PRO score: predictive scoring system for visual outcomes after rhegmatogenous retinal detachment repair.

BACKGROUND/AIMS: To compare risk factors for poor visual outcomes in patients undergoing primary rhegmatogenous retinal detachment (RRD) repair and to develop a scoring system. METHODS: Analysis of the Primary Retinal detachment Outcomes (PRO) study, a multicentre interventional cohort of consecutive primary RRD surgeries performed in 2015. The main outcome measure was a poor visual outcome (Snellen VA ≤20/200). RESULTS: A total of 1178 cases were included. The mean preoperative and postoperative logMARs were 1.1±1.1 (20/250) and 0.5±0.7 (20/63), respectively. Multivariable logistic regression identified preoperative risk factors predictive of poor visual outcomes (≤20/200), including proliferative vitreoretinopathy (PVR) (OR 1.26; 95% CI 1.13 to 1.40), history of antivascular endothelial growth factor (VEGF) injections (1.38; 1.11 to 1.71), >1-week vision loss (1.17; 1.08 to 1.27), ocular comorbidities (1.18; 1.00 to 1.38), poor presenting VA (1.06 per initial logMAR unit; 1.02 to 1.10) and age >70 (1.13; 1.04 to 1.23). The data were split into training (75%) and validation (25%) and a scoring system was developed and validated. The risk for poor visual outcomes was 8% with a total score of 0, 17% with 1, 29% with 2, 47% with 3, and 71% with 4 or higher. CONCLUSIONS: Independent risk factors were compared for poor visual outcomes after RRD surgery, which included PVR, anti-VEGF injections, vision loss >1 week, ocular comorbidities, presenting VA and older age. The PRO score was developed to provide a scoring system that may be useful in clinical practice.

Outcomes of Primary Rhegmatogenous Retinal Detachment Repair in Eyes With Preoperative Grade B or C Proliferative Vitreoretinopathy.

Purpose: This work evaluates the anatomic and functional outcomes of primary rhegmatogenous retinal detachments (RRDs) with preoperative grade B and C proliferative vitreoretinopathy (PVR) vs eyes without PVR. Methods: As a multi-institutional, interventional, retrospective study of all patients undergoing primary RRD surgical procedures from January 1, 2015, through December 31, 2015, this study evaluated the visual acuity (VA) outcomes and single-surgery anatomic success rates (SSAS) of patients with primary grade B and C PVR at the time of RRD repair. Results: A total of 2486 eyes underwent primary RD surgery during the study period, of which 153 eyes (6.2%) had documented preoperative PVR grade B or C. Eyes without PVR had better SSAS compared with eyes with grade B or C PVR (87% vs 83% vs 75%, respectively, P < .0001). Eyes without PVR also had better final mean (SD) logMAR VA (0.35 [0.47]; 20/45 Snellen equivalent) than eyes with PVR of grade B (0.50 [0.56]; 20/63 Snellen equivalent) or grade C (P < .0001). In only eyes with preoperative PVR, there were no significant differences in final VA or SSAS on multivariate analysis based on surgical approach or use of retinectomy or membrane peeling alone in the intraoperative management of PVR. Conclusions: Eyes with primary preoperative grade B and C PVR appear to have significantly worse VA outcomes and lower surgical success rates. Surgical approach and management of PVR membranes did not appear to affect VA or success rates, indicating that preoperative PVR severity may dictate these outcomes.

Scleral Buckling for Primary Retinal Detachment: Outcomes of Scleral Tunnels versus Scleral Sutures.

