Validation of M-CHARTS for Quantitative Assessment of Metamorphopsia Following Rhegmatogenous Retinal Detachment Repair.

PURPOSE: To validate the quantitative assessment of metamorphopsia in rhegmatogenous retinal detachment(RRD) using M-CHARTS by determining its correlation with subjective reporting of metamorphopsia with a validated metamorphopsia questionnaire(modified MeMoQ). METHODS: Research Ethics Board approved, prospective observational study carried out at St. Michael's Hospital, Toronto, Canada. Patients with primary, unilateral RRD and healthy controls were included. Metamorphopsia at 3-months was assessed with modified MeMoQ and M-CHARTS. RESULTS: 100 patients(50 with RRD,50 controls) were included. 70%(35/50) of the RRD group had metamorphopsia with M-CHARTS and 80%(40/50) with MeMoQ. The modified MeMoQ and total M-CHARTS scores were significantly higher in patients with RRD compared to controls(p<0.0001). Cronbach's alpha reliability coefficient was 0.934 in the RRD group. Horizontal, vertical, and total M-CHARTS scores were significantly correlated with MeMoQ scores(rs=0.465,p=0.0007;rs=0.405,p=0.004;rs=0.475,p=0.0005,respectively). M-CHARTS was 72.7% sensitive and 94.6% specific for detection of metamorphopsia(positive score≥0.2), with an area under the ROC curve=0.801. A stronger correlation was found in patients who scored ≥0.2 on the M-CHARTS and reported metamorphopsia with the MeMoQ(rs=0.454,p=0.001). CONCLUSION: We have validated M-CHARTS as a tool to quantitatively assess metamorphopsia in patients with RRD, which is significantly correlated with patient-reported outcomes using the metamorphopsia questionnaire(MeMoQ). A total score of ≥0.2 with M-CHARTS was more strongly correlated with MeMoQ.

POSTOPERATIVE PHOTORECEPTOR INTEGRITY AND ANATOMICAL OUTCOMES BASED ON PRESENTING MORPHOLOGIC STAGE OF RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To evaluate outer retinal recovery on postoperative optical coherence tomography (OCT) based on presenting morphologic stage of rhegmatogenous retinal detachment (RRD). METHODS: Retrospective cohort of consecutive primary fovea-involving RRDs, referred from January 2012 to September 2022. Baseline OCTs were assessed for morphologic stage of RRD. Postoperative OCT scans were graded at 3, 6, and 12 months for external limiting membrane, ellipsoid zone and interdigitation zone discontinuity, epiretinal membrane formation and severity, and residual subfoveal fluid. RESULTS: Three hundred and fifty-one patients were included. Increasing baseline morphologic stage of RRD was significantly associated with external limiting membrane, ellipsoid zone, and interdigitation zone discontinuity at all time points postoperatively ( P < 0.001) and was shown to be an independent predictor of foveal photoreceptor integrity after adjusting for height of detachment, time to surgery, and duration of fovea involvement ( P < 0.001). Earlier stages were associated with residual subfoveal fluid ( P < 0.001). There was no association between the stages of RRD and epiretinal membrane severity. However, late stages presented with earlier development of epiretinal membrane ( P = 0.012). CONCLUSION: Increasing morphologic stage of RRD is associated with delayed recovery of outer retinal bands in the first year and faster development of epiretinal membrane after RRD repair. The results of this study suggest that the stages may serve as a prognostic biomarker for postoperative photoreceptor recovery.

Impact of Baseline Morphologic Stage of Rhegmatogenous Retinal Detachment on Postoperative Visual Acuity.

