Pseudophakic rhegmatogenous retinal detachment in a large Asian tertiary eye centre: a cohort study

Retinal detachment after post-operative endophthalmitis: clinical characteristics, outcomes and risk factors

PURPOSE

To describe clinical characteristics, risk factors, and outcomes of rhegmatogenous retinal detachment (RRD) following treatment of postoperative endophthalmitis (PE).

METHODS

Analysis of cross-referenced data from two service reviews of patients with RRD and bacterial PE treated between 01/01/2013 and 01/07/2020. The main outcome measure was final best-corrected visual acuity (BCVA). Secondary measures include proportion of patients with BCVA of ≤ 0.3 logMAR and ≥ 1.0 logMAR, rate of phthsis, and rate of eye removal.

RESULTS

Ninety-four cases of PE were analysed finding 21 cases of RRD (22%). Seven (35%) experienced recurrent RRD. Seven eyes (35%) were left with permanent silicone oil fill. All RRD cases had vitrectomy. After PE with RRD the median BCVA was 1.1 logMAR, compared with 0.4 logMAR for PE without RRD (p < 0.04). Fifty-seven percent (12/21) of RRD eyes attained BCVA of ≥ 1.0 logMAR vs. 29% (21/73) of PE without RRD (p = 0.01). Nineteen percent (4/21) of eyes with RRD attained BCVA of ≤ 0.3 logMAR, whereas those without RRD did so in 43% (31/73) of cases (p = 0.02). Five eyes with RRD (24%) and 2 eyes without RRD (3%) developed phthisis (p < 0.01). Three non-RRD cases required removal of the eye (4%, p = 0.46). Higher bacterial virulence was associated with worse final BCVA (2.1 logMAR vs. 0.3 logMAR; p < 0.01). RRD rate did not differ by bacterial virulence (OR 1.9; CI95: 0.6-6.9; p = 0.24).

CONCLUSIONS

RRD following PE leads to worse clinical outcomes. Eyes which developed RRD were more likely to have undergone vitrectomy. Final BCVA was worse in cases with more virulent micro-organisms.

Visual Acuity Prior to Cataract Surgery and Risk of Retinal Detachment - A Population-Based Study

Purpose

To analyze preoperative visual acuity before cataract surgery regarding the risk of rhegmatogenous retinal detachment (RRD) after cataract surgery.

Methods

The preoperative visual acuity in an observational cohort study of patients undergoing cataract surgery in Skåne, southern Sweden, during 2015-2017 was analyzed with data retrieved from the Swedish National Cataract Register. This was then cross-referenced with patients undergoing surgery for retinal detachment at the Skåne University Hospital in Lund from 2015 to 2020. The main outcome was the risk-benefit ratio of measuring preoperative visual acuity before cataract surgery and the risk of RRD.

Results

The mean visual acuity in the whole study group (N=58,624), expressed as LogMAR, was 0.40 ± 0.32 (SD). In the group with RRD (n=298), the mean visual acuity was 0.44 ± 0.36 (p=0.07). In the subgroups of RRD, those aged <60 years 0.49 ± 0.44 (p=0.07), aged <60 years and axial length (AL) >25 mm 0.42 ± 0.38 (p=0.68), and in those aged <60 years, AL >25 mm and male sex 0.44 ± 0.39 (p=0.53). However, there is considerable variations in visual acuity of the various groups and in the high-risk group with RRD aged <60 years with AL>25 mm, 15% had a visual acuity of 0.8 or better in the operated eye.

Conclusion

There must be strong indications for performing cataract surgery in those with a high risk of retinal detachment, and the patient must be given adequate information on the risk of retinal detachment.

Automatic Detection of Peripheral Retinal Lesions From Ultrawide-Field Fundus Images Using Deep Learning

PURPOSE

To establish a multilabel-based deep learning (DL) algorithm for automatic detection and categorization of clinically significant peripheral retinal lesions using ultrawide-field fundus images.

