SF 6 COMPARED WITH C 2 F 6 FOR INFERIOR RHEGMATOGENOUS RETINAL REPAIR : The Manchester Pseudophakic Retinal Detachment Study

PURPOSE

To compare SF 6 relative with C 2 F 6 in the anatomical and functional outcomes following pars plana vitrectomy for uncomplicated primary pseudophakic rhegmatogenous retinal detachment with inferior causative breaks.

METHODS

This is a retrospective, comparative study on eyes with pseudophakic rhegmatogenous retinal detachment with inferior causative breaks that had small-gauge pars plana vitrectomy repair using SF 6 and C 2 F 6 tamponade between 2011 and 2020 at a tertiary centre in the United Kingdom. Primary outcome was single surgery anatomical success, and the secondary outcome was best-corrected visual acuity. Propensity score matching, using preoperative findings as covariates to account for relevant confounders, was performed.

RESULTS

From 162 pseudophakic rhegmatogenous retinal detachment eyes with inferior causative breaks, the median (interquartile range) follow-up was 82 (52-182) days. The single surgery anatomical success was 156 (96.3%) overall: 47 of 47 (100.0%) and 109 of 115 (94.8%) in the SF 6 and C 2 F 6 groups, respectively ( P = 0.182). Relative to the SF 6 group, the C 2 F 6 group had a higher mean number of tears (SF 6 : 3.1[2.0], C 2 F 6 : 4.5[2.7], P = 0.002) and greater retinal detachment extent (SF 6 : 5.3[2.9], C 2 F 6 : 6.2[2.6] clock hours, P = 0.025). Following propensity score matching analysis, 80 eyes were matched with 40 in each group to homogenize preoperative factors. No significant difference was found in single surgery anatomical success and best-corrected visual acuity between the groups following propensity score matching.

CONCLUSION

Primary pars plana vitrectomy with gas tamponade leads to a high single surgery anatomical success rate in uncomplicated pseudophakic rhegmatogenous retinal detachment with inferior causative breaks with no additional benefit associated with long-acting tamponade when comparing C 2 F 6 with SF 6 .

Global warming impact of fluorinated gases in ophthalmic surgeries at a tertiary eye center in India

PURPOSE

Global warming is one of the greatest health threats of the 21 st century. The ophthalmic sector contributes to the emission of greenhouse gases, thus altering the natural environment. There is currently no data on global emissions of fluorinated gases in ophthalmic surgery. This retrospective study from 2017 to 2021 aims to report the carbon dioxide (CO 2 ) equivalence of sulfur hexafluoride (SF 6 ), hexafluoroethane (C 2 F 6 ), and octafluoropropane (C 3 F 8 ) at a tertiary eye center.

METHODS

Data collected from 1842 surgical procedures that used injections of fluorinated gases were analyzed. Environmental impact (global warming potential over 100 years) was calculated by converting milliliters to grams by using modified ideal gas law at standard temperature and pressure for the canisters and then to their CO 2 equivalence.

RESULTS

Though 70% of surgeries used C 3 F 8 , the least greenhouse effect causing fluorinated gas, the total carbon emission was 1.4 metric tons. The most common indication was macular hole surgery (36.86%).

CONCLUSION

This study paves a step toward analyzing the problem statement, thus awakening us to contemplate options to make ophthalmic surgeries greener.

THE LONG-TERM RECOVERY OF VISION IN PSEUDOPHAKIC MACULA-OFF RHEGMATOGENOUS RETINAL DETACHMENTS

PURPOSE

To assess the long-term visual recovery in uncomplicated macula-off pseudophakic rhegmatogenous retinal detachment treated with pars plana vitrectomy and gas tamponade in the absence of other visual comorbidities.

METHODS

Single-center retrospective longitudinal study on eyes with macula-off pseudophakic rhegmatogenous retinal detachment successfully treated with pars plana vitrectomy between 2011 and 2020 and with at least 2 follow-ups (FU), first gas-free FU (first-FU) and a final-FU, were included. Patients with subsequent ocular surgery or comorbidities affecting best-corrected visual acuity were excluded. The duration between operation date and final-FU was calculated (total days FU) and split into total days quintiles-1: ≤57, 2: >57 and ≤77, 3: >77 and ≤152, 4: >152 and ≤508, and 5: >508 days. Multivariable regression was performed with logMAR gain between the first and the final-FU as the dependent variable.

RESULTS

In 209 eyes, the authors report association with increase of logMAR gain between the first and the final-FU, with reducing clock hours of pseudophakic rhegmatogenous retinal detachment ( P = 0.041) and relative to the total days Quintile 1. Mean (SD) logMAR gain between the first and the final-FU was 0.02 (0.07) in the first quintile, increasing to 0.14 (0.13) ( P < 0.001) by the fifth quintile on multivariable regression. For patients not achieving 0.30 logMAR at the first-FU, this was attained at the final-FU with a sensitivity of 51.9% and specificity of 95.5% at a cut off ≤0.58 logMAR at the first-FU (area under the curve 0.756 [95% confidence interval 0.664-0.848], P < 0.001).

CONCLUSION

The authors report a significant time-dependent visual improvement after uncomplicated pars plana vitrectomy with gas tamponade for macula-off pseudophakic rhegmatogenous retinal detachment without visual confounders and provide important quantitative data for counselling patients with macula-off repair.

Cytokines in Immune-mediated "Non-infectious" Uveitis

Uveitis is a significant cause of ocular morbidity and accounts for approximately 5 - 10% of visual impairments worldwide, particularly among the working-age population. Infections are the cause of ~ 50% cases of uveitis, but it has been suggested that infection might also be implicated in the pathogenesis of immune-mediated "non-infectious" uveitis. There is growing evidence that cytokines (i.e., interleukins, interferons, etc.) are key mediators of immune-mediated "non-infectious" uveitis. For example, activation of the interleukin-23/interleukin-17 signalling pathway is involved in immune-mediated "non-infectious" uveitis. Studies in animal models have been important in investigating the role of cytokines in uveitis. Recent studies of clinical samples from patients with uveitis have allowed the measurement of a considerable array of cytokines even from very small sample volumes (e.g., aqueous and vitreous humour). The identification of complex patterns of cytokines may contribute to a better understanding of their potential pathogenetic role in uveitis as well as to an improved diagnostic and therapeutic approach to treat these potentially blinding pathologies. This review provides further insights into the putative pathobiological role of cytokines in immune-mediated "non-infectious" uveitis.

The impact of 360-laser barricade on outcomes of vitrectomy for pseudophakic retinal detachment; The Manchester Pseudophakic Retinal Detachment Study

PURPOSE

To investigate the anatomical and functional outcomes and specifically, the effect of 360-degree barrier-laser, in pars plana vitrectomy (PPV) for primary pseudophakic rhegmatogenous retinal detachment (PRD).

METHODS

We conducted a single-centre retrospective, continuous and comparative study on eyes that had undergone PPV with focal-retinopexy (laser or cryotherapy) versus 360-laser for PRD repair between 2011-2020 at a single tertiary vitreoretinal centre in the UK. Primary outcomes were single surgery anatomical success (SSAS) rate and final postoperative visual acuity (VA). Multivariable regression covariates for primary re-detachment included age, gender, onset-of-detachment, pre-operative VA, ocular co-morbidities, macula-status, majority inferior (vs superior) PRD, number-of-tears and PRD extent (in clock-hours), 360-laser barricade, and perfluorocarbon liquid (PFCL) use. For VA gain, primary re-detachment was added as a covariate.

RESULTS

We included 467 eyes with a mean follow-up of 388 (161) days. The SSAS was 444/467 (95.1%) overall, and 351/370 (94.9%) and 93/97 (95.9%) in focal-retinopexy and 360-laser groups, respectively (p = 0.798). Compared to the focal-retinopexy group, the 360-laser group had significantly worse post-operative VA but similar logMAR gain (p = 0.812). A multivariable binary logistic regression found that only PFCL use was linked with increased primary re-detachment (OR:5.32 [p = 0.048]) and 360-laser did not contribute to increased SSAS. A multivariable linear regression analysis showed that poor logMAR gain was significantly associated with better pre-operative logMAR, ocular co-morbidities, greater PRD extent, use of 360-laser and primary re-detachment. However, when excluding macula-off RD (n = 211), 360-laser was no longer significant (p = 0.088).

CONCLUSIONS

Prophylactic 360-laser does not seem to impact on SSAS and functional outcomes following PPV for primary PRD.

Unilateral retinal neovascularization associated with recurrent vitreous hemorrhage in a patient with gyrate atrophy

BACKGROUND/PURPOSE

To describe the first case of unilateral peripheral retinal neovasularization associated with recurrent vitreous hemorrhage and localised tractional retinal detachment in a patient with gyrate atrophy (GA).

METHODS

Interventional case report.