PURPOSE: To evaluate the association of baseline morphologic stage of rhegmatogenous retinal detachment (RRD) using OCT with postoperative anatomic and visual acuity (VA) outcomes. DESIGN: Retrospective cohort study. SUBJECTS: Consecutive primary fovea-involving RRDs referred from January 2012 to September 2022. METHODS: Patients with primary RRD and no prior macular pathology with gradable baseline OCT were assessed. Best-corrected VA (BCVA) was assessed at presentation and at 3, 6, and 12 months postoperatively. OCT scans were graded for parafoveal morphologic stage of RRD and foveal photoreceptor integrity. MAIN OUTCOME MEASURES: Association of morphologic stage of RRD with 12-month BCVA. RESULTS: Three hundred fifty-one patients were included. Sixty-eight percent (238/351) were male, the mean (standard deviation) age was 61.2 (± 12.8) years, and 59% (206/351) were phakic. Thirteen percent (47/351) presented in stages 1 and 2, 15% (54/351) in stage 3a, 36% (126/351) in stage 3b, 24% (83/351) in stage 4, and 12% (41/351) in stage 5. Increasing stage was associated with worse foveal photoreceptor integrity, reduced baseline BCVA and longer duration of central vision loss (P < 0.001). Mean (standard deviation) 12-month BCVA by stage was 0.77 (± 0.64) for stages 1 and 2, 1.00 (± 0.53) for stage 3a, 1.36 (± 0.55) for stage 3b, 1.33 (± 0.66) for stage 4 and 1.55 (± 0.47) for stage 5. Increasing stage was associated with reduced postoperative BCVA (P < 0.001) at all time points after adjusting for covariates. A subgroup analysis of acute detachments with retinal pigment epithelium-photoreceptor dysregulation demonstrated no difference in postoperative BCVA between stages 1, 2, and 3a. However, 12-month BCVA was significantly better in stages 1, 2, and 3a vs. stage 3b (P = 0.002) and stage 3a vs. 3b (P = 0.008). CONCLUSIONS: This study validates the clinical relevance of a recently proposed OCT-based staging system for outer retinal morphologic changes over time in RRD. Postoperative BCVA was significantly reduced in patients with worse presenting stage at all time points. In acute RRDs, 12-month BCVA was significantly better in stages 1, 2, and 3a vs. stage 3b, which suggests early stages may have better retinal recovery compared with stage 3b or worse. Stage 3b may represent a critical point where substantial structural changes occur, leading to worse outcomes in acute RRDs. Patients presenting with fovea-involving RRDs in stages 1, 2, or 3a may benefit from more urgent intervention. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Poor Visual Outcome After First Attack in a Cohort of Patients With Myelin Oligodendrocyte Glycoprotein-Related Optic Neuritis.

BACKGROUND: Myelin oligodendrocyte glycoprotein-associated optic neuritis (MOG-ON) is typically a highly treatable condition that responds quickly to treatment with high doses of corticosteroids. We reviewed the cohort of patients with MOG-ON to identify patients who had poor visual outcome after the first attack despite rapid initiation of treatment. METHODS: Records of all patients diagnosed with MOG-ON seen in a tertiary neuro-ophthalmology practice were reviewed to identify and describe those with poor visual recovery (final visual acuity of 20/200 or worse in at least one eye) after the first attack despite initiation of treatment within 1 week of symptoms onset. RESULTS: Two patients of 36 fulfilled inclusion criteria: both had bilateral severe optic neuritis at presentation, and both were seen within 7 days of symptoms onset and treated immediately with pulse doses of intravenous corticosteroids followed by very-slow oral taper. Plasma exchange (PLEX) was performed 2 weeks after symptoms onset in both patients because of poor response to steroids, followed by monthly intravenous immunoglobulin infusions. Despite the use of all available treatment modalities, final visual outcome was poor in both patients. In both patients, there was enhancement of intracanalicular portion of optic nerve in the worse-seeing eye. CONCLUSIONS: In this cohort of patients with MOG-ON, 2 (5.6%) had very poor visual outcome after the first attack despite immediate initiation of treatment with pulse doses of corticosteroids and subsequent treatment with PLEX. These cases highlight that despite immediate initiation and escalation of treatment, some patients with MOG-ON can have very poor visual outcomes after the initial attack that may be because of the involvement of the intracanalicular portion of the optic nerves.

Outer Retinal Hyperreflective Dots: A Potential Imaging Biomarker in Rhegmatogenous Retinal Detachment.