METHODS

A total of 5958 ultrawide-field fundus images from 3740 patients were randomly split into a training set, validation set, and test set. A multilabel classifier was developed to detect rhegmatogenous retinal detachment, cystic retinal tuft, lattice degeneration, and retinal breaks. Referral decision was automatically generated based on the results of each disease class. t -distributed stochastic neighbor embedding heatmaps were used to visualize the features extracted by the neural networks. Gradient-weighted class activation mapping and guided backpropagation heatmaps were generated to investigate the image locations for decision-making by the DL models. The performance of the classifier(s) was evaluated by sensitivity, specificity, accuracy, F 1 score, area under receiver operating characteristic curve (AUROC) with 95% CI, and area under the precision-recall curve.

RESULTS

In the test set, all categories achieved a sensitivity of 0.836-0.918, a specificity of 0.858-0.989, an accuracy of 0.854-0.977, an F 1 score of 0.400-0.931, an AUROC of 0.9205-0.9882, and an area under the precision-recall curve of 0.6723-0.9745. The referral decisions achieved an AUROC of 0.9758 (95% CI= 0.9648-0.9869). The multilabel classifier had significantly better performance in cystic retinal tuft detection than the binary classifier (AUROC= 0.9781 vs 0.6112, P < 0.001). The model showed comparable performance with human experts.

CONCLUSIONS

This new DL model of a multilabel classifier is capable of automatic, accurate, and early detection of clinically significant peripheral retinal lesions with various sample sizes. It can be applied in peripheral retinal screening in clinics.

Unexpected Poor Vision within 24 h of Uneventful Phacoemulsification Surgery-A Review

Review on day one post uneventful phacoemulsification surgery is no longer standard practice due to the infrequency of complications when using modern cataract removal techniques. Clinicians are therefore likely to be unfamiliar with the potential causes of reduced vision when presented with a patient in the immediate postoperative period. The purpose of this review is to discuss the various differential causes of early visual loss, for the benefit of clinicians presented with similar patients in emergency care, with the use of an illustrative clinical case of paracentral acute middle maculopathy (PAMM), which recently presented to the authors. A thorough literature search on Google Scholar was conducted, and only causes of visual loss that would manifest within 24 h postoperatively were included. Complications are inherently rare in this period; however, various optical, anterior segment, lens-related and posterior segment causes have been identified and discussed. Front-line clinicians should be aware of these differentials with different mechanisms. PAMM remains to be the only cause of unexpected visual loss within this time frame that may have no abnormal findings on clinical examination.

Retinal detachment after cataract surgery: a population-based study

PURPOSE

To analyse the risk of rhegmatogenous retinal detachment (RRD) after cataract surgery, and to identify possible risk factors.

METHOD

Observational cohort study of patients undergoing cataract surgery in Region Skåne, southern Sweden, during 2015-2017 were retrieved from the Swedish National Cataract Register. These were then cross-referenced with cases of retinal detachment surgery performed at the Skåne University Hospital in Lund from 2015 to 2020. The main outcome was RRD after cataract surgery. The influence of sex, age, axial length of the eye, rupture of the posterior capsule, patient comorbidity and other cataract complications were analysed.

RESULTS

Among the 58 624 cases of cataract surgery, a total of 298 RRDs (0.51%) were identified up to the end of 2020. The mean time from cataract surgery to RRD was 667 days. The mean age was 65.3 years, compared to 74 years in the control group. A strong correlation was found between RDD and age: <60 years, incidence = 0.50%; 60-75 years, incidence = 0.14%; and >75 years, incidence = 0.04%. The correlation with axial length was also very strong: mean value 23.73 mm in those without RRD, and 25.13 mm in those with RRD (p < 0.001). Sex was also strongly correlated to RDD; 68.8% of cases of RRD being men. Among men younger than 60 years of age, with an axial length ≥25 mm, 9.46% exhibited RRD within the follow-up period (mean 4.7 years). Rupture of the posterior capsule was found in 2.01% of RRD patients compared to 0.74% in the control group. Diabetes, glaucoma or pseudoexfoliation had no impact on the prevalence of RRD.