RESULTS

A 23-year-old man with confirmed diagnosis of gyrate atrophy presented with vitreous hemorrhage and history of stable peripheral inferior tractional retinal detachment in the left eye. After three months, the vitreous hemorrhage partially reabsorbed and peripheral retinal vascular abnormalities with focal neovascularization were detected with associated tractional retinal detachment and confirmed on fluorescein angiography. Cryotherapy was performed to prevent any further bleeding. Twelve months later, the left eye remained stable and no further vitreous bleeding occurred.

CONCLUSIONS

The combination of peripheral retinal neovascularization, localised tractional retinal detachment and recurrent vitreous hemorrhage can be a unilateral complication of gyrate atrophy. In similar cases, cryotherapy may represent a valuable therapeutic option to prevent recurrent bleeding.

Expansile gas concentration in primary pseudophakic retinal detachment repair, effect on intraocular pressure and outcomes; the Manchester Pseudophakic Retinal Detachment Study

PURPOSE

To investigate the effect of isovolumetric and expansile gas tamponade concentrations on single surgery anatomical success (SSAS) and day 1 intraocular pressure (IOPD1) following pars plana vitrectomy (PPV) for mild-moderate complexity primary pseudophakic rhegmatogenous retinal detachment (PRD).

METHODS

We conducted a single-centre retrospective continuous and comparative study on eyes that had undergone small-gauge PPV using isovolumetric versus expansile gas for PRD repair between 2011 and 2020 at a single tertiary vitreoretinal centre in UK. We performed propensity score matching (PSM) using preoperative findings as covariates to account for relevant confounders. Significant risk factors such as proliferative vitreoretinopathy C or giant retinal tears were excluded.

RESULTS

From 456 eyes, PSM analysis matched 240 eyes with 120 in each group. The median (interquartile range) follow-up was 96 (59 to 218) days. The SSAS was 229/240 (95.8%) overall; 115/120 (95.8%) and 114/120 (95.0%) in isovolumetric and expansile groups, respectively (p = 1.000). Relative to the isovolumetric group, the expansile group had lower proportion of eyes with IOP ≤ 21 mmHg (odds ratio, 95% confidence interval, 0.40 [0.23-0.68], p < 0.001); but significantly higher number of eyes with IOP ≥ 22 mmHg (2.53 [1.48-4.34], p < 0.001), ≥ 25 mmHg (2.77 [1.43-5.33], p < 0.001), ≥ 30 mmHg (2.90 [1.28-6.58], p = 0.006) and ≥ 40 mmHg (p = 0.029, isovolumetric: 0 [0%] vs expansile group: 6 [5%]). There was only one case of hypotony (≤ 5 mmHg) 1/240 (0.4%) which occurred in the expansile group.

CONCLUSIONS

Expansile gas concentration does not impact SSAS but is associated with significantly raised IOPD1 with no reduction in hypotony rates following PPV for primary PRD.

The Role of Subretinal Injection in Ophthalmic Surgery: Therapeutic Agent Delivery and Other Indications

Subretinal injection is performed in vitreoretinal surgery with two main aims, namely, the subretinal delivery of therapeutic agents and subretinal injection of fluid to induce a controlled and localized macular detachment. The growing interest in this technique is mainly related to its suitability to deliver gene therapy in direct contact with target tissues. However, subretinal injection has been also used for the surgical management of submacular hemorrhage through the subretinal delivery of tissue plasminogen activator, and for the repair of full-thickness macular holes, in particular refractory ones. In the light of the increasing importance of this maneuver in vitreoretinal surgery as well as of the lack of a standardized surgical approach, we conducted a comprehensive overview on the current indications for subretinal injection, surgical technique with the available variations, and the potential complications.

Long-Term Safety and Efficacy of Pars Plana Vitrectomy for Uveitis: Experience of a Tertiary Referral Centre in the United Kingdom

AIM

To evaluate the effectiveness of pars plana vitrectomy (PPV) without macular intervention on uveitis eyes with persistent vitreous inflammation/opacities in terms of visual acuity (VA), intraocular inflammation and macular profile.

METHODS

We carried out a single-center retrospective study of patients with uveitic eyes that underwent PPV without intervention on the macula due to persistent vitreous inflammation/opacities. The primary outcome measures were best-corrected visual acuity (BCVA), intraocular inflammation and macular profile at 3, 12 and 24 months after surgery.

RESULTS

Twenty-seven eyes of twenty-six patients were analyzed. Overall, 77.8% had an improvement of VA (55% by 0.3 LogMAR or more); 62.5% of patients had no intraocular inflammation, and the number of patients on systemic steroids and second-line immunosuppressives was reduced by 26% at 12 months; 87.5% of patients had resolution of macular oedema at 12 months.

CONCLUSION

PPV for persistent vitreous inflammation/opacities is safe and effective, showing beneficial outcomes in terms of improvement of BCVA and the reduction in inflammation.

The use of fluorinated gases and quantification of carbon emission for common vitreoretinal procedures

PURPOSE

To report the contribution to carbon dioxide equivalent mass [CO2EM] of various types of VR surgery performed across three tertiary referral centres, according to their indication and fluorinated gas used. We secondarily reported on the difference in tamponade choice, and CO2EM between the different centres.

MATERIALS

Retrospective, continuous, comparative multicentre study of all procedures using fluorinated gases between 01/01/17-31/12/20 at the Manchester Royal Eye Hospital and Birmingham and Midland Eye Centre, and between 01/01/19-31/12/2020 at the University Hospitals Coventry and Warwickshire.

RESULTS

Across 4877 procedures, the use of fluorinated gases produced 284.2 tonnes (71.2 tonnes annually) CO2EM; an annual consumption of 30,330 l of gasoline. Rhegmatogenous-retinal-detachment (RRD) and macular hole repair had the highest CO2EM by indication, accounting for 191.4 tonnes CO2EM (67.3%) and 28.6 tonnes CO2EM (10.1%); a mean 60.0 kg and 32.0 kg of CO2EM produced per surgery respectively. The use of fluorinated gases and their respective CO2EM contributions were significantly different across all three centres (p < 0.001) for all indications. SF6, despite being used in 1883 procedures (38.6%), contributed to 195.5 tonnes CO2EM (68.8%). Relative to C2F6, procedures using C3F8 and SF6 produced 1.9 and 4.4 times more CO2EM.

CONCLUSION

We demonstrated that SF6 causes significantly higher carbon emissions relative to C2F6 and C3F8 with RRD and macular hole repair having the greatest environmental impact. We also reported large variations between different large VR centres in fluorinated gas use, and therefore in carbon emission contributions depending on indications for surgery. Evidence-based protocols might help in making VR surgery "greener".

Unexplained visual loss in retinal detachment repair: comparing gas, silicone oil and heavy silicone oil by multivariable regression

PURPOSE

To measure the proportion of unexplained and all causes of visual loss following primary rhegmatogenous-retinal-detachment (RRD) repair, comparing gas tamponade (SF₆, C₂F₆, C₃F₈), silicone oil (SO, 1000cs and 5000cs) and heavy silicone oil (Densiron).

METHODS

Retrospective, continuous, comparative study from 01/1/2017-31/5/2021. All primary RRDs were included after successful removal of SO and Densiron. Primary failures were excluded. Visual loss was defined as reduction of ≥0.30 logMAR units. Multivariable binary-logistic and linear regression models to compare tamponade, and all cases of unexplained visual loss and logMAR gain were performed. Covariates included age, ocular co-morbidities, pre-op vision, macula-status, high-myopia, giant-retinal-tear (GRT), perfluorocarbon-use, combined buckle/PPV, PVR-C, retinectomy, tamponade agent and post-operative lens status.

RESULTS

Of 1,012 primary RRDs, we found an incidence of unexplained visual loss in 15/1012 (1.5%, SF₆:1/341[0.3%], C₂F₆:4/338[1.2%], C₃F₈:2/239[0.8%], Densiron:0/33[0.0%], SO-1000cs:5/43[11.6%] and SO-5000cs:3/18[16.7%]), and visual loss of all causes in 57/1012 (5.6%, SF₆:13/341[3.8%], C₂F₆:14/338[4.1%], C₃F₈:15/239[6.3%], Densiron:2/33[6.1%], SO-1000cs:9/43[20.9%] and SO-5000cs:4/18[22.2%]). On multivariable binary-logistic regression, we report that macula-on RRD (Odds-Ratio[OR]5.7,95% Confidence-interval[CI]1.2-28.2, p=0.032), GRT (OR35.0,CI 2.0-617.3, p=0.015), combined buckle/PPV (OR37.7,CI 2.0-711.4, p=0.015), SO1000cs (OR86.6,CI 5.6-1,348.0), p=0.001) and 5000cs (OR37.2,CI 1.3-1,101.5, p=0.036) (Reference-tamponade:SF₆) were associated with unexplained visual loss. Duration of oil tamponade was not linked to increase in unexplained visual loss (p=0.569).

