRD cases operated using 20G instruments between 2008 and 2011 (group A) and 94 cases operated using 23G instruments between 2015 and 2019 (group B). The preoperative characteristics, the type of endotamponade, and the anatomical and functional success were reviewed. Results: The group A patients had a significantly higher rate of concomitant vitreous hemorrhage (VH) at presentation (64.7% vs. 37.2%) and of non-macular retinal detachments (52.9% vs. 39.3%). The rate of silicone oil endotamponade was high in both groups (76.4% vs. 68.1%), but in group B 25.5% were left without a tamponade (vs. none in group A). A postoperative anatomical success was obtained in 76.5% of eyes in group A and 84.04% of eyes in group B (where it was improved to 89.3% by reinterventions). The presenting visual acuity (VA) was very low in both groups (0.01 and 0.05, respectively). The proportion of eyes with improved or stabilized VA was 85.3% in group A and 79.8% in group B (statistically non-significant difference). Conclusions: The anatomical success rate improves quite slowly with increasing surgeon experience and can be further improved by reinterventions. Visual improvement does not match the rate of anatomical improvement. With increasing experience and self-confidence, the surgeon will approach more difficult cases, a fact that may slow down the increase in surgical success rates.

Incidence and Risk Factors Affecting the Recurrence of Primary Retinal Detachment in a Tertiary Hospital in Spain

(1) Objective: To determine the incidence, visual outcomes and risk factors associated with the recurrence of primary retinal detachment (RD) in a tertiary hospital. (2) Methods: A retrospective observational study was conducted, and data were collected on all eyes diagnosed with primary RD between January 2017 and December 2020. A detailed database was generated with data on anatomic and visual outcomes, and surgical technique information, for all the cases. (3) Results: 570 eyes with primary RD were included. Mean annual incidence of primary RD was 21.8 cases per 100,000 inhabitants. Mean follow-up time was 465 (±410.5) days. Mean time to redetachment was 114.4 (±215.8) days, with the median being 35 days. Statistically significant variables related to a higher risk of recurrence were: male sex (p = 0.04), type of tamponade (p = 0.01), surgeon (p = 0.035), inferonasal (p = 0.002) and inferotemporal (p = 0.032) involvement, complex RD (p < 0.001) and ocular comorbidity (p < 0.001). More satisfactory final visual acuity (VA) in patients not suffering redetachment was associated with shorter duration of central vision loss. (4) Conclusions: Sex, type of tamponade, inferior detachment, RD complexity, surgeon and ocular comorbidity were identified as prognostic factors for recurrence. Worse final postoperative VA was found in patients referring central vision loss for more than 4 days before surgery.

Effect of surgeon-related factors on outcome of retinal detachment surgery: analyses of data in Japan-retinal detachment registry

The purpose of this study was to investigate the effects of surgeon-related factors on the surgical outcome of pars plana vitrectomy (PPV) and scleral buckling (SB) surgery on eyes with a rhegmatogenous retinal detachment (RRD). This was a nationwide, multicenter, observational study of the data in the Japan-RD Registry. Registered cases that had undergone surgery for a RRD by 128 accredited surgeons in 26 institutions were studied. The surgeon-related factors that significantly affected surgical success and visual outcomes of simple RRD treated by PPV or SB at 6 months postoperatively were analyzed and compared. Among 3446 registered cases, 2533 cases met the inclusion criteria with 1896 in the PPV group and 637 cases in the SB group. The median total number of lifetime cases was 150 and the rate of surgeries/year was 22. Multivariate regression analyses showed that the number and rate of surgeries/year were not significantly associated with the surgical outcome in the PPV group. However, surgeons with a higher average annual number of surgeries had significantly better surgical outcomes in the SB group (P = 0.038). Analyses of a nationwide registry showed that SB but not PPV surgeries require sufficient experience and case numbers to acquire and maintain skills to treat RRDs successfully.

The Surgeon's Role in Inducing and Controlling Motion Errors During Intraocular Membrane Peeling Procedures

Objectives:

To understand the surgeon’s role in inducing and correcting movement inaccuracies during intraocular membrane peeling procedures.

Materials and Methods:

Optical sensors were used to record movement errors during actuation at the distal tip of 23-gauge pneumatic forceps both when the handle was handheld and when fixed with no human contact. Movements were also recorded at the proximal part of the forceps shaft (near the sclerotomy site) and compared to movement recorded at the distal end. The root mean square (RMS) and range values of the signals obtained from the sensors were calculated before and after applying high (7-13 Hz) and low (<5 Hz) frequency filters.