CONCLUSIONS

The three main risk factors for RRD following cataract surgery were found to be sex, age and axial length. The highest incidence of RRD (9.46%) were identified among men younger than 60 years of age and an axial length ≥25 mm.

Retinal detachment following cataract phacoemulsification-a review of the literature

A link between cataract surgery and rhegmatogenous retinal detachment (RRD) has long been considered. Indeed, pseudophakic retinal detachment (PPRD) forms a substantial and increasing proportion of RRD. We reviewed the literature to answer the following questions: what is the incidence of PPRD in eyes following phacoemulsification cataract surgery and how does its risk change over time following surgery? We also sought to assess how the risk is modified by intraoperative factors (operative complications, surgeon grade, subsequent laser capsulotomy), intrinsic eye-related factors (laterality, myopia, previous RRD, previous trauma, previous PVD) and patient factors (sex, age, ethnicity, affluence, systemic comorbidities). Secondarily we asked how the incidence of PPRD after phacoemulsification compares with the RRD incidence in the general population and how identified risk factors contribute to the pathophysiology of PPRD. A search of the Medline and Ovid databases was conducted for relevant publications from 1990 onwards using defined search terms with pre planned inclusion and exclusion criteria. The 10-year PPRD incidence after phacoemulsification was identified as being between 0.36 and 2.9%. This decreases over time to 0.1-0.2% annually but remains above the general population. The PPRD risk is further elevated by (in order of decreasing effect) intraoperative vitreous loss, increasing axial length, younger age, male sex and trainee operating surgeons. The PPRD risk after phacoemulsification is approximately ten times the general population's RRD risk. This risk is modified by the interplay of a hierarchy of risk factors, of which intraoperative vitreous loss, myopia, age and sex have the biggest effect.

Peak Occurrence of Retinal Detachment following Cataract Surgery: A Systematic Review and Pooled Analysis with Internal Validation

Introduction

Timing of retinal detachment (RD) following cataract surgery is of importance for both diagnostic and prognostic factors. However, results on RD onset-time following cataract surgery have been conflicting.

Method

A systematic pooled analysis of the literature regarding timing of retinal detachment following cataract surgery. Outcomes were verified against an independent dataset.

Results

Twenty-one studies, reporting on rates of RD in 3,352,094 eyes of 2,458,561 patients, met our inclusion criteria and were included in the analysis. The mean pooled time to RD following surgery was 23.12 months (95% CI: 17.79-28.45 months) with high heterogeneity between studies (I ²=100%, P < 0.00001). Meta-analytic pooling for the risk of retinal detachment revealed a risk of 1.167% (95% CI: 0.900 to 1.468, I ²=99.50%, P < 0.0001). A retrospective chart review identified 54 pseudophakic RD cases (mean age 65.5, 59.3% males). The 95% confidence interval for the mean time to RD was 3.1-6.75 years.

Conclusions

The interval between cataract surgery and RD in a pooled analysis revealed a mean time of approximately 1.5-2.3 years. However, there was high variability between studies. Validation based on our local results showed similar yet slightly longer time frames. Timing of pseudophakic retinal detachment might direct appropriate follow-up, assisting in earlier detection.

United Kingdom National Ophthalmology Database Study of Cataract Surgery: Report 3: Pseudophakic Retinal Detachment

PURPOSE

To investigate time to pseudophakic retinal detachment (RD) after cataract surgery with posterior capsule rupture (PCR) to provide an evidence-based guide for postoperative management.

DESIGN

Retrospective case series.

PARTICIPANTS

A total of 61 907 eyes of 46 824 patients undergoing cataract surgery.

METHODS

Subanalysis of the United Kingdom Royal College of Ophthalmologists' National Ophthalmology Database from 13 sites where data on both cataract and vitreoretinal surgery were recorded on the same electronic medical records system. Overall, 61 907 cataract operations were performed between October 2006 and August 2010. Analyses were restricted to cases with at least 3 months of potential postoperative follow-up.