CONCLUSIONS

Correlation between SO in detachment repairs and unexplained visual loss has been established, however incidence with HSO has not been compared to other agents. This study demonstrates that although SO was linked with risk-adjusted increased unexplained visual loss relative to gas tamponade, no such association was found for Densiron, on multivariable analysis.

Evaluating the quality and readability of online information on keratoconus treatment

OBJECTIVE

This study aims to evaluate the quality and readability of online resources on keratoconus treatment.

METHODS

A Google.com search was conducted on August 9, 2020; 32 web sites were selected for analysis. Popularity was assessed by Google and Alexa rank. The quality of web sites was analyzed using the quality criteria for consumer health information (DISCERN) tool, the Journal of the American Medical Association (JAMA) benchmark, and the Health On the Net Code of Conduct Certification (HONcode). The readability of the web sites was assessed using the Fleschwebr hea Reading Ease, the Automated Readability Index, and the Fleschted Readability RESULTS: The JAMA benchmark scores, unlike the DISCERN scores, were correlated with the Google and Alexa rank. One web site (3.1%) met all the JAMA benchmark criteria, and 3 (9.3%) others had HONcode certification. The median DISCERN score was 33 (range, 29.6-43.1; maximum possible, 80). Rnib.org.uk scored the highest at 57 (71.0%). The mean Flesch-Kincaid Reading Ease score (52.9 ± 7.1) corresponded to uk" n DIdifficult to read." Thirty-one web sites (96.8%) had a Flesch-Kincaid Grade higher than the American Medical Association recommendation of sixth grade level. The median Automated Readability Index score was 7 (range, 6.2-7.3).

CONCLUSION

The majority of online information currently available on keratoconus treatment is complex and highly variable. Rnib.org.uk is the best currently available source. Clinicians should inform patients on how to assess the credibility of online information and recommend suitable information sources.

PREDICTION OF MACULAR HOLE SIZE PROGRESSION BASED ON BASELINE OPTICAL COHERENCE TOMOGRAPHY FINDINGS

PURPOSE

To quantify the rate of idiopathic macular hole progression from presentation and identify factors that may influence stratification and urgency for surgical listing based on the initial optical coherence tomography scans.

METHODS

The minimal linear diameter (MLD), base diameter (BD), and hole height on nasal and temporal sides of idiopathic macular hole were measured on spectral domain optical coherence tomographies, on initial presentation and just before surgery. Mean hole height, hole height asymmetry (absolute difference between nasal and temporal height), MLD/BD, and MLD change per day (MLD/day) were calculated for each patient. Multivariable linear regression analysis with MLD/day as the dependent variable was performed to identify significant risk factors for MLD progression. Minimal linear diameter was grouped to quintiles: 1: ≤290 µ m, 2: >290 µ m and ≤385 µ m, 3: >385 µ m and ≤490 µ m, 4: >490 µ m and ≤623 µ m, and 5: >623 µ m.

RESULTS

In 161 eyes (157 patients), we report significant associations with MLD/day: 1) MLD/BD ( P = 0.039) (i.e., wide BD relative to MLD lead to faster progression of MLD), 2) hole height asymmetry ( P = 0.006) (larger absolute difference between nasal and temporal hole height lead to faster progression), and 3) days between scans ( P < 0.001) (longer duration between scans had reduced MLD/day, indicating more rapid increase initially then plateaux), and relative to MLD Quintile 1, MLD Quintile 3 ( P = 0.002) and MLD Quintile 4 ( P = 0,008), and MLD Quintile 5 ( P < 0.001) all lead to a reduced MLD/day rate on multivariable regression.

CONCLUSION

In addition to finding that the previously reported initial smaller MLD is a risk factor for rapid MLD progression, we report two novel findings, large hole height asymmetry and a low MLD/BD (wide base relative to MLD), that represent significant risk factors. These factors should be taken into consideration on presentation to stratify timing of surgery.

Sustained impact of COVID-19 on primary retinal detachment repair in a tertiary eye hospital from March to December 2020

Purpose

To review the sustained effect of COVID-19 on rhegmatogenous retinal detachment (RRD) baseline characteristics and outcomes.

Methods

This was a retrospective consecutive case series at the Birmingham and Midlands Eye Centre including patients undergoing primary RRD repair between 23 March and 31 December 2017-2019 (Group 1) and 2020 (Group 2). The deciles of indices of multiple deprivation (IMD) were determined by postcode to group patients into least deprived (IMD1-5) and most deprived (IMD6-10).

Results

In total we reviewed 1310 patients, 1003 in Group 1 and 307 in Group 2. Relative to 2017-2019, during the first lockdown, we observed (a) a reduction in the number of patients with RRD, (b) an increase in macula-off detachments, (c) an increase in RRD primary failure, and (d) that the least deprived had proportionately higher primary failure than the most deprived (p = 0.049) with a higher detachment rate than the pre-COVID-19 period (p = 0.010) and increased presentations of macula-off detachment. During the second lockdown, these differences were not observed.

Conclusion

The previously observed findings of lower presentation rates of RRD during the beginning of the first lockdown and the decreased number of macula-on RRD were not sustained over a longer period of observation or found to recur after a second national lockdown. Patients from areas with the least socioeconomic deprivation seemed to be more negatively affected by the first lockdown, with later presentation and higher rates of re-detachments compared with the most deprived during the first lockdown. Our findings offer reassurance that patient behaviour and health services had adapted to the pandemic by the second national lockdown.

Supplementary Information

The online version of this article (10.1007/s00717-022-00521-0) contains supplementary material, which is available to authorized users.

LASER PROPHYLAXIS IN STICKLER SYNDROME: The Manchester Protocol

PURPOSE

Patients with Stickler syndrome are at high risk of giant retinal tears (GRTs) and detachments. Vitreoretinal interventions can reduce this risk, but there is presently no consensus about the optimal prophylactic approach. The aim of our study was to determine whether 360° laser prophylaxis is a safe and effective procedure to prevent GRT detachments in patients with Stickler syndrome.

METHODS

Study subjects were recruited retrospectively through the databases of the vitreoretinal and ophthalmic genetic tertiary services in Manchester, United Kingdom. Clinical data were collected including on prophylactic intervention, the occurrence of retinal detachment, and the presence/type of retinal breaks.

RESULTS

One hundred thirteen eyes from 63 patients with Stickler syndrome were studied; 72.6% (82/113) of these eyes received 360° laser prophylaxis. Of these, 9% had a retinal detachment, but no GRTs occurred. Among the 27.4% (31/113) of eyes that had no prophylactic treatment, 23% suffered a retinal detachment and 42.9% of these were associated with a GRT.

CONCLUSION

Patients who underwent laser prophylaxis had fewer retinal detachments and no GRTs during an average of 6.1 years of follow-up (median 5 years), suggesting that this is a safe and effective approach for individuals with Stickler syndrome.

Functional and Anatomical Outcomes of Pars Plana Vitrectomy for Epiretinal Membrane in Patients with Uveitis

Purpose-To evaluate the anatomical and functional outcomes of vitrectomy and epiretinal membrane (ERM) peeling in patients with uveitis. Secondarily, we evaluated the effect of internal limiting membrane (ILM) peeling on surgical outcomes, and of surgery on uveitis activity and, thus, therapeutic regime. Methods-Bicentre, retrospective, interventional case series of 29 eyes of 29 consecutive patients affected by uveitis and ERM, that had undergone pars plana vitrectomy with ERM peel between 2012 and 2020, with a minimum postoperative follow-up (FU) of six-months. Demographic data, best-corrected visual-acuity (BCVA), clinical findings, intraoperative and postoperative complications, and macular optical-coherence-tomography scans were reviewed. Results-The mean (standard deviation) duration of follow-up was 32 (22) months. At six-month FU, mean central-retinal-thickness (CRT) significantly improved (from 456 (99) to 353 (86) microns; p < 0.001), and mean BCVA improved from 0.73 (0.3) to 0.49 (0.36) logMAR (p < 0.001), with only one (3%) patient experiencing worsening of vision. The rate of concomitant cystoid macular edema decreased from 19 (66%) eyes at presentation to eight (28%) eyes at final-FU (p = 0.003). Comparing eyes in which ILM peeling was performed in addition to ERM peeling only, BCVA or CRT reduction were comparable. Only a minority of six (21%) eyes had a worsening in uveitis activity requiring additional medications, whereas most patients resumed the same treatment (52%) or received less treatment (28%) (p = 0.673). Conclusions-Vitrectomy with ERM peeling led to favourable anatomical and functional outcomes in patients with uveitis regardless of whether the ILM is peeled or not. As in most patients, no activation of the uveitis requiring additional medications was noted, we do not recommend changes in anti-inflammatory/immunosuppressive therapy postoperatively.