PURPOSE: There are primarily two techniques for affixing the scleral buckle (SB) to the sclera in the repair of rhegmatogenous retinal detachment (RRD): scleral tunnels or scleral sutures. METHODS: This retrospective study examined all patients with primary RRD who were treated with primary SB or SB combined with vitrectomy from January 1, 2015 through December 31, 2015 across six sites. Two cohorts were examined: SB affixed using scleral sutures versus scleral tunnels. Pre- and postoperative variables were evaluated including visual acuity, anatomic success, and postoperative strabismus. RESULTS: The mean preoperative logMAR VA for the belt loop cohort was 1.05 ± 1.06 (Snellen 20/224) and for the scleral suture cohort was 1.03 ± 1.04 (Snellen 20/214, p = 0.846). The respective mean postoperative logMAR VAs were 0.45 ± 0.55 (Snellen 20/56) and 0.46 ± 0.59 (Snellen 20/58, p = 0.574). The single surgery success rate for the tunnel cohort was 87.3% versus 88.6% for the suture cohort (p = 0.601). Three patients (1.0%) in the scleral tunnel cohort developed postoperative strabismus, but only one patient (0.1%) in the suture cohort (p = 0.04, multivariate p = 0.76). All cases of strabismus occurred in eyes that underwent SB combined with PPV (p = 0.02). There were no differences in vision, anatomic success, or strabismus between scleral tunnels versus scleral sutures in eyes that underwent primary SB. CONCLUSION: Scleral tunnels and scleral sutures had similar postoperative outcomes. Combined PPV/SB in eyes with scleral tunnels might be a risk for strabismus post retinal detachment surgery.

Risk Factors for Presence of Cystoid Macular Edema following Rhegmatogenous Retinal Detachment Surgery.

Purpose: Cystoid macular edema (CME) following cataract surgery is a well-known entity. Less is known regarding the risk factors of developing CME following repair of rhegmatogenous retinal detachments (RRD).Methods: This was a multi-institutional study of primary RRD surgeries from 1/1/2015 through 12/31/2015. The primary outcome was the development of postoperative CME following RRD surgery. Post-operative optical coherence tomography imaging and 3 months of follow-up following RRD repair were required.Results: There were 1,466 eyes that met the inclusion criteria, and 140 (9.6%) developed postoperative CME following primary RRD repair. On multivariate analysis, the statistically significant metrics were older patient age (OR 1.03 per year, 95% CI 1.01 to 1.05), pre-operative proliferative vitreoretinopathy (PVR, OR 1.74, 95% 1.03 to 2.95), and cataract surgery following RRD repair (OR 2.18, 95% CI 1.47 to 3.25). Single surgery success was protective against CME (OR 0.20 (95% CI 0.14-0.30). Seventy-six (9.0%) of the phakic eyes and 60 (9.9%) of the pseudophakic eyes developed post-operative CME. Multivariate analysis showed that cataract surgery following RRD repair (p < .0001) for phakic eyes and older age (p = .0075) for pseudophakic eyes were risk factors. In eyes that underwent successful retinal reattachment with one surgery, post-operative cataract surgery (p = .0005) and pre-operative PVR (p = .0011) were risk factors for CME in this subgroup.Conclusion: CME occurred in nearly 10% of the eyes following RRD repair. The biggest risk factors were recurrent RRD, preexisting PVR, older age, and cataract surgery following RRD repair.

Surgical techniques for primary rhegmatogenous retinal detachments between surgeons with high versus low single surgery success rates.

BACKGROUND/AIMS: To identify differences in preoperative characteristics and intraoperative approaches between surgeons with higher versus lower single surgery success rates (SSSR) for repair of rhegmatogenous retinal detachments (RRDs). METHODS: This study is a sub-analysis of subjects who underwent RRD repair in the Primary Retinal Detachment Outcomes (PRO) study, a multi-institutional, retrospective comparative interventional study. The PRO study examined consecutive primary RRD surgeries from January 1, 2015 through December 31, 2015. The primary outcome was variations in surgical approach to different types of RRDs with secondary analyses of pre and intraoperative metrics for surgeons with SSSR > 90% compared to those <80% who performed at least 40 operations during the study period. RESULTS: A total of 689 surgeries were included in the analysis. The mean SSSR was 94% for the higher tier and 75% for the lower tier (p < 0.0001). Surgeons with >90% SSSR were more likely to have graduated fellowship more recently (p = 0.0025), use less perfluorocarbon liquid (p < 0.0001), perform less 360 degree laser retinopexy (p < 0.0001), and perform a higher percentage of primary buckles and combined PPV/SB (p < 0.0001). For pseudophakic eyes there was no difference between PPV and PPV/SB use (p = 0.6211). CONCLUSION: Surgeons with high SSSR typically performed SB as well as combination PPV/SB for more RRDs. Similar numbers of PPV and PPV/SB were performed for pseudophakic eyes, suggesting that the difference in SSSR between the two groups may be related to a combination of preoperative and intraoperative decisions as well as differences in technique.