Results:

Comparison of RMS and range values of movement errors at the distal end of the forceps during actuation when the forceps handle was fixed and handheld showed that without human contact, these values were significantly lower in the X axis at all frequencies and in the Z axis at high frequencies compared to handheld (p<0.05), while there were no significant differences in the Y axis. Comparison of values from the distal and proximal ends of the forceps showed that when the forceps were fixed, RMS and range values were significantly higher for movement errors at the distal end compared to the proximal end at all frequencies (p<0.05). There was significant positive correlation between the extent of actuation and the RMS and range values for high-frequency movement errors but not low-frequency errors in all three axes with the fixed pneumatic handle (r=0.21-0.51, p<0.05).

Conclusion:

Surgeon- and non-surgeon-related errors are apparent in all axes, but skilled surgeons correct these errors through visual feedback, resulting in better correction in the visible planes. Sclerotomy sites provide a pivoting and stabilizing point for the shaft of the forceps and it is likely that skilled surgeons make use of the sclerotomy point to dampen motion errors, a skill worth teaching to beginners.

The urgency of surgical treatment for rhegmatogenous retinal detachment

The ideal timing of surgery in patients with rhegmatogenous retinal detachment has been discussed for decades. The study situation has improved in recent years so that recommendations can now be made. When the macula is detached, surgical treatment of the retinal detachment should be undertaken within a few days. When the macula is still attached, the near fovea and bullous superotemporal detachment should be classified as an emergency. When planning the operation environmental factors must also be considered, meaning that the performance of the intervention by an experienced surgical team is usually more important for the final result than the retinal condition alone. Influencing factors are discussed in this article and recommendations for dealing with these emergency patients are discussed.

The learning curve of retinal detachment surgery

Purpose

To investigate the learning curve of vitreoretinal (VR) surgeons beginning training in retinal detachment (RD) surgery.

Methods

The files of all consecutive patients undergoing VR surgery for uncomplicated RD between Jan 2005 und Mar 2020 were retrospectively reviewed. Successful outcome was defined as no retinal redetachment within 3 months after surgery.

Results

Ten surgeons started their VR career during this period. Together, these 10 surgeons performed 3786 RD operations (mean 379; median 251; range 71–1053). Primary success rate after one operation was 90% (3420 of 3786). When starting to operate retinal detachments, VR surgeons had a primary success rate of about 80%. Redetachment rates steadily decreased and stabilized at just under 10% after about 200 operations. Beginners needed more than twice the time for the procedure compared to experienced surgeons. The individual learning curves varied widely. In our series, female surgeons seem to have a faster learning curve.

Conclusion

RD surgery performed by VR surgeons in training had acceptable results. With increasing experience, success rates continuously improve reaching stable levels after approximately 200 operations. The training of VR surgeons requires considerable resources.

Unintentional Movements During the Use of Vitreoretinal Forceps

Purpose

Intraocular forceps used in vitreoretinal surgery are actuated by squeezing their handles. We studied the relationship between actuation and any accompanying unintentional movements of the instrument tip, and compared different handle designs and gauges.

Methods

Optical sensors were used to measure involuntary movements of forceps tips while monitoring the extent of actuation. Mean root mean square (RMS) and ranges of signals obtained from sensors were computed before and after applying high (7–13 Hz) and low (<5 Hz) frequency filters. Four handle designs, two gauge sizes, and two users were compared to each other.

Results

In the absence of human contact, mean RMS of noise was 6.47 μ and mean range was 21.67 μ. When the forceps were held by the surgeon but kept motionless (no actuation), mean RMS was 58.01 μ and mean range was 156.66 μ. When the forceps were actuated, mean RMS was 214.71 μ and mean range was 566.11 μ. The differences were statistically significant (P < 0.001). The process of actuation by both users was positively correlated with unintentional movements mainly at low frequencies. No statistically significant differences were found between users and between two gauges (23 and 27) at mixed and low frequencies. Pneumatic handles showed less RMS and range values at higher frequencies compared to conventional handle designs. Eliminating human error by fixing pneumatic forceps to the model did not reduce unintentional movements, but eliminated their correlation with actuation.

Conclusions

Actuating forceps was associated directly with increased unintentional low frequency movements at the tip of the forceps when held by hand.

Translational Relevance

A novel system of measuring unintentional forceps tip movement during actuation is described which could be used to guide improved design.