Neovascular Glaucoma: An Update

Neovascular glaucoma (NVG) is a severe type of secondary glaucoma with devastating complications and generally poor visual prognosis. NVG is defined by the development of pathological neovessels over the iris and the iridocorneal angle that can block the outflow of aqueous humor, causing elevation of intraocular pressure (IOP). The pathogenesis of NVG is, in most cases, associated with ischemia of the posterior segment, which is most frequently associated with proliferative diabetic retinopathy or central retinal vein occlusion. The advanced stages of NVG are by iris and angle neovascularization, angle, and extremely high IOP, accompanied by ocular pain and poor vision. The therapeutic approach of NVG is based on the reduction of retinal ischemia by panretinal photocoagulation. Intravitreal anti-VEGF administration can contribute to the regression of neovascularization, and topical and systemic medications may be necessary for IOP control. However, if medical treatment with these agents is not enough, surgical procedures may be required to lower IOP and prevent glaucomatous optic neuropathy. Early and prompt diagnosis, with identification of the underlying etiology, can improve IOP control and final visual outcome. The aim of this study is to review current knowledge of the pathogenesis and management of NVG.

Deep Metagenomic Sequencing for Endophthalmitis Pathogen Detection Using a Nanopore Platform

PURPOSE

To evaluate the utility of nanopore sequencing for identifying potential causative pathogens in endophthalmitis, comparing culture results against full-length 16S rRNA nanopore sequencing (16S Nanopore), whole genome nanopore sequencing (Nanopore WGS), and Illumina (Illumina WGS).

DESIGN

Cross-sectional diagnostic comparison.

METHODS

Patients with clinically suspected endophthalmitis underwent intraocular vitreous biopsy as per standard care. Clinical samples were cultured by conventional methods, together with full-length 16S rRNA and WGS using nanopore and Illumina sequencing platforms.

RESULTS

Of 23 patients (median age 68.5 years [range 47-88]; 14 males [61%]), 18 cases were culture-positive. Nanopore sequencing identified the same cultured organism in all of the culture-positive cases and identified potential pathogens in two culture-negative cases (40%). Nanopore WGS was able to additionally detect the presence of bacteriophages in three samples. The agreements at genus level between culture and 16S Nanopore, Nanopore WGS, and Illumina WGS were 75%, 100%, and 78%, respectively.

CONCLUSIONS

Whole genome sequencing has higher sensitivity and provides a viable alternative to culture and 16S sequencing for detecting potential pathogens in endophthalmitis. Moreover, WGS has the ability to detect other potential pathogens in culture-negative cases. Whilst Nanopore and Illumina WGS provide comparable data, nanopore sequencing provides potential for cost-effective point-of-care diagnostics.

Outcomes of Heavy Silicone Oil (Densiron) compared to Silicone Oil in primary rhegmatogenous retinal detachment: a multivariable regression model

PURPOSE

To measure the visual outcomes, proliferative vitreoretinopathy (PVR) and retinectomy rates following primary rhegmatogenous retinal detachment (RRD) repair, comparing silicone oil (SO) and heavy SO (Densiron).

METHODS

Retrospective, continuous comparative study from January 2017 to May 2021 of all primary RRD. Multivariable linear (logMAR gain) and binary-logistic (PVR-C and retinectomy rate) regression models to compare tamponade were performed. Covariates included age, gender, ocular co-morbidities, high myopia, macula-status, giant-retinal-tear (GRT), pre-op vision, PVR-C, oil type, perfluorocarbon-use, combined scleral buckle/vitrectomy, combined phaco-vitrectomy, 360-degrees-endolaser and oil duration. Cases with trauma or less than six-month follow-up were excluded.

RESULTS

A total of 259 primary RD were analysed. There were 179 SO patients and 80 Densiron patients that had six-month primary re-detachment in 18 (10.1%) and 8 (10.0%) respectively (p = 1.000). No difference in logMAR gain was detected between tamponade choice on multivariable linear regression. Subsequent glaucoma surgery was 5 (2.8%) and 4 (5.0%) for SO and Densiron patients respectively (p = 0.464). On multivariate binary-logistic regression we found no difference in development of PVR-C between oil tamponades. However, SO had significantly higher subsequent retinectomy rate compared to Densiron (odds ratio 15.3, 95% CI 1.9-125.5, p = 0.011). Duration of oil tamponade was not linked to differences in logMAR gain, PVR-C formation or increased retinectomy rate.

CONCLUSIONS

We report no difference in primary anatomical success, number of further RRD surgeries, subsequent glaucoma surgery, visual outcomes, PVR-C between both tamponades on multivariable models. Densiron oil was found to be more retinectomy sparing relative to SO.

Primary retinopexy in preventing retinal detachment in a tertiary eye hospital: a study of 1157 eyes

PURPOSE

Retinopexy is the most common vitreo-retinal procedure performed in the eye emergency department and significantly reduces the risk of a rhegmatogenous retinal detachment (RRD). There are various indications for retinopexy, with the most common being horseshoe-tears (HST). Multiple treatment techniques exist, ranging from slit-lamp laser-retinopexy, indirect laser-retinopexy or cryopexy. We report on our primary retinopexy 6-month RRD rate, repeat retinopexy rate and compare outcomes of different indications and treatment modalities.

METHODS

Retrospective consecutive case series of 1157 patients attending Birmingham and Midlands Eye Centre, UK between January 2017 and 2020.

RESULTS

The RRD rate at 6 months was 3.9%, with 19.1% requiring subsequent retinopexies. Multivariate Cox survival regression analysis showed that significant risk factors for RRD following primary retinopexy included male gender (p = 0.012), high myopia (≤ - 6.00D, p = 0.004), HST (compared to round holes, p = 0.026) and primary cryopexy (compared to slit-lamp laser, p = 0.014). HST was the most common indication for retinopexy (812 [70.2%]) in which 118 (14.5%) had multiple tears. Slit-lamp laser was used in 883 (76.3%) of cases. The rate for subsequent epiretinal membrane peel surgery was 3 (0.3%) and was higher in eyes that required multiple retinopexy procedures (p = 0.035).

CONCLUSION

With our large cohort of patients over three years, we provide additional evidence on the RRD and subsequent retinopexy rate after primary retinopexy. Further retinopexy is a common occurrence, particularly in high-risk retinal tears such as HST. Strict monitoring and prompt follow-up after retinopexy is important to prevent progression to RRD and should be of priority in the clinicians post-retinopexy management plan, particularly in those with associated risk factors.

Molecular, Viral and Clinical Features of Alcohol- and Non-Alcohol-Induced Liver Injury

Hepatic cells are sensitive to internal and external signals. Ethanol is one of the oldest and most widely used drugs in the world. The focus on the mechanistic engine of the alcohol-induced injury has been in the liver, which is responsible for the pathways of alcohol metabolism. Ethanol undergoes a phase I type of reaction, mainly catalyzed by the cytoplasmic enzyme, alcohol dehydrogenase (ADH), and by the microsomal ethanol-oxidizing system (MEOS). Reactive oxygen species (ROS) generated by cytochrome (CYP) 2E1 activity and MEOS contribute to ethanol-induced toxicity. We aimed to: (1) Describe the cellular, pathophysiological and clinical effects of alcohol misuse on the liver; (2) Select the biomarkers and analytical methods utilized by the clinical laboratory to assess alcohol exposure; (3) Provide therapeutic ideas to prevent/reduce alcohol-induced liver injury; (4) Provide up-to-date knowledge regarding the Corona virus and its affect on the liver; (5) Link rare diseases with alcohol consumption. The current review contributes to risk identification of patients with alcoholic, as well as non-alcoholic, liver disease and metabolic syndrome. Additional prevalence of ethnic, genetic, and viral vulnerabilities are presented.

Environmental Effect of Fluorinated Gases in Vitreoretinal Surgery: A Multicenter Study of 4,877 Patients

PURPOSE

To investigate the direct contribution to carbon emissions of fluorinated gases used in all vitreoretinal (VR) procedures utilizing gas tamponade and assess the respective carbon footprint of the three different gas delivery systems.

DESIGN

A multicenter, retrospective, environmental impact study.

METHODS

All VR procedures using fluorinated gases between 2017 to 2020 at the Manchester Royal Eye Hospital (MREH) and Birmingham and Midland Eye Centre (BMEC) (the second and third largest VR centers in the UK), and between 2019 to 2020 at the University Hospitals Coventry and Warwickshire (UHCW) were included. CO2 equivalent mass (CO2EM) was calculated from the mass of each gas used, according to the Intergovernmental Panel on Climate Change.