PURPOSE: To investigate hyperreflective dots (HRDs) on baseline OCT in rhegmatogenous retinal detachment (RRD). DESIGN: Retrospective cohort study. SUBJECTS: Consecutive primary fovea-off RRDs presenting between January 2012 and September 2022. METHODS: Visual acuity (VA) was obtained at baseline, 3, 6, and 12 months. Baseline foveal OCT scans were graded for the presence of HRDs in the outer retina, morphologic stage of RRD in the parafovea, and foveal photoreceptor integrity (intact, patchy or complete loss of the bacillary layer). Epiretinal membrane (ERM) and cystoid macular edema (CME) were graded after surgery. MAIN OUTCOME MEASURES: The primary outcome was the proportion of patients in each morphologic stage with HRDs present on OCT and their association with postoperative VA. Secondary outcomes included association with the height of foveal detachment, duration of central vision loss, RRD extent, and development of ERM/CME. RESULTS: A total of 351 patients were included. The presence of HRDs by morphologic stage of RRD was 0% in stage 1, 4.5% (2/42) in stage 2, 13% (7/54) in stage 3a, 16% (20/126) in stage 3b, 48% (40/83) in stage 4, and 85% (35/41) in stage 5. Hyperreflective dots were associated with increasing stage of RRD (P < 0.001), reduced integrity of foveal photoreceptors (P < 0.001), and reduced postoperative VA at 3, 6, and 12 months (P < 0.001), after excluding visually significant cataracts and adjusting for covariates. There was also a significant association between HRDs and height of foveal detachment, duration of central vision loss, and RRD extent (P < 0.001). Hyperreflective dots were neither associated with postoperative ERM formation nor with its severity (P = 0.27). Nevertheless, they were associated with the occurrence of CME at 3 and 6 months after surgery (P = 0.01; P = 0.006). CONCLUSIONS: Hyperreflective dots have been hypothesized to consist of intraretinal inflammatory cells. We found that HRDs were significantly associated with the morphologic stage, extent, duration, and height of the RRD before surgery and with reduced VA and CME after surgery. Our results suggest that HRDs are associated with photoreceptor degeneration, as longstanding and extensive RRDs are more likely to present with HRDs. The association of HRDs with CME provides insight into the possible importance of inflammatory processes in RRD before and after surgery. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Retinal Displacement after Scleral Buckle versus Combined Buckle and Vitrectomy for Rhegmatogenous Retinal Detachment: ALIGN Scleral Buckle versus Pars Plana Vitrectomy with Scleral Buckle.

PURPOSE: To assess the risk of retinal displacement after scleral buckle (SB) versus pars plana vitrectomy with SB (PPV-SB). DESIGN: Multicenter prospective nonrandomized clinical trial. METHODS: The study took place at VitreoRetinal Surgery in Minneapolis, Minnesota, Sankara Nethralaya in Chennai, India, and St. Michael's Hospital in Toronto, Canada from July 2019 to February 2022. Patients who underwent successful SB or PPV-SB for fovea-involving rhegmatogenous retinal detachment with gradable postoperative fundus autofluorescence (FAF) imaging were included in the final analysis. Two masked graders assessed FAF images 3 months postoperatively. Metamorphopsia and aniseikonia were assessed with M-CHARTs and the New Aniseikonia Test, respectively. The primary outcome was the proportion of patients with retinal displacement detected with retinal vessel printings on FAF in SB versus PPV-SB. RESULTS: Ninety-one eyes were included in this study, of which 46.2% (42 of 91) had SB and 53.8% (49 of 91) underwent PPV-SB. Three months postoperatively, 16.7% (7 of 42) in the SB group and 38.8% (19 of 49) in the PPV-SB group had evidence of retinal displacement (difference = 22.1%; odds ratio = 3.2; 95% confidence interval [CI], 1.2-8.6; P = 0.02) on FAF. The statistical significance of this association increased after adjustment for extent of retinal detachment, baseline logarithm of the minimum angle of resolution, lens status, and sex in a multivariate regression analysis (P = 0.01). Retinal displacement was detected in 22.5% (6 of 27) of patients in the SB group with external subretinal fluid drainage and 6.7% (1 of 15) of patients without external drainage (difference = 15.8%; odds ratio = 4.0; 95% CI, 0.4-36.9; P = 0.19). Mean vertical metamorphopsia, horizontal metamorphopsia (MH), and aniseikonia were similar between patients in the SB and PPV-SB groups. There was a trend to worse MH in patients with retinal displacement versus those without retinal displacement (P = 0.067). CONCLUSIONS: Scleral buckle is associated with less retinal displacement compared with PPV-SB, indicating that traditional PPV techniques cause retinal displacement. There is a trend toward increased risk of retinal displacement in SB eyes that underwent external drainage compared with SB eyes without drainage, which is consistent with our understanding that the iatrogenic movement of subretinal fluid, such as that which occurs intraoperatively during external drainage with SB, may induce retinal stretch and displacement if the retina is then fixed in the stretched position. There was a trend to worse MH at 3 months in patients with retinal displacement. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Age related differences in primary testicular lymphoma: A population based cohort study.