Cost analysis of vitrectomy under local versus general anesthesia in a developing country

Purpose

To report cost reductions of vitrectomy under local anesthesia.

Patients and methods

This was a retrospective cohort study using medical records of consecutive patients undergoing vitrectomy surgery for retinal detachment under general or local anesthesia. Data of patient’s fulfilling the inclusion criteria were included in the study. The patients were divided into two groups: Group 1 (local anesthesia) and Group 2 (general anesthesia). The preoperative data were checked and validated by a peer group consisting of two ophthalmologists, two internists, and two anesthesiologists independently in a blind manner. The calculation of the cost was done using the cost minimization analysis. The cost data were obtained from the finance division of the hospital for each individual treatment. The cost data included unit cost of laboratory tests, surgery, and medications.

Result

There were 100 subjects (50 subjects in each group) assessed by peer groups and declared eligible to undergo surgery under either local or general anesthesia. Both groups were equal. The total average cost for vitreous surgery under general anesthesia for each patient was $322.17, whereas for local anesthesia it was $220.57. The mean difference was $101.60 (46.06%) saving on local anesthesia.

Conclusion

Vitrectomy surgery under local anesthesia can reduce the cost by almost half that of general anesthesia. The present study showed that the type of anesthesia determined the ultimate cost for the surgery. Hence, surgery under local anesthesia appears affordable and cost-effective, especially in a developing country like Indonesia.

[Retinal detachment surgery: Evaluation of the anatomical success and functional outcomes in a consecutive series of patients operated between 2011 and 2014 at Nantes University Medical Center]

OBJECTIVE

Evaluate the anatomical and functional outcomes of retinal detachment (RD) surgery from January 2011 to November 2014.

MATERIALS AND METHODS

We conducted a retrospective study of 182 eyes of 175 patients with a minimum follow-up of 6 months, operated for RD at Nantes University Medical Center. It consists of 56 simple RDs and 126 complex RDs treated in first intention by Scleral Buckling (SB), vitrectomy or combined surgery. The analysis is based on anatomic reattachment at the end of a follow-up of at least 6 months after the first surgery and the progression of the best corrected visual acuity (BCVA).

RESULTS

One hundred and seventy-two vitrectomies, 15 SB and 5 combined surgeries (vitrectomy+SB) were performed. The overall anatomical success rate after a single operation was 131 eyes (72 %). It increased to 163 eyes (90 %) at the end of the follow-up. Depending on the type of RD, anatomic success at 6 months after surgery was achieved for 47 simple RDs (84 %) and 84 complex RDs (67 %). At the end of the follow-up, after one or more operations, these rates increased to 53 simple RDs (95 %) and 110 complex RDs (87 %). For all RDs with an anatomically successful result, we observed a visual improvement≥2 lines in 45 % of cases and a postoperative BCVA≥5/10 in 40 % of cases.

CONCLUSION

This study confirms the evolution toward vitrectomy surgery for retinal detachment. It finds anatomical and functional results consistent with the literature, with a percentage of approximately 5 % of RDs still not reattached in spite of several operations.

Differences in Surgical Performance of Internal Limiting Membrane Peeling for Macular Hole Repair Between Supervised Vitreoretinal Fellows and Vitreoretinal Faculty at a Single Institution

Purpose:

To investigate the differences in surgical maneuvers between vitreoretinal fellows and experienced vitreoretinal surgeons (attendings) when performing internal limiting membrane (ILM) peel during macular hole (MH) surgery and repair.

Methods:

Prospective case series. Macular hole surgeries performed by fellows and attendings at St Michael’s Hospital (Toronto, Canada) were recorded during a 12-month period. Evaluation of recordings was masked. Total peel time (TPL) in seconds, total movement attempts initiating and extending ILM flaps, intrasurgical complications, and surgical efficiency (ratio of approaches leading to case progression to total approaches) were quantified.

Results:

A total of 145 surgeries were evaluated; 44 met inclusion and exclusion criteria. Of the 44 cases, 25 were performed by fellows and 19 by attendings. Mean TPL was shorter for attendings (336 vs 506 seconds, P = .0032). Attendings had a lower average total movement attempts (32.2 vs 43.2, P = .045) and average flap initiation attempts (16.1 vs 23.3, P = .042). Surgical efficiency was better for attendings (45% vs 37% of approaches led to case progression, P = .038). There was no significant difference between groups in total flap extension attempts or intrasurgical complications.

Conclusions:

Compared to fellows, attendings peel ILM in MH surgery faster, more efficiently with a lower number of flap initiation attempts and total movements.