RESULTS

A total of 4877 (1883 SF6 [38.6%], 2096 C2F6 [43.0%], and 897 C3F8 [18.4%]) procedures were analyzed. UHCW and BMEC utilized single-use 30 mL and 75 mL cannisters, respectively. MREH used four cylinders of each gas over 4 years (2 kg SF6, 1 kg C2F6, 1 kg C3F8). Mean CO2EM per patient was: MREH 111.8 kg, BMEC 7.5 kg, and UHCW 2.7 kg. For MREH and BMEC, the CO2EM was 73.4 metric tons annually (if all cases were performed with i) 30 mL: 3.7 tons and ii) cylinders: 148.0 tons, x 40-fold difference), equating to 599,400 (30,500-1.2 million) km travelled by a passenger car. The current use of SF6 in VR surgery accounts for 0.11% of total SF6 use; if 30 mL cylinders were exclusively used in the UK, this could be lowered to 0.01%.

CONCLUSIONS

This study highlights the significant waste associated with large gas cylinders and demonstrated that 30 mL cannisters can lead to a marked reduction in carbon emissions, even after accounting for the increased carbon footprint involved in their manufacture and disposal.

Environmental effect of air versus gas tamponade in the management of rhegmatogenous retinal detachment VR surgery: A multicentre study of 3,239 patients

Purpose

To report the potential reduction of carbon emissions by utilising air-tamponade (AT), where possible, instead of fluorinated gases in the management of rhegmatogenous retinal detachment (RRD). We compared the carbon CO₂ emissions produced at two large tertiary referral vitreoretinal (VR) centres where RRD are exclusively repaired using fluorinated gases to a tertiary VR mass of each gas used according to the Intergovernmental Panel on Climate Change.

Materials and methods

Retrospective, continuous, comparative multicentre study of all procedures using fluorinated gases between 01/01/17-31/12/20 at the Manchester Royal Eye Hospital (MREH) and Birmingham and Midland Eye Centre (BMEC), and between 01/01/19-31/12/2020 at the University Hospitals Coventry and Warwickshire (UHCW).

Results

We report on 3,239 (SF₆:1,415 [43.7%], C₂F₆:1,235 [38.1%], C₃F₈:541 [16.7%], Air:48 [1.5%]) procedures. UHCW and BMEC utilise single use 30ml and 75ml cannisters, respectively and MREH use multi-use gas cylinders. UHCW used AT in 48 (70%) of RRD repairs. Mean equivalent mass CO₂/patient was MREH:115.9kg, BMEC:7.9kg and UHCW:1.9kg. If assuming all centres used 30ml cannisters, the mean equivalent mass CO₂/patient was MREH:3.5 kg, BMEC:3.1kg and UHCW:1.9kg. AT enabled UHCW to greatly reduce the need for the most environmentally damaging SF₆ gas, leading to lower CO₂ emissions by 47.0% and 41.1% compared to MREH and BMEC, respectively.

Conclusion

We demonstrate how AT vs. the fluorinated gases can reduce in carbon footprint in the management of RRD. Further studies are required to determine the most ‘environment-friendly’ intraocular tamponade without compromising patient outcomes centre that also routinely employs AT in selected RRD cases.

Vitreoretinal specialists compared with residents on outcomes of primary laser retinopexy in preventing retinal detachment in 958 eyes

Objective

Retinal tears are the most common vitreoretinal (VR) emergency and retinopexy aims to reduce the risk of rhegmatogenous retinal detachment (RRD). Currently retinal laser is a required competence by the Royal College of Ophthalmologists for residents. We report 6-month detachment rate and repeat retinopexy rate of VR specialists compared with residents.

Methods and analysis

A retrospective, consecutive study of 958 eyes undergoing primary laser retinopexy (slit lamp or indirect laser) from January 2017–2020 was divided into training level by operator: specialty training (ST) 2–3, ST4–5, ST6–7 and VR specialists.

Results

We report an overall 6-month RRD rate in 32/958 (3.3%) (ST2–3: 9/221 (4.1%), ST4–5: 15/373 (4.0%), ST6–7: 2/72 (2.8%) and VR specialists: 6/292 (2.1%)). We additionally report a repeat retinopexy rate of 189/958 (19.7%), (ST2–3: 44/221 (19.9%), ST4–5: 80/373 (21.4%), ST6–7: 16/72 (22.8%) and VR specialists: 49/292 (16.8%)]). Multivariable Cox survival regression analysis showed significant risk factors for developing RRD include male gender (p=0.018), high myopia (≤−6.00 Dioptres, p=0.004), ST2–3 (p=0.022) and ST4–5 (p=0.040) (relative to VR specialists) and by ST6–7, no significance was found (p=0.151). Significantly higher repeat retinopexy rates were associated with horseshoe tears (relative to round holes, p<0.001) and high myopia (p=0.026) with no difference between different training levels.

Conclusion

There was a decreasing trend in RRD rate following primary retinopexy with increase in training. Although junior residents had a higher RRD rate than VR specialists, it was still favourable relative to other large case series. While there was no difference in subsequent laser retinopexy rate between training levels, the retreatment rate was associated with the type of tear and high myopia.

Retinal Detachment Repair With Vitrectomy: Air Tamponade Integration to a Vitreoretinal Service, Comparison With Gas Tamponade, and Literature Review

BACKGROUND AND OBJECTIVE

Rhegmatogenous retinal detachment (RRD) repair by pars plana vitrectomy and gas tamponade (GT) has significant clinical and quality-of-life impacts compared with repair by short-acting air tamponade (AT). With AT, most authors minimize cryotherapy because of prolonged chorioretinal scar formation and use perfluorocarbon to maximize subretinal fluid drainage; this deviates from traditional technique, which discourages popularization of AT.

PATIENTS AND METHODS

Prospective 12-month study from January to December 2019 of all primary macula-on RRD cases. Patients fulfilling the inclusion criteria for the Pneumatic Retinopexy Versus Vitrectomy for Retinal Detachment Trial received AT and otherwise were assigned to receive GT.

RESULTS

Forty-six patients were enrolled: 22 (48%) receiving AT and 24 (52%) receiving GT. The primary success rate of AT was 21 (95%) and the primary success rate of GT was 23 (96%), with 100% final success. Cryopexy was used in 64% of AT cases and 58% of GT cases. Cataract surgery was required less when AT was used (1 [6%]) than when GT was used (3 [21%]). AT was used in 48% of primary macula-on RRD and 27% of all primary RRD cases.

CONCLUSIONS

AT has visual and anatomical outcomes comparable to those of GT with conventional vitrectomy techniques, with faster postoperative rehabilitation enabling a swift return to normal daily activities. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:87-95.].

Effect of demographics and ethnicity on laser retinopexy in preventing retinal detachment in a tertiary eye hospital in 812 eyes

PURPOSE

To investigate different baseline characteristics, clinical indications, repeat retinopexy rate, and 6-month detachment rate of primary laser retinopexy across different ethnicities.

METHOD

Retrospective, single-centre, consecutive comparative study, looking at all patients who had primary laser retinopexy between January 2017 and 2020. Multivariate Cox survival [reporting hazard ratio (HR)] and binary logistic regression (reporting odds ratio) analyses were performed to investigate differences between ethnicities with age, gender, operator level (vitreoretinal or general ophthalmologist) and high myopia status (≤-6.0 Dioptres) as covariates.

RESULTS

We report on 812 patients in three ethnicities: Black [69 (8.5%)], South Asian [SA, 156 (19.2%)] and White [587 (72.3%)] with overall 6-month detachment rate of 31 (3.8%). Rate for subsequent retinopexies was Black: 12 (17.4%), SA: 15 (9.6%) and White: 131 (22.3%), p = 0.002. Multivariate Cox survival regression analysis found no difference in detachment rate between ethnicities. South Asian (SA) had lower repeat retinopexy rate than White patients [HR, 0.40 (95% confidence interval [CI], 0.22-0.71, p = 0.002)]. Multivariate binary logistic regression found that Black and SA patients compared with White, have the following: (i) higher proportion of round holes relative to horseshoe tears [OR, 2.31 (95% CI, 1.19-4.49, p = 0.014) and OR, 2.06 (95% CI, 1.25-3.40), p = 0.004, respectively] and (ii) higher proportion of high myopia [OR, 2.99 (95% CI, 1.20-7.46, p = 0.019) and OR, 2.35 (95% CI, 1.11-4.96), p = 0.025, respectively]. Ethnic minorities were younger than White patients: SA [43, interquartile range (IQR), 28-61], Black (49, IQR, 35-57) and White (61, IQR, 54-67 years, p < 0.001) and had more indirect and 360 retinopexy compared with slit lamp (p < 0.001).

CONCLUSION

We demonstrate a significant difference in baseline characteristics, retinal tear morphology and treatment course between the ethnic groups. Further studies are necessary to investigate the genetic and biological differences that may influence these variations and may help to allow for more targeted health care.

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.

816 Managing Acute Appendicitis During the First Wave of the COVID-19 Pandemic: A Single-Centre Retrospective Study

Introduction

The COVID-19 pandemic provoked a change to normal surgical practice and led to a higher proportion of acute appendicitis (AA) patients being treated conservatively with antibiotics. We aim to analyse patients presenting with AA during the first wave of the pandemic, comparing surgically and conservatively managed patients.

