Reoperation for rhegmatogenous retinal detachment as quality indicator for disease management: a register study

Retinal surgery quality indicators for uncomplicated primary rhegmatogenous retinal detachment without a national registry

PURPOSE

The objective of this study was to evaluate the possibility of analysing quality indicators for uncomplicated primary rhegmatogenous retinal detachment in a hospital department of ophthalmology without the support of a national registry or need to collect data from referring ophthalmological centres.

METHODS

In 2014, we operated 231 consecutive eyes with uncomplicated retinal detachment. Our quality indicators were primary anatomical success, final anatomical success and postoperative endophthalmitis. We reviewed medical records in our university surgical department retrospectively and compared them with medical records from the regional hospitals that had referred most of the operated patients and done their own postoperative examination. Our hypothesis was that any retinal re-detachment and/or serious postoperative complication would be reported back.

RESULTS

The medical records at the surgical department revealed primary anatomic success for 91.3% of eyes and final anatomical success of 99.6%. The data from the regional hospitals confirmed that our hypothesis was correct. All patients with adverse outcomes were referred back for reoperation. Patients who were not referred again had an attached retina and showed no signs of endophthalmitis.

CONCLUSION

Our hypothesis that data in the surgical department's medical records would closely reflect those in referring hospitals was borne out. This supports, under current conditions, an effective strategy for analysing chosen quality indicators without relying on a national registry or reviewing records from regional hospitals.

Return to the Operating Room After Repair of Rhegmatogenous Retinal Detachment

Purpose

To report the rate of all-cause returns to the operating room (OR) after surgery for rhegmatogenous retinal detachment (RRD).

Patients and Methods

This was a retrospective consecutive case series; 1278 eyes underwent RRD repair from 1/1/2014 to 12/31/2016 at a tertiary care center. A total of 507 eyes returned to the OR. Surgical indication, procedure, number of reoperations, and final vision were recorded.

Results

At least one secondary procedure was performed in 24.9% at 6 months, 34.7% at 1 year, and 39.7% as of last follow-up. The most common indications for reoperation were cataract (43.9%) and recurrent RRD (12.8%). Cornea, glaucoma, and oculoplastic issues were rare (each <1.1%). There was no association between final visual outcome and number of reoperations (p > 0.05). SB/PPV had the highest rate of return to OR (p < 0.001) but lowest rate of recurrent RRD (p = 0.007).

Conclusion

To our knowledge, there are no other large studies that examine all-cause returns to the OR after primary RRD repair. This study provides important risk-benefit and prognostic information to patients undergoing RRD repair.

A comparative study of strabismus surgery with retained or removed scleral explant after retinal detachment surgery

PURPOSE

To compare, in a larger study population, the outcomes of strabismus surgery in patients who either had the scleral explant (EX) retained or removed after surgery for retinal detachment.

METHODS

A comparative retrospective study includes data from 2 centres. Surgical outcome, motor success, sensory success, the number of secondary operations for strabismus and complications were compared between the two groups. Motor success was defined as horizontal deviation of ≤6 prism diopters (PD) and vertical deviation of ≤6PD. Sensory success was defined as no diplopia without use of prism.

RESULTS

Forty-seven patients were included in the study; 70% had retained the EX and 74% had vertical strabismus. Horizontally, the final alignment was equal between the 2 groups, 4 PD vs.5 PD in the EX removed group. The patients with retained EX were referred with a significant lower mean vertical deviation and had a significant lower post-operative mean vertical deviation of 2 PD vs. 3 PD in the EX-removed group. The rates of motor success (76% vs. 71%) and sensory success (79% vs. 93%) did not differ significantly between the EX-retained and EX-removed groups. No patients underwent more than 2 operations. Two complications occurred in the EX-retained group: a subconjunctival cyst and an exposed EX. In the EX-removed group, 2 patients with retinal re-detachment were found in the follow-up period.

CONCLUSION

Good surgical outcomes including high motor and sensory success were obtained regardless of the presence of the EX. Retinal re-detachment was observed in two patients with previously removed EX.

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.

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.

Simulators in the training of surgeons: is it worth the investment in money and time? 2018 Jules Gonin lecture of the Retina Research Foundation

This paper describes transfer of skills obtained from training with the EyeSI virtual reality simulator of ophthalmic surgery to real-life surgical performance. Skills in real-life phacoemulsification surgery were assessed by systematic blinded evaluation of surgical videos based on the OSACCS system. Nineteen Danish cataract surgeons with varying clinical experience levels had their cataract surgery skills evaluated before and after completing a standardized mastery learning program on the EyeSI. It was found that transfer of skills could be demonstrated only for surgeons with a real-life experience of less than 75 completed, independent cases. We could not demonstrate transfer of skills from the EyeSI cataract module to the EyeSI vitreoretinal module, so each subspecialty seems to require specific training. Finally, the discriminative power of EyeSI simulation between emerging surgeons and experts was found to reside only in the first training sessions. The EyeSI simulator in its current state of development, and our implementation of it, seems to require further development before it can be used as a tool to select residents for surgical training and to re-certify more senior surgeons.