Applying Sutureless Encircling Number 41 Band and Transscleral Chandelier-Assisted Laser Retinopexy for Scleral Buckling Procedure

Purpose

To assess the outcome of sutureless encirlcing number 41 band and transscleral laser retinopexy in uncomplicated rhegmatogenous retinal detachment (RRD), using a wide-angle viewing system (WAVS) and chandelier endoillumination.

Methods

Prospective intervention study included 30 eyes of 30 patients presenting with RRD of recent onset indicated for SB. All cases were treated by sutureless encircling number 41 band and transscleral laser retinopexy. Visualization was provided by the Resight WAVS and a single 27-gauge chandelier endoillumination. Anatomical and visual outcomes were evaluated.

Results

The mean age of our group was 49.8 ± 12.3 years, and the mean duration of RD was 7 (0–50) days. Twenty-four eyes (80.0%) were phakic while the remaining 6 eyes (20%) were either pseudophakic or aphakic. The primary retinal reattachment rate was 83.3% (25 out of 30 eyes). LogMAR visual acuity improved from 1.3 (0.30–2.0) preoperatively to 1.0 (0.40–1.60) at first month (p = 0.002) and to 0.70 (0.20–1.92) at third month (p < 0.001).

Conclusion

Sutureless encircling number 41 band with chandelier-assisted transscleral laser retinopexy is a safe and effective technique for managing uncomplicated RRD. It provides a high primary success rate while eliminating the complications of cryotherapy, sutures, and broad buckles.

Intravitreal Injection of Bevacizumab in Primary Vitrectomy to Decrease the Rate of Retinal Redetachment: A Randomized Pilot Study

Purpose:

To evaluate the effect of intravitreal bevacizumab (IVB) as a surgical adjunct in prevention of proliferative vitreoretinopathy (PVR) after retinal detachment surgery.

Methods:

In this controlled, randomized pilot study, 27 patients with primary retinal detachment undergoing pars plana deep vitrectomy were included. Of these, 12 received IVB at the end of procedure. The anatomic success and best corrected visual acuity (BCVA) were compared to the control group at months 3 and 6 postoperatively.

Results:

At three month follow-up, 3 of 11 eyes (27.3%) had detached retinas in the IVB group versus 6 of 12 (50.0%) in the control group (P = 0.40). At six-month follow-up, 3 of 10 eyes (30%) had detached retinas in the IVB group versus 3 in 8 (37.5%) in the control group (P > 0.99). Mean logMAR BCVA improved significantly in both groups relative to baseline, but did not show a significant difference at three-and six-month follow-ups between the two groups.

Conclusion:

Our preliminary results show neither a benefit nor any harm from intervention in both anatomic and visual outcomes. Our results support conducting additional studies to evaluate the effect of intravitreal bevacizumab on postoperative PVR.

Macula-Sparing Rhegmatogenous Retinal Detachment: Is Emergent Surgery Necessary?

The status of the macula is a significant factor in determining final visual outcomes in rhegmatogenous retinal detachment (RRD) and should be considered in the timing of surgical repair. Several studies have shown that macula-involving RRDs attain similar visual and anatomic outcomes when surgery is performed within seven days as compared to emergent surgery (within 24 hours). In contrast, surgery prior to macular detachment in macula-sparing RRDs generally yields the best visual outcomes. In the case of macula-sparing RRDs, it is not clear how long the macula may remain attached, therefore, standard practice dictates emergent surgery. Timing of presentation, examination findings, case complexity, co-existing medical conditions, surgeon expertise, and timing and quality of access to operating facilities and staff, however, should all be considered in determining whether a macula-sparing RRD requires immediate intervention or if equivalent visual and possibly better overall outcomes can be achieved with scheduled surgery within an appropriate time frame.

Sequential Hypothesis Testing to Characterise the Learning Curve and Monitor Surgical Performance in Retinal Detachment Surgery

PURPOSE

To characterise the learning curve of primary retinal detachment (RD) repair for trainee surgeons and monitor the outcomes of surgery for established surgeons.

PROCEDURES

Primary RD operations were analysed sequentially using the cumulative sum (CUSUM) and the sequential probability ratio test (SPRT).

RESULTS

359 analysed cases of primary RD were audited with a recurrent RD (ReRD) rate of 14.7%. The individual rate of ReRD ranged from 9.4 to 17.4% (p = 0.74). SPRT and CUSUM analyses showed that ReRD occurred at random when operated by senior surgeons but a learning curve was discernible for junior surgeons. There was a trend for a higher proportion of ReRD caused by untreated breaks in cases operated by junior surgeons (p = 0.75).