Method

All patients presenting to our centre with AA between March and July 2020 were included. Six-month follow-up data was collected retrospectively using electronic records. Patients were categorised into surgically and conservatively managed groups. The primary outcome was the complication rate (post-operative complications vs failure of antibiotic treatment) and the secondary outcome was length of hospital stay.

Results

Fifty-seven patients (n = 57) were admitted with AA, 45.6% (n = 26) managed conservatively compared to 54.4% (n = 31) treated surgically. Higher complication rates were observed amongst the conservatively managed group, although not statistically significant (16% vs 35%; p = 0.131). There was no significant difference in length of hospital stay observed between the two groups (surgical: median, 2; interquartile range, 2-3 vs conservative: median, 3; interquartile range, 2-4). White cell count (WCC) and Alvarado score were higher on admission in the surgical group with statistical significance (p = 0.012 and p = 0.028 respectively).

Conclusions

Stratification criteria, such as Alvarado score and WCC may identify patients more suitable for conservative management. Longer term follow-up will be carried out, which may alter complication rates in either group. We suggest all patients treated conservatively should undergo computerised tomography (CT) to exclude complicated appendicitis. Further UK-based studies will add to the evidence-base surrounding management of AA during the COVID-19 pandemic.

Refractive Outcomes of Phacovitrectomy in Retinal Detachment Compared to Phacoemulsification Alone Using Swept-Source OCT Biometry

BACKGROUND AND OBJECTIVE

To assess the refractive outcomes in patients who underwent combined phacovitrectomy for retinal detachment compared to phacoemulsification and intraocular lens (IOL) implant utilizing newer swept-source optical-coherence-tomography (SS-OCT) biometry and determine the requirement of an adjustment factor for superior predicted refractive outcomes.

PATIENTS AND METHODS

Retrospective study of 95 eyes: 52 eyes that underwent phacovitrectomy and 43 eyes with phacoemulsification only that served as the control group. Mean refractive error (ME) and mean absolute error (MAE) were used to compare the groups.

RESULTS

No statistically significant postoperative refractive shift was found between phacoemulsification and phacovitrectomy eyes for (1) ME (0.05 D [± 0.51 diopters (D)] and (0.03 [± 0.73 D], respectively; P = .348), (2) MAE (0.41 D ± 0.29 D and 0.60 ± 0.44 D, respectively), or (3) MAE of the control compared to macula-on/off eyes (P = .160 and P = .078, respectively).

CONCLUSION

The authors do not recommend an adjustment factor for IOL selection when utilizing SS-OCT biometry, as it provided refractive outcomes superior to those found in previous studies utilizing a partial coherence interferometry system. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:432-437.].

The impact of the COVID-19 pandemic on microbial keratitis presentation patterns

BACKGROUND

Microbial keratitis (MK) is the most common non-surgical ophthalmic emergency, and can rapidly progress, causing irreversible sight-loss. This study explored whether the COVID-19 (C19) national lockdown impacted upon the clinical presentation and outcomes of MK at a UK tertiary-care centre.

METHODS

Medical records were retrospectively reviewed for all patients with presumed MK requiring corneal scrapes, presenting between 23rd March and 30th June in 2020 (Y2020), and the equivalent time windows in 2017, 2018 and 2019 (pre-C19).

RESULTS

In total, 181 and 49 patients presented during the pre-C19 and Y2020 periods, respectively. In Y2020, concurrent ocular trauma (16.3% vs. 5.5%, p = 0.030) and immunosuppression use (12.2% vs 1.7%, p = 0.004) were more prevalent. Despite proportionately fewer ward admissions during the pandemic (8.2% vs 32.6%, p<0.001), no differences were observed in baseline demographics; presenting visual acuity (VA; median 0.6 vs 0.6 LogMAR, p = 0.785); ulcer area (4.0 vs 3.0mm2, p = 0.520); or final VA (0.30 vs 0.30 LogMAR, p = 0.990). Whilst the overall rates of culture positivity were similar in Y2020 and pre-C19 (49.0% vs. 54.7%, p = 0.520), there were differences in the cultures isolated, with a lower rate of poly-microbial cultures in Y2020 (8.3% vs. 31.3%, p = 0.022).

CONCLUSIONS

Patient characteristics, MK severity and final visual outcomes did not appear to be affected in the first UK lockdown, despite fewer patients being admitted for care. Concurrent trauma and systemic immunosuppression use were greater than in previous years. The difference in spectra of isolated organisms may relate to behavioural changes, such as increased hand hygiene.

ASSESSING REFRACTIVE OUTCOMES AND ACCURACY OF BIOMETRY IN PHACOVITRECTOMY AND SEQUENTIAL OPERATIONS IN PATIENTS WITH RETINAL DETACHMENT COMPARED WITH ROUTINE CATARACT SURGERY

PURPOSE

To compare refractive outcomes and accuracy of modern optical biometry, swept-source optical coherence tomography, ultrasound biometry, and effect of the macula status in rhegmatogenous retinal detachment managed with either combined phacovitrectomy or sequential vitrectomy and cataract surgery compared with a control, phacoemulsification alone.

METHODS

Retrospective, comparative, consecutive study of 154 eyes; Group 1 underwent phacovitrectomy (n: 70), Group 2 underwent vitrectomy with subsequent cataract surgery (n: 41), and Group 3 underwent cataract surgery alone (n: 43).

RESULTS

No difference in the mean absolute error was found between Group 2 (0.41 ± 0.56) and Group 3 (0.41 ± 0.29); both were superior to Group 1 (0.74 ± 0.57). Between Group 1 and Group 2, no statistically significant difference in the mean absolute error was found between macula-on subgroups (P = 0.057), but this was statistically significant between macula-off subgroups (P = 0.009). Subgroup analysis by biometry showed that the difference in the mean absolute error between macula-off optical biometry Group 1 and Group 2 against our control, Group 3, were not significant (P = 0.078 and P = 0.119, respectively); the mean absolute error was significantly different when considering macula-off ultrasound biometry cases (P < 0.001 and P = 0.038, respectively).

CONCLUSION

All three groups had comparable refractive outcomes when using optical biometry. However, phacovitrectomy macula-off cases had inferior refractive outcomes when the ultrasound biometry had to be used. In macula-off rhegmatogenous retinal detachment, when optical biometry is not reliable, it is preferable to perform sequential surgery rather than phacovitrectomy.

Surgical Versus Conservative Management of Acute Appendicitis During the COVID-19 Pandemic: A Single-Centre Retrospective Study

Introduction The COVID-19 pandemic provoked a change to normal surgical practice in the United Kingdom and led to an increase in acute appendicitis (AA) patients being treated conservatively with antibiotics. We aim to analyse the management of patients presenting with AA to our institution during the first wave of the pandemic, comparing surgically and conservatively managed patients. Method All patients presenting to our centre with AA between March and July 2020 were included. Six-month follow-up data were collected retrospectively using electronic records. Patients were categorised into surgically and conservatively managed groups. The primary outcome was the complication rate (post-operative complications vs failure of antibiotic treatment) and the secondary outcomes were length of hospital stay and Alvarado score. Results  Fifty-seven patients (n=57) were admitted with AA, 45.6% (n=26) managed conservatively compared to 54.4% (n=31) treated surgically. Higher complication rates were observed amongst the conservatively managed group, although not found to be statistically significant (16% vs 35%; p=0.131). There was no significant difference in length of hospital stay observed between the two groups (surgical: median, 2; interquartile range, 2-3 vs conservative: median, 3; interquartile range, 2-4). White cell count (WCC) and Alvarado score were higher on admission in the surgical group with statistical significance (p=0.012 and p=0.028, respectively). Conclusions COVID-19 has led to a significant cohort of conservatively managed AA patients in the United Kingdom. We propose a stratification pathway based on clinical severity, Alvarado score and imaging to facilitate safe selection for conservative management of AA, in order to reduce failure of treatment rates in this patient group. Further UK-based studies will add to the evidence-based surrounding safe management of AA with conservative treatment.

The impact of COVID-19 on primary retinopexy in preventing retinal detachment in a tertiary eye hospital emergency department

PURPOSE

To review the effect of COVID-19 on rhegmatogenous retinal detachment (RRD) rate following primary retinopexy.

METHODS

Retrospective consecutive case series of 183 patients attending Birmingham and Midlands Eye Centre undergoing primary retinopexy (cryotherapy and laser) between March 23rd to June 30th in 2019 (Group 1) and 2020 (Group 2).

