Vitreoretinal Surgery in the Post-Lockdown Era: Making the Case for Combined Phacovitrectomy

Impact of COVID-19 pandemic on a world-wide private ophthalmic practice

Purpose

To assess the impact of the COVID-19 pandemic on a worldwide private ophthalmic practice.

Design

In this retrospective study, we reviewed the 2020 monthly outpatient and surgical volume of refractive, cataract, and retinal disease in Aier Eye clinics/hospitals of different regions, including the United States, Germany, Spain, Italy, and six major cities in China (Wuhan, Beijing, Shanghai, Shenyang, Urumqi and Yili). All of these data were compared to those of the same period of 2019.

Results

Overall, during the early stage (2020 January to 2020 April) of COVID-19 outbreak, the outpatient and surgical volume of three main type ocular diseases (refractive, cataract and retinal surgery) showed an obvious reduction and reached the bottom in February in China. The data from the United States, Germany, Spain and Italy revealed the same trend, but the visit count nadir occurred until April, which is consistent with the spread trend of COVID-19 disease around the world. The average change rates of surgery volume (refractive, cataract and retinal surgery) in Chinese centers are 5.59%, -26.38%, 11.76%. The change rates of refractive (REF) and cataract volumes (CAT) in the United States are -8.62% and -10.58%, in Germany are -13.71% and -20.49%, in Spain are 15.35% and 27.97%, in Italy are 30.43% and -22.64%. In addition, the optometry outpatient volumes keep going up since May, with an average increasing rate of 21.18%, ranging from 7.43% to 49.51%.

Conclusion

In conclusion, in this global chain of eye care units, the visit volumes of cataract, retinal and refractive changed significantly with the spread of COVID-19 pandemic. Among them, cataract surgery was the most affected sub-specialty, and refractive surgery and optometry volumes showed a potential growth in the near future. Therefore, medical institutions should make corresponding adjustments to the disease diagnosis and treatment strategies.

Rotational stability of plate haptic toric intraocular lenses after combined 25-gauge vitrectomy and cataract surgery

AIM

To evaluate the postoperative intraocular lens (IOL) rotational stability and residual refractive astigmatism following combined 25-gauge vitrectomy and cataract surgery with implantation of a plate haptic toric IOL.

METHODS

In this retrospective case series, 32 eyes of 32 patients underwent a combined 25-gauge vitrectomy and phacoemulsification for vitreoretinal diseases and cataract with regular corneal astigmatism of at least 1 diopter (D). A plate haptic toric IOL (AT Torbi 709M, Carl Zeiss Meditec AG) was implanted in all eyes. The outcome measures were rotational stability and refractive astigmatism up to 6mo postoperatively as well as the best corrected visual acuity (BCVA).

RESULTS

Preoperative refractive astigmatism was 2.14±1.17 D, which was significantly reduced to 0.77±0.37 D six to eight weeks postoperatively and remained stable throughout the observation period (0.67±0.44 D at three months and 0.75±0.25 D at six months; for all groups: P<0.0001 compared to baseline). BCVA improved significantly from 0.36±0.33 logMAR preoperatively to 0.10±0.15 logMAR following surgery (P=0.02). Mean IOL axis deviation from the target axis was 3.4°±2.9° after six to eight weeks and significantly decreased over time (2.4°±2.6° six months after surgery; P=0.04). In one patient IOL, re-alignment was performed.

CONCLUSION

Corneal astigmatism is significantly reduced following combined 25-gauge vitrectomy and cataract surgery. The plate haptic toric IOL position and axis remain stable during the observation period of six months.

Influence of endotamponade on anterior chamber depth and refractive outcome after combined phacovitrectomy: case-control study

PURPOSE

To compare the changes in the anterior chamber depth (ACD) and in the refractive outcomes after combined phacovitrectomy with respect to the endotamponade (balanced salt solution, air, sulfur hexafluoride [SF 6 , gas]).

SETTING

Department of Ophthalmology, University Hospital Ulm, Ulm, Germany.

DESIGN

Retrospective, longitudinal case-control study.