RETINAL DETACHMENT WITH INFERIOR RETINAL BREAKS: Primary Vitrectomy Versus Vitrectomy With Scleral Buckle (PRO Study Report No. 9).

INTRODUCTION: Rhegmatogenous retinal detachments with inferior retinal breaks are believed to have a higher risk of recurrent rhegmatogenous retinal detachment. This study compared anatomic and visual outcomes between primary pars plana vitrectomy (PPV) and combination PPV with scleral buckle (PPV/SB) for rhegmatogenous retinal detachments with inferior retinal breaks. METHODS: This is an analysis of the Primary Retinal Detachment Outcomes study, a multi-institutional cohort study of consecutive primary rhegmatogenous retinal detachment surgeries from January 1, 2015, through December 31, 2015. The primary outcome was single-surgery success rate. Only eyes with inferior retinal breaks (one break in the detached retina between five and seven o'clock) were included. RESULTS: There were 238 eyes that met the inclusion criteria, 95 (40%) of which underwent primary PPV and 163 (60%) that underwent combined PPV/SB. The single-surgery success rate was 76.8% for PPV and 87.4% for PPV/SB (P = 0.0355). This remained significant on multivariate analysis (P = 0.01). Subgroup analysis showed that a superior single-surgery success rate of PPV/SB was especially noted in phakic eyes (85.2% vs. 68.6%; P = 0.0464). CONCLUSION: Retinal detachment with inferior retinal breaks had a higher single-surgery success rate if treated with PPV/SB compared with PPV alone, particularly in phakic eyes.

Comparison of Visual and Anatomic Outcomes Following RRD Surgery Using 23-Gauge Versus 25-Gauge Vitrectomy: PRO Study Report No. 12.

BACKGROUND AND OBJECTIVE: Most surgeons now utilize small-gauge (23- or 25-gauge) pars plana vitrectomy (PPV) with or without scleral buckling for repair of rhegmatogenous retinal detachments (RRD), in addition to primary scleral buckle (SB), but comparative data between the two gauges are limited. PATIENTS AND METHODS: This study is an analysis of primary RRD repairs comparing 23- versus 25-gauge vitrectomy for PPV or combination PPV/SB from January 1, 2015, through December 31, 2015, across multiple institutions. The primary outcome was single-surgery success and secondary outcomes included postoperative complications. RESULTS: There were 1,932 eyes that met inclusion criteria. There was no statistically significant difference in single-surgery success (82.9% vs. 83.8%; P = 0.6329). There were similar rates of postoperative hypotony, endophthalmitis, vitreous hemorrhage, and choroidal detachment. The findings were similar when analyzing only eyes that underwent primary PPV without SB. CONCLUSION: Both 23- and 25-gauge vitrectomy systems have similar anatomic and visual outcomes in the primary repair of RRD. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:70-76.].

Impact of contact versus non-contact wide-angle viewing systems on outcomes of primary retinal detachment repair (PRO study report number 5).

BACKGROUND/AIMS: Vitrectomy to repair retinal detachment is often performed with either non-contact wide-angle viewing systems or wide-angle contact viewing systems. The purpose of this study is to assess whether the viewing system used is associated with any differences in surgical outcomes of vitrectomy for primary non-complex retinal detachment repair. METHODS: This is a multicenter, interventional, retrospective, comparative study. Eyes that underwent non-complex primary retinal detachment repair by either pars plana vitrectomy (PPV) alone or in combination with scleral buckle/PPV in 2015 were evaluated. The viewing system at the time of the retinal detachment repair was identified and preoperative patient characteristics, intraoperative findings and postoperative outcomes were recorded. RESULTS: A total of 2256 eyes were included in our analysis. Of those, 1893 surgeries used a non-contact viewing system, while 363 used a contact lens system. There was no statistically significant difference in single surgery anatomic success at 3 months (p=0.72), or final anatomic success (p=0.40). Average postoperative visual acuity for the contact-based cases was logMAR 0.345 (20/44 Snellen equivalent) compared with 0.475 (20/60 Snellen equivalent) for non-contact (p=0.001). After controlling for numerous confounding variables in multivariable analysis, viewing system choice was no longer statistically significant (p=0.097). CONCLUSION: There was no statistically significant difference in anatomic success achieved for primary retinal detachment repair when comparing non-contact viewing systems to contact lens systems. Postoperative visual acuity was better in the contact-based group but this was not statistically significant when confounding factors were controlled for.