CONCLUSION

SPRT and CUSUM are useful methods to monitor surgical outcomes and should be included in audits of sequential operations such as RD. Trainee surgeons experience a quantifiable learning curve.

Scleral buckling for primary rhegmatogenous retinal detachment using noncontact wide-angle viewing system with a cannula-based 25 G chandelier endoilluminator

Purpose

The aim of this study is to report the result of scleral buckling (SB) using a combination of a noncontact wide-angle viewing system and a cannula-based 25 G chandelier endoilluminator.

Methods

Retrospective analyses of the medical records of 79 eyes of 79 patients with primary uncomplicated rhegmatogenous retinal detachments who had underwent SB using a combination of a noncontact wide-angle viewing system and a chandelier endoilluminator were performed.

Results

There were 50 men and 29 women. The mean ± standard deviation age was 43.7±16.0 years. Their preoperative best-corrected visual acuity (BCVA) was 0.31±0.65 logMAR units. The final BCVA was 0.10±0.31 logMAR units, which was significantly better than the preoperative BCVA (P<0.01). The initial and final anatomical success rates were 92.4% and 100%, respectively. Backward logistic multiple regression analysis revealed no relationship between explanatory variables and the primary anatomic success (P=0.104).

Conclusion

SB using a combination of a noncontact wide-angle viewing system and a chandelier endoilluminator is a modified new technique and may be a valid option for the management of rhegmatogenous retinal detachments.

Scleral buckling surgery using multiple radial buckles: A valid option?

PURPOSE

To determine whether radial buckling surgery using two or more radial buckles with or without circumferential silicone tires is still a treatment option for rhegmatogenous retinal detachment (RRD) in the current scenario.

METHODS

Retrospective chart review. Patients with RRD with two or more horse-shoe tears with/without proliferative vitreoretinopathy up to grade C1 who underwent buckling surgery using at least two radial buckle segments without encircling bands or drainage and with at least a 3 year follow up were included in the study. Data collected included demographics, corrected distance visual acuity (CDVA) at baseline and final follow up, details of the examination, surgical procedure(s) and complications noted, if any. Appropriate statistical analysis was done. Statistical significance was set at p < 0.05.

OUTCOME MEASURES

Proportion of patients who had an attached retina at final follow up, improvement in CDVA and complications.

RESULTS

25 patients (25 eyes; 12 males and 13 females; 9 pseudophakic) were included.

MEDIAN AGE

35.15 ± 8.32 years. Median baseline CDVA: 1.97 ± 1.12 log MAR. Median final CDVA: 0.65 ± 0.37 log MAR (significant improvement). Most common presenting complaint was decreased vision (87.5%). Number of radial buckle segments placed varied between 2 and 4 per eye. One patient required vitrectomy for persistent retinal detachment. One required buckle removal for infection 5 years after the primary procedure. One patient required strabismus surgery.

MEDIAN FOLLOW UP

12.25 years ± 2.14 years. None of the other patients had any complications.

CONCLUSION

Radial buckling surgery (two or more segments) is a reasonably safe and valid alternative to vitrectomy for RDs with multiple breaks in different planes.

Intraocular Microsurgical Forceps (20, 23, and 25 gauge) Membrane Peeling Forces Assessment

Background. To assess the peeling forces exerted by different calibers of microsurgical forceps on an experimental model of epiretinal membrane. Methods. A model of epiretinal membrane was constructed using thin cellulose paper and heptanes-isopropyl alcohol 1% mixture. The model was mounted on a force censoring device. Subsequently, flaps were created with three different microsurgical forceps of different calibers. We recorded the number of attempts, the duration of the event, and the pushing and the pulling forces during the peeling. The results were compared by a one-way ANOVA and a Fisher unprotected least significant difference test with an alpha value of 0.05 for statistically significance. Results. There was a statistical significant difference on the pulling and pushing forces between the 25 gauge (13.79 mN; -13.27 mN) and the 23 (6.63 mN; -5.76 mN) and 20 (5.02 mN; -5.30 mN) gauge, being greater in the first (P < 0.001). There were no differences in the duration of all events, meaning that all the forces were measured within the same period of time. Conclusions. The 25 gauge microsurgical forceps exerted the greatest mechanical stress over our simulated epiretinal membrane model and required more attempts to create a surgical suitable flap. The clinical implication of this finding is still to be determined.