METHODS

160 eyes of 160 patients were included in the study. 120 eyes underwent phacoemulsification with in-the-bag implantation combined with vitrectomy and were divided into 3 groups according to tamponade (balanced salt solution, air, gas). 40 control eyes with cataract surgery only were included. Further inclusion criteria were uneventful surgery, no postoperative complications and absence of corneal pathology. Endpoints were ACD as measured by swept-source optical coherence tomography-based biometry (IOLMaster 700) preoperatively, 1 to 2 days and 6 weeks postoperatively and refractive prediction error (PE) using the Barrett and Haigis formulas.

RESULTS

Within the first 2 days after surgery the ACD was shallower in the eyes left with gas or air tamponade, when compared with balanced salt solution or cataract surgery alone ( P < .001). This effect diminished 6 weeks later, and all eyes reached comparable ACD ( P = .396). The refractive PE was slightly, but statistically significantly higher in the gas group when compared with cataract surgery alone ( P = .012 for Barrett, P = .006 for Haigis).

CONCLUSIONS

The resulting ACD after combined phacovitrectomy was independent of the tamponade used, but a gas-tamponade was associated with a higher refractive PE.

Combined versus Sequential Pars Plana Vitrectomy and Phacoemulsification for Macular Hole and Epiretinal Membrane - A Systematic Review and Meta-Analysis

TOPIC

To compare the efficacy and safety between combined and sequential pars plana vitrectomy and phacoemulsification for macular hole (MH) and epiretinal membrane (ERM).

CLINICAL RELEVANCE

The standard of care for MH and ERM is vitrectomy, which increases risk of developing cataract. Combined phacovitrectomy eliminates the need for a second surgery.

METHODS

Ovid MEDLINE, EMBASE, and Cochrane CENTRAL were searched in May 2022 for all articles comparing combined versus sequential phacovitrectomy for MH and/or ERM. The primary outcome was mean best-corrected visual acuity (BCVA) at 12-months follow-up. Meta-analysis was conducted using a random effects model. Risk of bias was assessed using the Cochrane RoB 2 tool for randomized controlled trials (RCTs) and ROBINS-I tool for observational studies. (PROSPERO, registration number, CRD42021257452) RESULTS: Of the 6470 studies found, 2 RCTs and 8 non-randomized retrospective comparative studies were identified. Total eyes for combined and sequential groups were 435 and 420, respectively. Meta-analysis suggested no significant difference between combined and sequential surgery for 12-month BCVA (combined = 0.38 logMAR, sequential = 0.36 logMAR; mean difference (MD) = +0.02 logMAR; 95% CI = -0.04 to 0.08; p = 0.51, I² = 0%, n = 4 studies, 398 participants), as well as absolute refractive error (p = 0.76, I² = 97%, n = 4 studies, 289 participants), risk of myopia (p = 0.15, I² = 66%, n = 2 studies, 148 participants), MH non-closure (p = 0.57, I² = 48%, n = 4 studies, 321 participants), cystoid macular edema (p = 0.15, I² = 0%, n = 6 studies, 526 participants), high intraocular pressure (p = 0.09, I² = 0%, n = 2 studies, 161 participants), posterior capsule opacification (p = 0.46, I² = 0%, n = 2 studies, 161 participants), posterior capsule rupture (p = 0.41, I² = 0%, n = 5 studies, 455 participants) and retinal detachment (p = 0.67, I² = 0%, n = 6 studies, 545 participants).

CONCLUSION

No significant difference was detected between combined and sequential surgeries for visual outcomes, refractive outcomes, or complications. Given that most studies were retrospective and contained a high risk-of-bias, future high-quality RCTs are warranted.

Rhegmatogenous retinal detachment repair-does age, sex, and lens status make a difference?

PURPOSE

To analyze the correlation between lens status, age, and sex in the epidemiology and success rates of rhegmatogenous retinal detachment (RRD) surgery.

METHODS

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

RESULTS

5502 eyes with uncomplicated primary RRD were included. Mean age of the patients was 61.1 years (± 13.6 SD). In the age group over 40 years, a male predominance was found. The percentage of pseudophakic RRD increased from 25 to 40% during the 15 years observation period. In the age group 50 to 69 years, patients with pseudophakic detachments were male in 786 out of 1079 cases (72.9%). In the same age group, 1285 of 2110 (60.9%) patients with phakic RRD were male. Overall, primary success rate after one procedure was 91.2% (5018 of 5502). In the phakic eyes, the primary success rate was higher in those eyes that underwent combined phacovitrectomy (93.0%), compared to those without simultaneous cataract surgery (88.7%; p = 0.002).