RESULTS

In total we reviewed 183 retinopexies, 122 in Group 1 and 61 in Group 2, a reduction of 50%. In Group 2 compared to Group 1, we showed a significant difference in characteristics of patients having primary retinopexy with an increase in proportion of male patients from 50 (41.0%) to 39 (63.9%) (p = 0.005), increase in high myopes from 1 (0.8%) to 4 (6.6%) (p = 0.043), more slit lamp laser retinopexy from 83 (68.0%) to 52 (85.2%) (p = 0.013) and less cryopexy from 21 (17.2%) to 2 (3.3%) (p = 0.008). In Group 2, primary retinopexy resulted in significantly more 3-month RRD rate 1 (0.8%) to 5 (8.2%) (p = 0.016). There were no changes in number of patients requiring further retinopexy (p = 1.000).

CONCLUSION

This study demonstrates a reduction of primary retinopexy, an increased risk for RRD following primary retinopexy and a significant shift in type of primary retinopexy performed, demographics, operator and change in characteristics of type of retinal break observed during this pandemic. This study contributes to the growing literature of the secondary effects of the COVID-19 pandemic on other aspects of healthcare that is not just limited to the virus itself.

Vitrectomy with air tamponade and cryotherapy for retinal detachment repair without perfluorocarbon use: A UK 12-month prospective case series

INTRODUCTION

Rhegmatogenous retinal detachment (RRD) is commonly managed by pars plana vitrectomy (PPV). Gas tamponade has significant clinical and quality of life factors that affect the patient. Using shorter acting air tamponade, intuitively leads to surgical concern for higher rate of primary detachment. To circumvent this, surgeons advocate the use of perfluorocarbon to maximise sub-retinal-fluid drainage when using air tamponade and/or avoid using cryotherapy due to longer duration for scar formation relative to laser. These steps are a deviation from traditional technique for otherwise routine primary RRD repair and discourages popularisation of using air tamponade despite the benefits to patients.

METHOD

Prospective 12-month, single centre, single surgeon, consecutive study from January to December 2019. Inclusion criteria was as per based on the pneumatic retinopexy versus vitrectomy for retinal detachment: (i) single retinal break or group of breaks, no larger than 1-clock-hour (30°), in detached retina; (ii) all breaks in detached retina lie above the 8 to 4 o'clock meridian; and (iii) breaks or lattice degeneration in attached retina at any location. We excluded PVR formation and RRD in the inferior 4 o'clock hours.

RESULTS

We report primary and final success rate of 96% and 100%, respectively in 23 eyes (22 macular-on and one macular-off) with RRD eyes in a 12-month period. Cryopexy was utilised in 65% patients and in isolation in 23% with no perfluorocarbon use in all eyes.

CONCLUSION

We show cryotherapy can be used safely in AT-RRD without PFCL in RRD fulfilling PIVOT trial criteria with minimal cataract formation and IOP spikes and faster post-operative visual rehabilitation.

Calculating the economic burden of presumed microbial keratitis admissions at a tertiary referral centre in the UK

Purpose

Microbial keratitis (MK) is the most common non-surgical ophthalmic emergency admission in the UK. However, few prospective health-economic studies of MK have been performed, and no specific healthcare resources group (HRG) code exists. This study is designed to determine the feasibility of a data collection tool derived from the microbiology ophthalmology group (MOG) clinical record form, to enable quantification of direct costs of inpatient care, as well as prospective capture of epidemiological data relating to outcomes of MK.

Methods

Clinical, demographic and economic data were collected retrospectively between January and December 2013 for 101 consecutive patients admitted with MK, using an adaption of the MOG toolset. The direct cost of admission (COA) was calculated using national reference costs and compared to actual income to generate profit/deficit profiles for individual patients. Indices of multiple deprivation were used to assess effect of deprivation on the COA.

Results

The total income generated through discharge coding was £252,116, compared to a COA of £357,075, yielding a deficit of £104,960 (median: £754 per patient). The cost deficit increased significantly with length of stay (LOS, p < 0.001), whilst patients with short LOS were income generators; cost neutrality occurred at 4.8 days. Greater socioeconomic deprivation was also associated with a significantly higher cost deficit.

Conclusion

LOS is the key driver for COA of care for MK admissions. Protocols should encourage discharge of patients who are able to self-administer treatment after the sterilisation phase. The MOG-derived data collection toolset captures pertinent clinical data for quantification of COA. Further development into a multiuser and multisite platform is required for robust prospective testing, together with expansion to capture indirect costs of disease burden, including impact of treatment, visual morbidity and quality of life.

Restructuring emergency eye services during COVID-19 in a tertiary referral centre

BACKGROUND/AIMS

Maintaining emergency eye services is crucial during the COVID-19 pandemic. This article describes the introduction of a new restructured referral pathway to reduce the burden on healthcare providers and create a safe environment.

METHODS

During January and February 2020 (group 1), all appointments were face-to-face with a walk-in eye casualty. The first audit cycle comprised all patients in group 1. The primary audit criteria were discharge rates, referral to subspeciality and reattendance. In April 2020, a remodelled system was implemented in which walk-in attendance ceased and was replaced with telephone triage coupled with digital imaging via NHS email for remote clinical review. Patients requiring further assessment following this triage were invited in for face-to-face appointments. A reaudit was conducted during April-July 2020 (group 2) following implementation of these COVID-19 protocol changes.

RESULTS

In group 1, 2868 appointments (100.0%) were face-to-face and in group 2 4870 (100.0%) appointments were telephone consults that resulted in 2639 (54.2%) face-to-face appointments. The rate of discharge in the first cycle and second cycle were 55.3% and 76.9% respectively (P<0.0001). Furthermore 2298 (47.2%) patients were able to be discharged following telephone consultation in group 2.

CONCLUSIONS

Using this telephone and digital imaging review triage system, the authors have demonstrated a significant reduction in the need for face-to-face reviews. The reduction in avoidable patient face-to-face reviews allows the system to move from saturated to sustainable while increasing accessibility to services for patients who may not be able to present for face-to-face review. This complete audit cycle successfully charts interventions that maximise accessibility, reduce unnecessary hospital visits and deliver safe and prompt management during the pandemic.

Using the West Midlands CONCERT to characterise regional incidence of acute-onset post cataract surgery endophthalmitis

BACKGROUND

Whilst research and innovation is embedded within the UK's National Health Service (NHS) constitution, Doctors-in-training have little opportunity to contribute to designing, leading and recruiting into clinical trials or cohort studies. We formed the West Midlands Collaborative Ophthalmology Network for Clinical Effectiveness & Research by Trainees (The West Midlands CONCERT) and undertook a characterisation of post cataract surgery endophthalmitis as a proof-of-concept study to test the feasibility of the CONCERT model.

METHODS

Doctors-in-training formed a collaborative working group to test the concept of delivering a pan-regional clinical effectiveness study across multiple hospital sites by performing retrospective analyses of post cataract endophthalmitis over a 6-year period.

RESULTS

Overall, 157,653 cataract surgeries were performed by participating centres accredited to deliver the Royal College of Ophthalmologists training curriculum. Thirty-eight cases of post cataract endophthalmitis were identified, giving an incidence of 2.41 per 10,000 cases (0.0241%). A further 15 endophthalmitis cases presented who had surgery in non-training centres, giving a total of 53 cases. The most common organisms were S. epidermidis (14 (51.9%)) and P. aeruginosa (5 (18.5%)). Anterior-chamber and vitreous sampling yielded positive culture in 33.3% (6/18) and 50.9% (27/53), respectively. At 6 months follow-up, 19 (51.4%) patients achieved visual acuities of ≤0.5 LogMAR. Repeat intravitreal injections (11 (20.8%)) and vitrectomy (n = 22 (41.5%)) were not associated with better outcomes.

CONCLUSIONS

Using post cataract endophthalmitis as a pilot cohort, this study highlights the feasibility of using the CONCERT model for studies across multiple sites. A UK-CONCERT could provide a powerful infrastructure enabling characterisation of patient cohorts and a platform for high-quality interventional studies, improving patient care.

Redeployment of ophthalmologists in the United Kingdom during the Coronavirus Disease Pandemic

BACKGROUND

During the current coronavirus (COVID-19) pandemic, some ophthalmologists across the United Kingdom (UK) have been redeployed to areas of need across the National Health Service (NHS). This survey was performed to assess aspects of this process including training & education, tasks expected, availability of personal protection equipment (PPE) used and the overall anxiety of ophthalmologists around their redeployment.

METHOD

Online anonymous survey around the existing guidance on safe redeployment of secondary care NHS staff and PPE use by NHS England and Public Health England respectively. The survey was open to all ophthalmologists across the UK irrespective of their redeployment status.

FINDINGS

145 surveys were completed and returned during a 2-week period between 17th April 2020 and 1st May 2020, when 52% of ophthalmologists were redeployed. The majority of this group consisted of ophthalmologists in training (79%). 81% of those redeployed were assigned to areas of the hospital where patients with confirmed Coronavirus disease were being treated as inpatients. There was a statistically significant improvement in anxiety level following redeployment which was mainly attributed to the support received by staff within the redeployed area. 71% of the redeployed group were found to have sufficient PPE was provided for the area they worked in.