INTRODUCTION: Primary testicular non-Hodgkin's lymphoma (PTL) is a very rare disease, comprising 1% of all non-Hodgkin's lymphoma and <5% of all cases of testicular tumors. With a median age at diagnosis of 67 years, PTL is the most common testicular malignancy in men aged >60 years. There is limited published data on PTL incidence and outcomes in younger patients. The aim of this study is to compare the clinical parameters and survival outcomes between the patients older and younger than 50. METHODS: The SEER database was queried for all patients diagnosed with PTL between 1983 and 2017. Data collected consisted of demographic, and clinical parameters, including staging, pathological assessments, and survival data. Patients were stratified according to their age and compared. RESULTS: There was a total of 1,581 patients diagnosed with PTL between the year 2000 and 2017, of whom 215 (13.6%) were younger than 50 years old. The median age at diagnosis was 41 (interquartile range [IQR] 1-50), and 72 (IQR 51-95) years old for patients ≤50 and patients > 50 years of age, respectively. Comparison of younger and older patients detected similarities in disease laterality (92% vs. 94%, P = 0.38) and Ann Arbor stage I to II at diagnosis (76% vs. 75%, P = 0.59). The most common diffuse large B-cell lymphoma (DLBCL) subtype was more common in older patients (61% vs. 87%, P < 0.001). Radical orchiectomy (71% vs. 79%, P = 0.004) and radiation treatment (40% vs. 37%, P = 0.49) rates were comparable between both groups. However, a higher proportion of younger patients underwent chemotherapy (83% vs. 72%, P < 0.001). Patients ≤50 and >50 years old had a hazard ratio (HR) of 0.63 (95% CI: 0.57-0.71) and 0.34 (95% CI: 0.31-0.37), respectively, for 10-year OS with a median survival time for patients >50 of 5.75 years (95% CI: 5.25-6.33), P < 0.001. Patients ≤50 years old had a HR of 0.33 (95% CI: 0.26-0.40) compared to HR of 0.40 (95% CI: 0.37-0.43) in patients >50 years old for cumulative disease-specific mortality (DSM, P = 0.0204). Age >50 years was associated with worse DSM with a HR of 1.39 (95% CI: 1.05- 1.86, P = 0.024). Ann Arbor stage II and higher was also associated with worse DSM, while undergoing surgery, radiotherapy, and chemotherapy were associated with improved DSM. CONCLUSIONS: PTL is the most common testicular malignancy in men older than 60 years of age, but more than a quarter of the patients are younger than 60 and more than 13% are ≤50 years. Younger patients are more likely to receive chemotherapy and radiation, and overall do better in terms of DSM. Being younger, having a lower Ann Arbor stage and being treated with chemotherapy and radiotherapy increase the chances of survival.

Morphologic Stages of Rhegmatogenous Retinal Detachment Assessed Using Swept-Source OCT.

PURPOSE: To describe the sequential morphologic changes after rhegmatogenous retinal detachment (RRD) utilizing a novel, objective, and clinically relevant staging system based on swept-source OCT (SS-OCT) and determine its association with the duration of fovea-off and postoperative visual acuity (VA). DESIGN: Prospective cohort study. SUBJECTS: Consecutive patients with primary fovea-involving RRD referred to St. Michael's Hospital, Toronto, Canada, from January 2020 to April 2022. METHODS: All patients underwent SS-OCT and ultrawide-field SS-OCT at baseline. Primary RRDs with breaks above the 8- and 4-o'clock meridians were included. Patients with vision loss for ≥ 3 months, proliferative vitreoretinopathy grade C or worse, a demarcation line, previous vitrectomy, or other retinal pathology were excluded. The staging was based on an assessment of outer retinal morphology on successive SS-OCT scans from the peripheral break to the most posterior aspect of the RRD, following its direction of progression. MAIN OUTCOME MEASURES: Sequential outer retinal morphologic changes observed using SS-OCT and associated VA at 3 months after surgery. RESULTS: Forty-nine eyes were included. The mean age (standard deviation [SD]) was 61.2 (15.2) years. The mean presenting logarithm of the minimum angle of resolution (SD) acuity was 1.09 (0.75). All stages observed on a high-definition horizontal 51-line scan were reported. Outer retinal changes occurred in 5 stages: (1) separation of the neurosensory retina from the retinal pigment epithelium (42/49, 85.7%); (2) thickening of inner and outer segments of photoreceptors (45/49, 91.8%); (3) outer retinal corrugation formation: (3a) low-frequency (44/49, 93.6%) and (3b) high-frequency outer retinal corrugations (42/49, 85.7%); (4) loss of the definition of outer retinal corrugations, with concurrent thickening of inner and outer segments (26/49, 53.1%); and (5) patchy (moth-eaten) or complete loss of inner and outer segments (17/49, 34.7%). The mean duration of fovea-off by stage in the parafovea (SD) was 2 (1.4), 2.3 (1.2), 11.4 (8.1), and 12 (13.3) days for stages 3a, 3b, 4, and 5, respectively. There was a statistically significant association between increasing stage of RRD and longer duration of foveal involvement (P = 0.001) and, most importantly, between increasing stage and worse VA at 3 months after surgery (P = 0.011). CONCLUSIONS: This novel staging system describes the sequential morphologic changes in RRD using SS-OCT. Increasing stage of RRD was associated with worse VA at 3 months after surgery. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Student-senior isolation prevention partnership: a Canada-wide programme to mitigate social exclusion during the COVID-19 pandemic.