CONCLUSION

The ratio of male and female patients with RRD varies between age groups. The proportion of pseudophakic RRD has increased within 15 years. The male predominance in RRD is stronger in pseudophakic than in phakic eyes. In phakic eyes with RRD, a combined phacovitrectomy yielded better anatomical results.

Emergency Vitrectomies for Retinal Detachment Before and During the Coronavirus Pandemic - A Retrospective Single Centre Analysis

Background While the corona pandemic and the resulting containment measures affect the number of elective surgical procedures, the impact on emergency surgical interventions is less tangible. This analysis quantifies the frequency of emergency vitrectomies for retinal detachment and investigates underlying factors.

Methods Retrospective identification of patients who underwent primary emergency vitrectomies for retinal detachment at the Cantonal Hospital of Lucerne between 01.01.2018 – 31.12.2020. Parameters were collected, including demographics, date of hospitalisation, reported onset of symptoms, pre-operative best corrected visual acuity (BCVA), involvement of the macula, and canton of residence.

Results Overall, a total of 665 patients with 683 eyes underwent emergency surgery for primary retinal detachment in the time span of 01.01.2018 – 31.12.2020. Median monthly number of surgeries was 20. During the first Swiss national lockdown (16.03.2020 – 19.04.2020), a minimum of 9 vitrectomies was recorded in March 2020. A maximum of 36 vitrectomies was conducted in August 2020. The mean age of patients was 61.5 years. Of the 665 patients, 133 (20.0%) were residents of the canton of Ticino. Median pre-operative BCVA was 0.25 over all three years, and no significant reduction in pre-operative BCVA was observed during or after the lockdown. The proportion of eyes with involvement of the macula was 52.2%. In 2018, this proportion (47.6%) was significantly lower than in 2019 and 2020 (Chi ² test, p < 0.001). However, cases with macular involvement in post lockdown months were not more frequent. Median time in days from reported symptom onset to hospitalisation was 5 days. In April 2020, the proportion of patients with > 14 days symptom duration was significantly higher (Chi ² test, p < 0.001). During the lockdown, there was a significant reduction in cases from Ticino. Also, patients from Ticino showed proportionally longer symptom duration after the lockdown.

Conclusion A significant reduction in the number of emergency vitrectomies was observed for the initial period of the coronavirus pandemic. Delayed emergency presentation is not assumed, since there was no increase in severity (i.e. macular involvement) or prolonged symptoms in the months following the lockdown. More protracted symptoms were only observed in patients from Ticino. The initial low numbers were generally made good later in the year.

Differences in Axial Length and IOL Power Based on Alternative A-Scan or Fellow-Eye Biometry in Macula-Off Rhegmatogenous Retinal Detachment Eyes

INTRODUCTION

This study was performed to observe the potential refractive prediction error based on alternative A-scan ultrasound and fellow-eye biometry for phacovitrectomy in macula-off rhegmatogenous retinal detachment (RRD) eyes.

METHODS

Phakic macula-off RRD eyes without axial length (AL) measurements obtained using IOLMaster were included. Vitrectomy without lens extraction was performed for RRD repair. Preoperative AL was measured using alternative A-scan ultrasound (AL-US). Postoperative AL was obtained in eyes with silicone oil tamponade (AL-SO) and preoperative fellow-eye biometry (AL-FE) using IOLMaster. Other eyes that faced the same preoperative situation but underwent phacovitrectomy based on fellow-eye biometry were recruited as controls.