CHARACTERISTICS AND SURGICAL OUTCOMES OF RHEGMATOGENOUS RETINAL DETACHMENT IN OLDER ADULTS: A Multicenter Comparative Cohort Study.

PURPOSE: To describe characteristics and outcomes of primary rhegmatogenous retinal detachment in older adults (age ≥ 80). METHODS: Consecutive patients with rhegmatogenous retinal detachment undergoing pars plana vitrectomy (PPV), scleral buckling (SB), or PPV/SB in the Primary Retinal Detachment Outcomes Study were evaluated. Outcome measures included single surgery anatomic success and visual acuity. RESULTS: Of 2,144 patients included, 125 (6%) were 80 years or older. Compared with younger patients (age 40-79), older adults were more likely to be pseudophakic (P < 0.001), have macula-off detachments (P < 0.001), and have preoperative proliferative vitreoretinopathy (P = 0.02). In older adults, initial surgery was PPV in 73%, PPV/SB in 27%, and primary SB in 0%. Single surgery anatomic success was 78% in older adults compared with 84% in younger patients (P = 0.03). In older adults, single surgery anatomic success was 74% for PPV and 91% for PPV/SB (P = 0.03). The final mean logMAR was lower for older adults (0.79 [20/125] vs. 0.40 [20/40], [P < 0.001]). In older adults, the final mean logMAR for eyes that underwent PPV was 0.88 (20/160) compared with 0.50 (20/63) for PPV/SB (P = 0.03). CONCLUSION: Octogenarians and nonagenarians presented with relatively complex pseudophakic rhegmatogenous retinal detachments. Single surgery anatomic success and visual outcomes were worse compared with younger patients, and PPV/SB had better outcomes compared with PPV alone.

Surgical Outcomes of Primary RRD With and Without Concurrent Full-Thickness Macular Hole (PRO Study Report No. 7).

BACKGROUND AND OBJECTIVE: Non-causal macular holes (MHs) can occur concurrently with rhegmatogenous retinal detachments (RRDs). The visual outcomes and surgical approach for these eyes are variable. PATIENTS AND METHODS: This was a multi-institutional, retrospective review of all primary retinal detachment surgeries from January 1, 2015, through December 31, 2015. Pre-, intra-, and postoperative metrics were recorded. RESULTS: There were 2,242 eyes that had pars plana vitrectomy for primary RRD, 43 (1.9%) of which had a MH at the time of surgery. The mean postoperative logMAR visual acuity (VA) for the MH cohort was 0.87 ± 0.64 (20/148) and for eyes without a MH was 0.47 ± 0.63 (20/59; P < .0001). The single-surgery re-attachment rate for the MH cohort and no MH cohort was 86.1% and 84.9%, respectively (P = 1.0000). CONCLUSIONS: Patients with noncausal MHs and RRD had significantly worse VA than patients without a MH. Preoperative counseling is imperative in patients with both RRD and MH. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:500-505.].

Primary Retinal Detachment Outcomes Study: Methodology and Overall Outcomes-Primary Retinal Detachment Outcomes Study Report Number 1.

PURPOSE: To detail the methodology for a large multicenter retrospective cohort study (RCS) of primary rhegmatogenous retinal detachment (RRD) with detailed data collection and to present overall anatomic outcomes. DESIGN: This study used an RCS method. PARTICIPANTS: All patients undergoing pars plana vitrectomy (PPV), scleral buckling (SB), and combined PPV/SB for primary RRD in 2015 from 5 large retina groups were included in the database. METHODS: To ensure validity of the cohort method, a large and detailed database was generated. Double data entry validation was conducted, and data audits were conducted. Anatomic and visual outcomes for all the cases in the dataset will be described but not compared, because the cases were not matched. In future studies, comparable cases of moderate-complexity RRD will be chosen naive to surgeon, surgery, and outcome for subgroup analysis. MAIN OUTCOME MEASURES: Precision of data entry was confirmed by inter-rater reliability (IRR). Main surgical outcome for each procedure type was single-surgery anatomic success (SSAS). RESULTS: Inter-rater reliability showed significant agreement among raters (P < 0.001). Of 2620 patients, 2335 had >90 days of follow-up. Of these, 320 eyes (13.7%) underwent SB, 1200 eyes (51.4%) underwent PPV, and 815 eyes (34.9%) underwent PPV/SB. The SSAS was 84.2% for PPV, 91.2% for SB, and 90.2% for PPV/SB. CONCLUSIONS: We compiled a large, accurately documented database of primary RRD cases repaired by PPV, SB, and PPV/SB from which cohort studies of moderately complex RRDs can be carried out. All 3 approaches had a high SSAS rate. Procedures chosen and their outcomes are described, but the broad case mix makes comparisons not possible until future cohort studies are completed.

