A Novel Postoperative Drop Regimen Reduces Risk of Ocular Hypertension Following Pars Plana Vitrectomy.

INTRODUCTION: Postoperative steroid/antibiotic drop regimens are known to effectively suppress inflammation and infection following pars plana vitrectomy (PPV), but the steroid frequently induces ocular hypertension (OHT). The aim of this contemporaneous cohort-control study was to assess safety and efficacy of a novel post-PPV drop regimen conceived to address this problem. METHODS: Electronic case notes of consecutive eyes undergoing PPV between December 2020 and April 2021 at St. Thomas' Hospital, London, UK, were reviewed retrospectively. Postoperative drops in the intervention cohort consisted of 1-week g. dexamethasone 0.1%/antibiotic QDS and 1-month g. ketorolac TDS. Standard care controls received 1-month g. dexamethasone 0.1%/antibiotic QDS. RESULTS: Fifty-eight patients were in the intervention cohort, and 151 received standard care. The primary outcome measure was IOP ≥30 mm Hg 2 weeks postoperatively. This occurred in none of the intervention group but in 14% of controls (p = 0.01). Secondary outcomes of rates of anterior uveitis and cystoid macular edema did not differ significantly between the groups, but those in the intervention cohort had fewer hospital visits (p = 0.0004). CONCLUSION: A post-PPV drop regimen of 1-week dexamethasone 0.1%/antibiotic and 1-month ketorolac may be as effective as an anti-inflammatory but safer in terms of OHT incidence than standard care 1-month dexamethasone 0.1%.

EXTENT AND LOCATION OF INTRARETINAL AND SUBRETINAL FLUID AS PROGNOSTIC FACTORS FOR THE OUTCOME OF PATIENTS WITH OPTIC DISK PIT MACULOPATHY.

PURPOSE: To determine if baseline fundoscopic and optical coherence tomography (OCT) features influence the clinical course of optic disk pit maculopathy. METHODS: A multicenter retrospective case note review was undertaken, using standardized OCT and clinical data collection. Visual success was defined as at least a two-line visual acuity improvement, anatomical success as full resolution of OCT foveal fluid with restoration of the normal foveal contour, and partial anatomical success as incomplete resolution of the OCT foveal fluid. Outcomes were compared with a synthesis of the literature, using similar eligibility criteria. RESULTS: Of 36 patients (36 eyes), 2 spontaneously improved and 34 underwent surgery. Visual success was achieved in 64% of surgical cases, anatomical success in 36%, and partial anatomical success in 47%. Cases with multilayer intraretinal and subretinal fluid were less likely to have visual success (P = 0.003). Cases where the fluid did not extend to the macular arcade vessels also had better visual and anatomical outcomes (P = 0.004 and 0.005, respectively). CONCLUSION: Fundoscopic and OCT features can help predict surgical outcome in optic disk pit maculopathy.

How should we report the foveal status in eyes with "macula-off" retinal detachment?

Whilst pre- and postoperative multimodal imaging technologies including optical coherence tomography (OCT) have investigated the morphological correlates of worsened visual outcomes in rhegmatogenous retinal detachment (RRD) with foveal involvement, the nomenclature has adhered to the traditional ophthalmoscopy-based and rather vague term "macula-off". This article appraises the current literature with regard to the preoperative assessment and nomenclature of the foveal status in macula involving retinal detachment (MIRD). A literature review of recent publications assessing functional or morphological outcomes in MIRD was conducted, using the search terms "fovea-off" or "macula-off". The search date was April 28th, 2021. Original studies in English language were included. Case reports, review articles or letters were excluded. Forty relevant articles (range of publication dates: July 29th, 2020 - April 18th, 2021) were reviewed to assess the diagnostic modalities used, morphological parameters assessed, and any specific nomenclature introduced to specify the extent of macular detachment. The results suggest widespread variability and inconsistencies with regard to the preoperative assessment, diagnostic modalities and nomenclature used to describe the foveal status in eyes with RRD termed "macula-off". The extent of macular detachment may be classified by a wide range of morphological parameters, including the height of foveal detachment and the ETDRS grid as overlay tool in OCT devices. There is a scientific and clinical need for an updated nomenclature for eyes with "macula-off" RRD. Preoperative OCT findings should be reported on a regular and standardized basis in order to establish a consensus how to report the foveal status in eyes with MIRD.

Safety of intracameral cefuroxime in pars plana vitrectomy.

BACKGROUND/OBJECTIVES: Postoperative endophthalmitis is a rare, but serious complication of pars plana vitrectomy (PPV). Subconjunctival cefuroxime injection has been the traditional choice for post vitrectomy endophthalmitis prophylaxis. Its effectiveness and safety in this context are however poorly understood and cases of retinal toxicity have been reported. The traditional standard subconjunctival antibiotic prophylaxis has been superceded in cataract surgery by intracameral antibiotic prophylaxis. SUBJECTS/METHODS: The primary aim of this three centre non-randomised retrospective database cohort study of 7,532 PPV procedures was to identify the rate of endophthalmitis in cohorts of patients treated with intracameral or subconjunctival cefuroxime. A secondary aim was to estimate the achieved intraocular antibiotic concentrations of cefuroxime in eyes with intracameral versus subconjunctival administration using mathematical modelling. RESULTS: The overall incidence of postoperative endophthalmitis was 0.07% (5/7532). There were no cases of endophthalmitis in eyes receiving intracameral cefuroxime alone or in combination with subconjunctival cefuroxime (0/5586). Patients receiving subconjunctival cefuroxime alone had a higher incidence of endophthalmitis (0.22%, 4/1835), and there was one case of endophthalmitis in eyes not receiving any perioperative antibiotics (0.9%, 1/111). No cases of cefuroxime toxicity were identified. With subconjunctival cefuroxime, in the presence of a sclerotomy leak, we estimated the vitreous drug concentration to be higher than that for intracameral cefuroxime and potentially toxic. CONCLUSIONS: Intracameral cefuroxime appears to be a safe and efficient choice for prophylaxis against endophthalmitis after PPV. Small eyes with intraocular tamponade seem to be at particular risk of drug toxicity if cefuroxime is administered via the subconjunctival route.