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

BACKGROUND/PURPOSE

To audit variations in primary rhegmatogenous retinal detachment (RD) anatomical failure rates between surgeons, grades of surgeons, and techniques of RD surgery.

METHODS

Clinical data of a total of 5,857 eyes undergoing primary RD surgery, from 2000 to 2013 were retrospectively extracted from 15 centers using the same commercially available electronic medical record system, from three vitreoretinal units using an in-house electronic medical record, and from the British and Eire Association of Vitreoretinal Surgeons online registry.

RESULTS

The 5,857 primary RD operations were performed by 117 surgeons: 3,349 (57.2%) by consultants, 520 (8.9%) by independent nonconsultants, and 1,988 (33.9%) by trainees. Surgery comprised pars plana vitrectomy for 4,666 (79.7%) operations, scleral buckle for 815 (13.9%), and pars plana vitrectomy + scleral buckle for 376 (6.4%). The RD reoperation rate at 6 months after primary surgery was 13.9% (725/5,202) and did not differ significantly between consultants and trainees (P = 0.382). For surgeons contributing ≥50 cases, the mean (range) reoperation rates were 13.1% (6.7%-26.8%), 15.1% (11.3%-18.2%), and 15.3% (9.4%-22.1%) for consultants, independent nonconsultants, and trainee surgeons, respectively. The scleral buckle failure rate was not significantly different from pars plana vitrectomy (P = 0.095). Data were not adjusted for case-mix complexity.

CONCLUSION

The grades of surgeons and the technique of surgery were not associated with a significant difference in primary unadjusted RD failure rates.

RISK OF MULTIPLE RECURRING RETINAL DETACHMENT AFTER PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT REPAIR

PURPOSE

To evaluate functional and anatomical outcomes of patients with retinal redetachments (re-RD) after surgery for primary rhegmatogenous retinal detachment.

METHODS

Medical records of eyes with re-RD after rhegmatogenous retinal detachment surgery between 1999 and 2014 at the Department of Ophthalmology, University of Cologne, Germany, were retrospectively evaluated. Data included preoperative and postoperative clinical findings, best-corrected visual acuity, presence and grade of proliferative vitreoretinopathy, surgical procedures, and complication rates.

RESULTS

Three hundred and twenty-eight eyes of 2,457 developed a re-RD (13.3%). Of these 328 eyes, 242 eyes (73.8%) had only one re-RD, whereas 86 eyes (26.2%) had 2 or more re-RDs. Visible presence of proliferative vitreoretinopathy during first redetachment surgery increased risk of re-RD with relative risk ratio of 1.46 (P = 0.05). Best-corrected visual acuity deteriorated with every additional re-RD (P < 0.001). Two hundred and thirty-seven eyes received oil endotamponde at least once. In 91 cases, oil endotamponade was left for long-term until last follow-up.

CONCLUSION

Multiple re-RD (≥2 re-RDs) is an infrequent complication after rhegmatogenous retinal detachment surgery. After a first re-RD occurred, risk for multiple re-RD doubles compared with the risk of a first redetachment. Mean functional outcome is unfavorable, whereas predictability remains nevertheless poor because of the wide range of interindividual postoperative best-corrected visual acuity.

Key Factors to Improve the Outcome of Retinal Reattachment Surgery in Proliferative Vitreoretinopathy and Proliferative Diabetic Retinopathy

INTRODUCTION

For management of complicated retinal detachments, a pars plana vitrectomy with temporary silicone oil (SO) fill is the method of choice. According to literature, the retinal redetachment rate varies between <10% and >70% with around 36% in our own group (retrospective data analysis, n = 119 eyes).

METHODS

The main goal was to reduce the retinal redetachment rate. Standard operating procedures (SOPs) and evaluation protocols (EVALPs) were developed to prospectively analyse risk factors. Lab analysis of SO was performed, and the role of surgical experience was evaluated and investigated with Eyesi®.

RESULTS

We achieved a significant reduction of the retinal redetachment rate (to 6.80%, n = 101, p = 0.002). After surgery with SO injection, neither further membrane peeling (in 16.5%) nor retinal laser coagulation (in 100%) during revision surgery had a significant effect on the reattachment rate (p = 0.167, p = 0.23), while extensive additional laser coagulation reduced visual acuity (p = 0.01). A 3-port approach had to be set up to complete SO removal. A difference in success rate depending on surgical experience was confirmed, and the performance in Eyesi correlated with that in the patients' eye.

CONCLUSIONS

A SOP- and EVALP-based management and new strategies to secure the surgical performance seem to be essential for successful surgery.

Primary vitrectomy for rhegmatogenous retinal detachment in pseudophakic eyes: 20-gauge versus 25-gauge vitrectomy

PURPOSE

To report anatomical and functional outcome of 20-gauge versus 25-gauge primary pars plana vitrectomy for management of complex rhegmatogenous retinal detachment in pseudophakic eyes.