RESULTS

Pseudophakic RD surgery was performed on 131 eyes of 129 patients (0.21%; 95% confidence interval [CI], 0.18%-0.25%). Of these, 36 were in eyes that had PCR during cataract surgery (3.27%; 95% CI, 2.37%-4.50%) and 95 were in eyes that did not have PCR (0.16%; 95% CI, 0.13%-0.19%). For eyes that progressed to RD surgery, the median time to pseudophakic RD surgery was 44 days for eyes with PCR, and 6.3 months for eyes without PCR. For all eyes (both with and without PCR), pseudophakic RD occurred earlier in cases performed by a trainee cataract surgeon.

CONCLUSIONS

Pseudophakic RD occurs earlier after cataract surgery complicated by PCR. Surgeon grade is a risk factor for pseudophakic RD. Posterior vitreous detachment and RD symptoms should be discussed with patients who undergo cataract surgery and have PCR to facilitate early attendance, and careful dilated postoperative examination for retinal tears is recommended in the first 2 months after surgery.

Risk factors for retinal detachment following cataract surgery: the impact of posterior capsular rupture

AIM

To investigate risk factors for retinal detachment (RD) after cataract surgery, particularly posterior capsular rupture (PCR) with or without vitreous loss.

METHODS

Single centre electronic medical record database study of 18 065 consecutive first eye cataract operations performed between 2005 and 2014. Survival analysis was performed with Kaplan-Meier curves and a Cox proportional hazard regression analysis to calculate HRs with respect to RD.

RESULTS

The RD rate at 3 months and 7 years was 0.067% and 0.30%, respectively, with a median time to RD of 15 months (mean: 18 months, range: 0-84 months). Men had a higher RD risk (HR 2.00; 95% CI 1.03 to 3.88; p=0.03) in the univariate model. Patients <60 years and those >80 years had an HR of 5.12 (95% CI 2.60 to 10.07; p<0.001) and 0.16 (95% CI 0.38 to 0.69; p=0.01), respectively, compared with patients 60-80 years of age. Eyes longer than 25 mm had an HR of 3.98 (95% CI 1.93 to 8.20; p<0.001) compared with eyes 23-25 mm. PCR occurred in 400 (2.2%) eyes. The HR for RD was 12.83 (95% CI 5.62 to 29.30; p<0.001) for PCR with vitreous loss. There were no RD events in eyes with PCR without vitreous loss.

CONCLUSIONS

The risk for RD after cataract surgery is higher in younger patients and eyes with longer axial length or PCR with vitreous loss during surgery.

Incidence, Risk Factors, and Impact of Age on Retinal Detachment after Cataract Surgery in France: A National Population Study

PURPOSE

To assess the incidence, risk factors, and impact of age on retinal detachment (RD) after cataract surgery.

DESIGN

Cohort study.

PARTICIPANTS

All patients older than 40 years of age who underwent a primary cataract surgery in France between January 2009 and December 2012.

METHODS

A Cox proportional-hazard regression model was used to analyze risk factors of RD after cataract surgery.

MAIN OUTCOME MEASURES

Risk factors of RD after cataract surgery.