Primary Retinal Detachment Outcomes Study: Pseudophakic Retinal Detachment Outcomes: Primary Retinal Detachment Outcomes Study Report Number 3.

PURPOSE: This study evaluates outcomes of comparable pseudophakic rhegmatogenous retinal detachment (RRD) treated with pars plana vitrectomy (PPV) or PPV with scleral buckle (PPV-SB). DESIGN: Multicenter, retrospective, interventional cohort study. PARTICIPANTS: Data were gathered from patients from multiple retina practices in the United States with RRD in 2015. METHODS: A large detailed database was generated. Pseudophakic patients with RRD managed with PPV or PPV-SB were analyzed for anatomic and visual outcomes. Eyes with proliferative vitreoretinopathy, giant retinal tears, previous invasive glaucoma surgery, and ≤90 days of follow-up were excluded from outcomes analysis. Single surgery anatomic success (SSAS) was defined as retinal attachment without ongoing tamponade and with no other RRD surgery within 90 days. MAIN OUTCOME MEASURES: Single surgery anatomic success and final Snellen visual acuity (VA). RESULTS: A total of 1158 of 2620 eyes (44%) with primary RRD were pseudophakic. A total of 1018 eyes had greater than 90 days of follow-up. Eyes with proliferative vitreoretinopathy, previous glaucoma surgery, and giant retinal tears were excluded, leaving 893 pseudophakic eyes eligible for outcome analysis. A total of 461 (52%) were right eyes. A total of 606 patients (67%) were male, with a mean age of 65±11 years. Pars plana vitrectomy and PPV-SB as the first procedure were performed on 684 eyes (77%) and 209 eyes (23%), respectively. The mean follow-up was 388±161 days, and overall SSAS was achieved in 770 eyes (86%). Single surgery anatomic success was 84% (577/684) for PPV and 92% (193/209) for PPV-SB. The difference in SSAS between types of treatment was significant (P = 0.009). In eyes with macula-on RRD, SSAS was 88% in eyes treated with PPV and 100% in eyes treated with PPV-SB (P = 0.0088). In eyes with macula-off RRD, SSAS was 81% in eyes treated with PPV and 89% in eyes treated with PPV-SB (P = 0.029). Single surgery anatomic success was greater for PPV-SB than PPV for inferior (96% vs. 82%) and superior (90% vs. 82%) detachments. Mean final VA was similar for PPV (20/47) and PPV-SB (20/46; P = 0.805). CONCLUSIONS: In pseudophakic RRDs, SSAS was better in patients treated with PPV-SB compared with PPV alone, whereas visual outcomes were similar for both groups.

Primary Retinal Detachment Outcomes Study Report Number 2: Phakic Retinal Detachment Outcomes.