METHODS

Prospective single-centre randomized comparative pilot trial. Fifty patients with retinal detachment (RD) not complicated by proliferative vitreoretinopathy grade B or C, who cannot be treated with a single meridional sponge, were randomized (1:1) from November 2006 to January 2010 to either 20-gauge or 25-gauge vitrectomy as first surgical intervention and followed up over a 12-month period, evaluating change in best-corrected visual acuity, anatomical success and intraocular pressure dysregulation.

RESULTS

Mean visual acuity improved by 0.88 (SD 0.67) from 1.22 logMAR (SD 0.63) to 0.34 logMAR (SD 0.31) in the 20-gauge group and by 0.53 (SD 0.91) from 0.86 logMAR (SD 0.73) to 0.34 logMAR (SD 0.46) in the 25-gauge group. Final anatomical success rate was 100% and primary success rate was 69% at 6 months of follow-up. In the 20-gauge group, the retina was attached after one single procedure in 18 eyes (72%) and in 21 eyes (84%) of the 25-gauge group. Two patients in the 25-gauge group had hypotony at the first postoperative day which normalized within 6 weeks.

CONCLUSION

In our series, transconjunctival sutureless 25-gauge and 20-gauge vitrectomy showed comparable results in pseudophakic RD not suitable for single sponge surgery with respect to visual outcome and retinal reattachment. Postoperative hypotony does not seem to be a significant problem of transconjunctival sutureless vitrectomy.

Epidemiologic characteristics of retinal detachment surgery at a specialized unit in Denmark

PURPOSE

To examine the incidence of retinal detachments and to evaluate patient profiles and surgical characteristics.

METHODS

Retrospective review of patients operated for primary retinal detachment (RD) and redetachment between 2010 and 2012 at the Department of Ophthalmology, Odense University Hospital, Denmark. We included all RD such as rhegmatogenous retinal detachment (RRD), tractional retinal detachment (TRD) and exudative retinal detachment (ERD).

RESULTS

In total, 779 RD surgeries were performed: 83.7% (n = 652) primary operations and 16.3% (n = 127) reoperation. For primary operation, pars plana vitrectomy (PPV), scleral buckling and combined operations were performed in 95.1% (n = 620), 4.6% (n = 30) and 0.3% (n = 2) respectively. Over time there was less use of silicone oil and greater use of gas tamponade (p = <0.001), less simultaneous cataract operations (p = <0.001), less use of cryotherapy (p = 0.045) and more use of peeling procedures (p = <0.001) in primary operations. The annual incidence of surgery for primary RD was 22.0 [95% confidence interval (CI) 20.4-23.8] per 100 000 inhabitants aged >15 years. Retinal detachment (RD) was more common in males than females (1.8:1), and mean age at presentation was 61.8 years (standard deviations ± 12.3). The annual incidence for RRD and TRD operation was 20.72 (95% CI 19.11-22.43) and 1.25 (95% CI 0.9-1.7) per 100 000 inhabitants >15 years.

CONCLUSION

This study presents the first overall incidence for RD in Denmark. The highest incidence of RRD was among males aged 60 to 79 years, whereas TRD was among females at same age. Pars plana vitrectomy (PPV) was the preferred surgical technique, and during 2012 all RD patients were treated with PPV, independent of lens status and age.

What made you wait so long? Delays in presentation of retinal detachment: knowledge is related to an attached macula

PURPOSE

In rhegmatogenous retinal detachment, the time between first symptoms and reattachment surgery is critical to prevent macular detachment. We explored which determinants discriminate between 'macula-ON' and 'macula-OFF' retinal detachments to improve timely treatment.

METHODS

Eight-hundred patients with rhegmatogenous retinal detachment admitted for surgery at the Rotterdam Eye Hospital in the Netherlands were eligible to complete a questionnaire to explore the following determinants: (i) patient's delay and doctor's delay; (ii) patient-reported causes for delay; (iii) symptoms as early warning signals; (iv) patient's prior knowledge about retinal detachment; and (v) trait anxiety.

RESULTS

Five hundred and twenty-one questionnaires (65%) were analysed. Median interval between first symptoms and surgery was 14 days. Macula-ON/OFF ratio was 46/54. Patient's delay in macula-ON patients (median 3 days) was shorter than in macula-OFF (5 days, p = 0.026). No difference was found in doctor's delay except for 'waiting time for surgery': macula-ON patients were operated on faster (median 1 day) than macula-OFF (median 5 days, p < 0.001). Macula-ON patients more often attributed symptoms to retinal problems. Except floaters, no symptoms were determined as early warning signals for macula-ON. Macula-ON patients more often reported knowing that prognosis would be worse when treated later, even when controlled for previous experience with retinal detachment.

CONCLUSION

Macula-ON patients seem to self-refer faster to a healthcare provider, seem more sensitive to floaters and seem more informed. This suggests that increasing awareness, especially about floaters, might increase the proportion of patients with macula still on at the moment of referral to the ophthalmologist.