Amidst the pandemic, Canada has taken critical steps to curb the transmission of the 2019 novel coronavirus disease (COVID-19). A key intervention has been physical distancing. Although physical distancing may protect older adults and other at-risk groups from COVID-19, research suggests quarantine and isolation may worsen mental health. Among older adults, social exclusion and social safety nets are social determinants of health (SDOH) that may be uniquely affected by the COVID-19 physical distancing measures. Health promotion programmes designed to reduce social exclusion and enhance social safety nets are one way to mitigate the potential mental health implications of this pandemic. The Student-Senior Isolation Prevention Partnership (SSIPP) is a student-led, community health promotion initiative that has scaled into a nation-wide effort to improve social connection among older adults. This initiative began with in-person visits and transformed into a tele-intervention guided by health promotion principles due to COVID-19. SSIPP continued to target the SDOH of social exclusion and social safety nets by pairing student volunteers with older adults to engage in weekly phone- and video-based interactions. Informed by the community partnership model by Best et al., SSIPP is built on the three orientations of empowerment, behaviour and organization, which are achieved through cross-disciplinary collaboration. This article reviews the importance of the adaptability of health promotion programmes, such as SSIPP during a pandemic, placing an emphasis on the lessons learned and future steps.

A common way to slow the spread of the 2019 novel coronavirus disease (COVID-19) is for people to keep their distance from one another. This has led to isolation and loneliness, especially for older adults. The Student­Senior Isolation Prevention Partnership (SSIPP) is a programme developed by students and physicians in Toronto, Canada. The programme pairs student volunteers with older adults for weekly social interactions. These interactions were in-person before COVID-19. Following the physical distancing recommendations as a result of COVID-19, the programme quickly adapted to use phone and video calls instead. Establishing and leveraging key partnerships, identifying a window of opportunity, assessing community-specific needs and creating national manuals and protocols were key factors in facilitating simultaneous expansion across Canada. This article addresses the importance of programmes like SSIPP in preventing negative health impacts associated with loneliness and isolation. The authors also discuss the adaptability of SSIPP, lessons learned for future pandemic efforts and next steps.

Why does continuity of care with family doctors matter? Review and qualitative synthesis of patient and physician perspectives.

OBJECTIVE: To summarize and synthesize qualitative studies that report patient and physician perspectives on continuity of care in family practice. DATA SOURCES: MEDLINE (Ovid), EMBASE (Ovid), and PsycInfo (Ovid) were searched for qualitative primary research reporting perspectives of patients, physicians, or both, on continuity of care in family practice. STUDY SELECTION: English-language qualitative studies were selected (eg, interviews, focus groups, mixed methods) that were conducted in Canada, the United States, the United Kingdom, the European Union, New Zealand, or Australia. SYNTHESIS: Themes were extracted, summarized, and synthesized. Six overarching themes emerged: continuity of care enables person-centred care; continuity of care increases quality of care; continuity of care leads to greater confidence in medical decision making; continuity of care comes with drawbacks; the absence of continuity of care may lead to medical and psychological harm; and continuity of care can foster greater joy and meaning in a physician's work. Out of the 6 themes, patients and physicians shared the first 5. CONCLUSION: To the authors' knowledge, this is the first qualitative review reporting the unique perspectives of both patients and family physicians on continuity of care. The findings add nuanced insight to the importance of continuity of care in family practice.