PURPOSE: Anatomically similar rhegmatogenous retinal detachments (RRDs) can be treated with scleral buckle (SB), pars plana vitrectomy (PPV), or SB combined with PPV (PPV/SB). This study compares moderately complex phakic primary RRD treated with SB, PPV, or PPV/SB to review anatomic and visual outcomes. DESIGN: Multicenter, retrospective, interventional cohort study. PARTICIPANTS: Data were gathered on all patients from multiple retina practices in the United States with RRD in 2015 and >90 days of follow-up. The cohort of phakic patients with moderately complex RRD was analyzed. METHODS: A large and detailed database was generated. Eyes with findings that would bias toward PPV (vitreous hemorrhage, dense cataract, proliferative vitreoretinopathy, giant retinal tear, among others) were excluded. Age <40 years (bias toward SB) was excluded. Comparable cases of moderately complex RRD were then chosen naive to surgeon, surgery, and outcome for subgroup analysis. MAIN OUTCOME MEASURES: Single surgery anatomic success (SSAS), defined as retinal attachment with no other RRD surgery within 90 days, is the main outcome measure. Final visual acuity is the secondary outcome measure. Pearson's chi-square and analysis of variance were used to test treatment effect of surgery type on SSAS and vision. RESULTS: Single surgery anatomic success was noted in 155 of 169 SB cases (91.7%), 207 of 249 PPV cases (83.1%), and 271 of 297 PPV/SB cases (91.2%). Scleral buckle and PPV/SB were superior to PPV for SSAS (P = 0.0041). For macula-on or split cases, SB had significantly better visual outcomes than PPV or PPV/SB even after controlling for cataract (cases with minimal cataract at final follow-up or after cataract surgery) (P < 0.001). CONCLUSIONS: For phakic moderately complex primary RRDs in this study of PPV versus SB versus PPV/SB, SB had the best visual outcomes, and PPV had the worst SSAS outcomes.

FACTORS ASSOCIATED WITH THE USE OF 360-DEGREE LASER RETINOPEXY DURING PRIMARY VITRECTOMY WITH OR WITHOUT SCLERAL BUCKLE FOR RHEGMATOGENOUS RETINAL DETACHMENT AND IMPACT ON SURGICAL OUTCOMES (PRO STUDY REPORT NUMBER 4).

PURPOSE: To determine factors associated with 360-degree laser retinopexy (360LR) during primary pars plana vitrectomy ± scleral buckle for rhegmatogenous retinal detachment (RRD) and its impact on surgical outcomes. METHODS: This is a multicenter, retrospective, interventional study. Patients undergoing primary pars plana vitrectomy or primary pars plana vitrectomy + scleral buckle for noncomplex primary RRD in 2015 were evaluated. Primary outcomes were single surgery anatomical success (SSAS) and final anatomical success. Secondary outcomes included final logarithm of the minimum angle of resolution visual acuity, epiretinal membrane formation, cystoid macular edema development, and number of subsequent vitrectomies. Multivariate regressions were performed. RESULTS: Two thousand two hundred and forty-eight surgeries by 61 surgeons were included; of which, 516 underwent 360LR. Younger age (P = 0.01), more retinal breaks (P = 0.01), more extensive RRD (P < 0.001), and surgeon ID (P < 0.001) were significantly associated with 360LR. No significant associations between 360LR and single surgery anatomical success (P = 0.44), epiretinal membrane formation (P = 0.14), cystoid macular edema development (P = 0.28), or number of subsequent vitrectomies (P = 0.41) were found. Controlling for case complexity, 360LR was significantly associated with lower final anatomical success (P < 0.001) and worse final logarithm of the minimum angle of resolution visual acuity (P < 0.001). CONCLUSION: Multiple factors influenced whether 360LR was performed during primary pars plana vitrectomy ± scleral buckle for RRD. However, 360LR was not associated with improved surgical outcomes, and in fact, it may be associated with poorer outcomes.

Seven-Year Evaluation of Insecticide Tools for Emerald Ash Borer in Fraxinus pennsylvanica (Lamiales: Oleaceae) Trees.

Emerald ash borer (EAB), Agrilus planipennis (Fairmaire; Coleoptera: Buprestidae), is decimating ash trees (Fraxinus spp.) in North America. Combatting EAB includes the use of insecticides; however, reported insecticide efficacy varies among published studies. This study assessed the effects of season of application, insecticide active ingredient, and insecticide application rate on green ash (Fraxinus pennsylvanica Marsh.) (Lamiales: Oleaceae) canopy decline caused by EAB over a 5- to 7-yr interval. Data suggested that spring treatments were generally more effective in reducing canopy decline than fall treatments, but this difference was not statistically significant. Lowest rates of decline (<5% over 5 yr) were observed in trees treated with imidacloprid injected annually in the soil during spring (at the higher of two tested application rates; 1.12 g/cm diameter at 1.3 m height) and emamectin benzoate injected biennially into the stem. All tested insecticides (dinotefuran, emamectin benzoate, and imidacloprid) under all tested conditions significantly reduced the rate of increase of dieback.