RESULTS

AL-US, AL-FE, and AL-SO were 25.39 ± 2.14 mm, 25.85 ± 2.16 mm and 26.08 ± 2.53 mm, respectively. The Bland-Altman agreement among AL-US, AL-FE and AL-SO was good (95.5%, 21/22 of cases were in the LoA). The mean IOL power calculated using AL-US (Power-US), AL-FE (Power-FE) and AL-SO (Power-SO) was 16.81 ± 7.19 D, 14.74 ± 6.95 D and 13.54 ± 8.32 D, respectively. The difference between AL-US and AL-SO was significant (P < 0.05), while that between AL-FE and AL-SO was not (P > 0.05). The difference between Power-US and Power-SO was significant (P < 0.05), while that between Power-FE and Power-SO was not (P > 0.05). Nine eyes underwent phacovitrectomy based on fellow-eye biometry and had a final postoperative myopic shift of 0.64 ± 0.78 D.

CONCLUSIONS

Alternative A-scan ultrasound led to a significant difference in AL and a prediction error in IOL power, while fellow-eye biometry provided similar results to silicone oil-filled eyes after RRD repair.

The ophthalmic surgical backlog associated with the COVID-19 pandemic: a population-based and microsimulation modelling study

BACKGROUND

Jurisdictions worldwide ramped down ophthalmic surgeries to mitigate the effects of COVID-19, creating a global surgical backlog. We sought to predict the long-term impact of COVID-19 on the timely delivery of non-emergent ophthalmology sub-specialty surgical care in Ontario.

METHODS

This is a microsimulation modelling study. We used provincial population-based administrative data from the Wait Time Information System database in Ontario for January 2019 to May 2021 and facility-level data for March 2018 to May 2021 to estimate the backlog size and wait times associated with the COVID-19 pandemic. For the postpandemic recovery phase, we estimated the resources required to clear the backlog of patients accumulated on the wait-list during the pandemic. Outcomes were accrued over a time horizon of 3 years.

RESULTS

A total of 56 923 patients were on the wait-list in the province of Ontario awaiting non-emergency ophthalmic surgery as of Mar. 15, 2020. The number of non-emergency surgeries performed in the province decreased by 97% in May 2020 and by 80% in May 2021 compared with the same months in 2019. By 2 years and 3 years since the start of the pandemic, the overall estimated number of patients awaiting surgery grew by 129% and 150%, respectively. The estimated mean wait time for patients for all subspecialty surgeries increased to 282 (standard deviation [SD] 91) days in March 2023 compared with 94 (SD 97) days in 2019. The provincial monthly additional resources required to clear the backlog by March 2023 was estimated to be a 34% escalation from the prepandemic volumes (4626 additional surgeries).

INTERPRETATION

The estimates from this microsimulation modelling study suggest that the magnitude of the ophthalmic surgical backlog from the COVID-19 pandemic has important implications for the recovery phase. This model can be adapted to other jurisdictions to assist with recovery planning for vision-saving surgeries.

Retinal detachment during COVID-19 era: a review of challenges and solutions

Background

Since the beginning of the Coronavirus disease 2019 (COVID-19) pandemic, there have been obstacles in the proper diagnosis and management of many diseases. We evaluated the changes in retinal detachment (RD) presentation and surgery during the COVID-19 pandemic and propose solutions to minimize the detrimental effects of lockdown on RD diagnosis.

Materials and methods

PubMed, Embase, Scopus, Web of Science, and Google Scholar were searched for relevant articles with the keywords “Retinal detachment” AND “Coronavirus OR COVID-19 OR SARS OR MERS.”

Results

The COVID-19 lockdown was associated a 53–66% reduction in RD presentation. The decrease in the rate of macula-on RD, the increase in the mean duration of symptoms, and the rise in the number of patients with proliferative vitreoretinopathy were all suggestive of a delayed presentation of RD. Moreover, a drop of 56–62% in RD repair surgeries was observed. However, the most frequently performed ophthalmic surgery changed from cataract surgery in April 2019 to RD repair in April 2020. Using phacovitrectomy instead of vitrectomy alone can reduce the number of operations in ophthalmology centers, decrease the use of personal protective equipment by 50%, and cut costs per patient by 17–20%. Also, developing a well-organized telemedicine system can decrease unnecessary visits and delayed presentations.

Conclusion

Delay in RD presentation and surgery is associated with a poorer prognosis. Optimizing the guidelines of RD management and developing a well-organized telemedicine system can minimize the impact of lockdown on RD management.