INTERPRETATION

This is the first national survey performed on redeployment of ophthalmologists in the UK. The study showed that ophthalmologists across all grades were able to contribute in most aspects of patient care. Anxiety of redeployment was reduced by prior training and good support in the redeployment area.

Optical coherence tomography of cutaneous lupus erythematosus correlates with histopathology

Diagnosis of cutaneous forms of lupus erythematosus (LE), including chronic discoid LE (CDLE) and subacute cutaneous LE (SCLE), is usually based on characteristic clinical and histopathological findings. We aimed to visualize morphological changes in lesions of cutaneous LE using optical coherence tomography (OCT), and to correlate the OCT findings with histopathology. Six patients with CDLE and five patients with SCLE were investigated. Prior to skin biopsy, OCT assessment was performed on previously marked lesions. The images of OCT and corresponding histology were evaluated side-by-side on the PC screen. The thickening and disruption of the entrance signal in OCT images correlated with the hyperkeratosis which was observed in the histological sections. Atrophy of the epidermis, which was demonstrated by histology, could also be detected in the OCT pictures showing a thinned layer below the entrance signals. On OCT, a patchy reduction of reflectivity was observed in the upper dermis corresponding to dense patchy, partly lichenoid, lymphocytic infiltrates and oedema of the upper dermis. Furthermore, OCT images displayed increased signal-free cavities which histopathologically corresponded to dilated vessels in the upper dermis. All OCT parameters studied significantly (P < 0.05) correlated with histopathological features as indicated by coefficients of correlation ranging from 0.55 to 0.94. OCT enables to demonstrate micromorphological changes in cutaneous LE which correlate with histopathological findings. Nevertheless, the current technique does not allow one to visualize definite diagnostic features of cutaneous LE. However, OCT may be a promising method for objective monitoring of LE activity and treatment effects over time in vivo

Long-Term Follow-up of a Cohort of HIV-Infected Patients Who Discontinued Maintenance Therapy for Cytomegalovirus Retinitis

PURPOSE

To determine the long-term safety of discontinuation of maintenance therapy for cytomegalovirus retinitis (CMVR) and to identify predictors for relapse.

METHOD

This was a prospective cohort study. Patients with treated CMVR who responded to HAART were followed by ophthalmologic assessment, markers for CMV replication (blood and urine cultures, CMV antigenemia, CMV DNA by PCR), and in vitro lymphoproliferative responses to CMV and other antigens after discontinuation of CMVR maintenance therapy.

RESULTS

23 patients were followed a median of 34 (range, 5-61) months. Median CD4 count was 321/mm3 at enrollment and 395/mm3 at last follow-up. HIV RNA was <50 copies/mL in 78% of patients at enrollment and 65% at last follow-up. One CMVR reactivation occurred at 12 months at a CD4 count of 395/mm3 (21%) and HIV RNA <50 copies/mL. Urine cultures were a poor predictive marker for reactivation. Other CMV replication markers had good negative predictive value. 96% of patients had a good lymphoproliferative response to CMV antigen in vitro.

CONCLUSION

Maintenance therapy for CMVR can safely be discontinued in patients who have responded to HAART. Combining our results with the published literature, the risk of reactivation is estimated at 0.016 per person year of follow-up. Markers to predict relapse and the need for re-initiation of maintenance therapy are not yet identified.

Volvulus of the liver with intrathoracic herniation

INTRODUCTION

We present a rare case of a liver volvulus, stomach and transverse colon herniating through the diaphragm. This scenario has not been reported previously. We discuss the presentation and management of this interesting case.

CASE HISTORY

A 65-year-old woman with a history of sarcoidosis and recurrent pericardial effusions, treated previously with a subxiphoid pericardial oval window fenestration, presented with acute upper abdominal pain radiating to the chest. High contrast computed tomography showed a volvulus of the liver with consequent venous congestion, and herniation of the liver, stomach and transverse colon through an anterior diaphragmatic defect. With liver perfusion threatened, an urgent laparoscopic repair was performed. The stomach and transverse colon were reduced, and the twisted left lobe of the liver was unrotated and reduced into the abdominal cavity. A double-sided synthetic mesh was used to repair the defect. The patient made an uneventful recovery.

CONCLUSIONS

This is a novel complication of a patient presenting with abdominal pain with a previous history of pericardial window fenestration. A laparoscopic reduction and repair can be performed safely with excellent postoperative results.

Drug-induced severe adverse reaction enhanced by human herpes virus-6 reactivation

Reactivation of certain latent viruses has been linked with a more severe course of drug-induced hypersensitivity reaction (HSR). For example, reactivation of human herpes virus (HHV)-6 is associated with severe organ involvement and a prolonged course of disease. The present study discusses an HSR developed in a previously healthy male exposed to ceftriaxone, doxycycline, vancomycin, and trimethoprim/sulfamethoxazole (co-trimoxazole; TMP/SMX). Initially, the patient presented clinical manifestations of HSR, as well as clinical and laboratory measurements compatible with liver and renal failure. Moreover, the patient presented skin desquamation compatible with Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis. During the reaction, it was observed HHV-6 reactivation. The severity of clinical symptoms is correlated with HHV-6 titer, as well as with results of the in vitro lymphocyte toxicity assay (LTA). Serum levels of a large panel of cytokines are compared between the patient, a large population of SJS patients, and a cohort of healthy controls, using data collected by our laboratory over the years. HHV-6 was measured in the cell culture media from lymphocytes incubated with each of the 4 drugs. Moreover, we describe a new assay using cytokines released by patient lymphocytes following in vitro exposure to the incriminated drugs as biomarkers of HSR. Based on LTA results, HHV-6 reactivation and cytokine measurements, we establish that only doxycycline and TMP/SMX were involved in the HSR. As result of this analysis, the patient could continue to use the other 2 antibiotics safely.

Cell-mediated immunity to predict cytomegalovirus disease in high-risk solid organ transplant recipients

Late-onset cytomegalovirus (CMV) disease commonly occurs after discontinuation of antiviral prophylaxis. We determined the utility of testing CD8+ T-cell response against CMV as a predictor of late-onset CMV disease after a standard course of antiviral prophylaxis. Transplant patients at high-risk for CMV disease were enrolled. CD8+ T-cell-mediated immunity (CMI) was tested using the QuantiFERON-CMV assay at baseline, 1, 2 and 3 months posttransplant by measurement of interferon-gamma response to whole blood stimulation with a 21-peptide pool. The primary outcome was the ability of CMI testing to predict CMV disease in the first 6 months posttransplant. There were 108 evaluable patients (D+/R+ n = 39; D-/R+ n = 34; D+/R- n = 35) of whom 18 (16.7%) developed symptomatic CMV disease. At the end of prophylaxis, CMI was detectable in 38/108 (35.2%) patients (cutoff 0.1 IU/mL interferon-gamma). CMV disease occurred in 2/38 (5.3%) patients with a detectable interferon-gamma response versus 16/70 (22.9%) patients with a negative response; p = 0.038. In the subgroup of D+/R- patients, CMV disease occurred in 1/10 (10.0%) patients with a detectable interferon-gamma response (cutoff 0.1 IU/mL) versus 10/25 (40.0%) patients with a negative CMI, p = 0.12. Monitoring of CMI may be useful for predicting late-onset CMV disease.

An assessment of herpesvirus co-infections in patients with CMV disease: correlation with clinical and virologic outcomes

The effect of herpesvirus co-infections (HHV-6, HHV-7) on cytomegalovirus (CMV) disease and its response to therapy is unknown. We prospectively analyzed herpesvirus co-infections in transplant recipients with CMV disease. All patients received 3 weeks of antiviral therapy. Samples were collected at baseline (day 0) and then day 3, 7, 14 and 21 poststart of therapy. Viral load testing for CMV, HHV-6 and HHV-7 was done using quantitative PCR assays in 302 patients of whom 256 had documented symptomatic CMV viremia. In this subset, day 0 HHV-6 co-infection was present in 23/253 (9.1%) and HHV-7 in 17/253 (6.7%). Including those positive at any time point raised the prevalence to 79/256 (30.9%) for HHV-6 and 75/256 (29.3%) for HHV-7. Viral co-infection did not influence the response of CMV disease to antiviral therapy. Baseline CMV viral loads, time to eradication and risk of recurrence were similar in patients with and without HHV-6 or HHV-7 co-infection. Ganciclovir and valganciclovir had no clear effect on HHV-6 and HHV-7 viremia. In conclusion, herpesvirus co-infections are common in patients with CMV disease but with standard antiviral therapy, no clear clinical effects are discernable. Routine monitoring for viral co-infection in patients with CMV disease is not indicated.