RESULTS

Over 4 years, 2680167 eyes in 1787021 patients (59.4% women; mean age, 73.9±9.5 years) underwent cataract surgery. A total of 11 424 patients experienced RD after cataract surgery, with an estimated risk of 0.99% at 4 years after surgery. The odds ratio associated with increased risk of RD was 3.87 (95% confidence interval [CI], 3.79-3.95) for cataract surgery itself. The multiadjusted hazard ratio (HR) associated with increased risk of RD was 5.22 (95% CI, 5.05-5.39) for patients 40 to 54 years of age, 3.69 (95% CI, 3.60-3.79) for those 55 to 64 years of age, and 1.98 (95% CI, 1.93-2.03) for those 65 to 74 years of age as compared with those 75 years of age or older. Retinal detachment was associated with high myopia (HR, 6.12; 95% CI, 5.84-6.41), vitrectomy for perioperative capsular rupture (HR, 4.36; 95% CI, 4.07-4.68), history of eye trauma (HR, 3.98; 95% CI, 3.69-4.30), extracapsular extraction (HR, 3.11; 95% CI, 2.94-3.30), male gender (HR, 2.39; 95% CI, 2.35-2.44), and history of diabetes (HR, 1.18; 95% CI, 1.15-1.21). In myopic patients, the multiadjusted HR associated with increased risk of RD was 25.02 (95% CI, 24.76-25.18) for patients 40 to 54 years of age, 20.37 (95% CI, 20.21-20.53) for those 55 to 64 years of age, and 17.05 (95% CI, 16.85-17.25) for those 65 to 74 years of age as compared with nonmyopic patients 75 years of age or older.

CONCLUSIONS

We provide a hierarchy of risk factors for RD onset: high myopia, young age, capsular rupture, history of eye trauma, extracapsular extraction technique, male gender, and diabetes. Young age was an additional risk factor in myopic patients.

Trends and factors related to outcomes for primary rhegmatogenous retinal detachment surgery in a large asian tertiary eye center

PURPOSE

To describe trends and outcomes of vitreoretinal surgery for primary rhegmatogenous retinal detachment in a large Asian tertiary eye center.

METHODS

Retrospective review of 1,530 eyes with primary retinal detachment between 2005 and 2011 managed at the Singapore National Eye Center by one of the following: scleral buckling (SB), pars plana vitrectomy (PPV), and combined SB and PPV (SB + PPV). Anatomical and functional outcomes were assessed.

RESULTS

There was a trend toward PPV and PPV + SB as the primary reattachment procedure from 2005 to 2011. The primary anatomical success rate for PPV (78.6%) was worse than that for SB (88.8%) or SB + PPV (89.0%, P = 0.000). Final anatomical success rates were similar for all 3 procedures: SB 97.7%, PPV 95.2%, and SB + PPV 96.4%. Better functional success was achieved in the SB group (86.1%) than both the PPV (72.5%) and SB + PPV groups (77.5%, P = 0.000), partly attributable to the less complex nature of retinal detachments in the SB group. Older age and proliferative vitreoretinopathy were related to the poor functional outcomes in both phakic and pseudophakic eyes.

CONCLUSION

There was an increasing trend toward PPV and PPV + SB as the primary retinal reattachment surgery from 2005 through to 2011. High rates of anatomical and functional outcomes were achieved with SB, PPV, and SB + PPV, proliferative vitreoretinopathy and older age were negatively correlated with the functional success in both phakic and pseudophakic eyes.

2013 update on the management of posterior capsular rupture during cataract surgery

PURPOSE OF REVIEW

Posterior capsular rupture (PCR) is an infrequent complication of cataract surgery that can lead to significant ocular morbidity and permanent vision loss. In the setting of PCR, the primary objective is the safe and thorough evacuation of vitreous and lens fragments from the anterior segment. The secondary objective is the stable placement of an intraocular lens (IOL) selected for best refractive outcomes. Expedited referral to vitreoretinal specialists is recommended for management of posteriorly dislocated lens material and surveillance for retinal injury. It is the intention of this review to present current guidelines for the management of PCR.

RECENT FINDINGS

There are new techniques available to anterior and posterior segment surgeons in the setting of PCR. Endoillumination may facilitate visualization during anterior vitrectomy and the IOL may be used as a pupillary barrier to prevent loss of lens fragments. When secondary procedures are needed, early return to the operating room and small-gauge pars plana techniques may reduce patient morbidity.

SUMMARY

When approached carefully and systematically, patients may have good outcomes in the setting of PCR. Recent advancements in instrumentation and technique encourage further study and may lead to new standards of care.