Acute retinal necrosis: the effects of intravitreal foscarnet and virus type on outcome.

PURPOSE: To study the effects of intravitreal foscarnet and the clinical differences between varicella zoster virus (VZV) and herpes simplex virus (HSV) induced acute retinal necrosis (ARN). DESIGN: Retrospective comparative case series. PARTICIPANTS: Eighty-one eyes of 74 patients. METHODS: A retrospective case note analysis was performed in 2 tertiary referral centers. MAIN OUTCOME MEASURES: Presenting and final visual acuity, and progression to retinal detachment. RESULTS: Thirty-three eyes had HSV-ARN and 48 had VZV-ARN. The average age for HSV-ARN was 34 years and 51 for VZV-ARN (P<0.001). Visual acuity on presentation was similar (P = 0.48), but a larger proportion had better vision (> or =20/60) in the HSV-ARN group (52%) than the VZV-ARN group (35%). A greater proportion of eyes with poor vision (< or =20/200) was found at the 12-month follow-up in the VZV-ARN group (60%) compared with the HSV-ARN group (35%). A greater degree of visual loss in the VZV-ARN group (0.4 logarithm of the minimum angle of resolution [logMAR]) compared with the HSV-ARN group (0.04 logMAR) was detected (P = 0.016). Retinal detachment was 2.5-fold more common in VZV-ARN (62%) compared with HSV-ARN (24%). When comparing eyes treated with (n = 56) and without (n = 25) intravitreal foscarnet, there was a 40% lower rate in retinal detachment (53.6% vs 75.0%) for VZV-ARN (P = 0.23). The numbers with HSV-ARN were too small for analysis. CONCLUSIONS: The results support the difference of outcome in HSV-ARN and VZV-ARN. Therefore, viral identification serves as a key to predicting outcome in these patients. Intravitreal foscarnet seems to be a useful adjunct for the treatment of ARN in that it reduced rate of retinal detachment.

Effect of letter separation on computerised visual acuity measurements: comparison with the gold standard Early Treatment Diabetic Retinopathy Study (ETDRS) chart.

Contour interaction plays an important role in letter recognition and has long been known to influence clinical visual acuity measurements. LogMAR charts originally employed between-letter and line spacing of one letter width/height; however, in more recent designs, half letter width spacing has become accepted without validation. COMPlog is a computerised visual acuity measurement device being developed and validated for routine and research clinical use and is available commercially. This study was performed to investigate the effect of letter separation on computerised visual acuity measurements. An iterative series of experiments was performed in which test and retest fully interpolated five letters-per-line logMAR visual acuity measurements were taken in three groups of a total 100 adult subjects. Each group had visual acuity measured using ETDRS charts 1 and 2 and on COMPlog using various combinations of letter and line spacing. The first group consisted of 31 subjects tested using 3.75 and 2.50 stroke width spacing, the second 45 subjects using 2.50 and 1.25 stroke width spacing and the last group, 24 subjects tested using 1.90 stroke width spacing. The methods of Bland and Altman were used to analyse the data. No significant bias was noted between the gold standard ETDRS measurements and those taken using COMPlog with 3.75 stroke width spacing. Significant bias of half a logMAR line was found with crowding of 1.90 and 1.25 stroke widths. A small systematic bias with a reduction of 1 ETDRS letter was found with spacing of 2.50 stroke widths which has not been demonstrated in previous validation studies. Crowding of 2.50 stroke widths is the smallest spacing which can be used in the design of COMPlog.

Intravitreal bevacizumab to facilitate vitrectomy in idiopathic ischaemic retinal vasculitis.

To describe the use of intravitreal bevacizumab in idiopathic retinal vasculitis prior to vitrectomy and delamination. A young healthy male presented with idiopathic retinal vasculitis. His condition was refractory to panretinal photocoagulation and systemic steroids. The progression of his condition necessitated vitrectomy and delamination. Intravitreal bevacizumab was used to facilitate the surgical procedure, with effective results. Intravitreal bevacizumab can be an adjunct to vitrectomy in idiopathic retinal vasculitis. However, caution must be taken due to its ability to promote fibrosis and to produce further tractional and/or rhegmatogenous retinal detachment. Further controlled studies are required to understand its benefits in managing complicated idiopathic retinal vasculitis.

Facedown Positioning Following Surgery for Large Full-Thickness Macular Hole: A Multicenter Randomized Clinical Trial.

Importance: The value of facedown positioning following surgery for large full-thickness macular holes is unknown. Objective: To determine whether advice to position facedown postoperatively improves the outcome for large macular holes. Design, Setting, and Participants: This randomized, parallel group superiority trial with 1:1 randomization stratified by site with 3 months' follow-up was conducted at 9 sites across the United Kingdom and included participants with an idiopathic full-thickness macular hole of at least 400 µm minimum linear diameter and a duration of fewer than 12 months. All participants had vitrectomy surgery with peeling of the internal limiting membrane and injection of perfluoropropane (14%) gas, with or without simultaneous surgery for cataract. Interventions: Following surgery, participants were randomly advised to position either facedown or face forward for 8 hours daily for 5 days. Main Outcomes and Measures: The primary outcome was closure of the macular hole determined 3 months following surgery by masked optical coherence tomography evaluation. Secondary outcome measures at 3 months were visual acuity, participant-reported experience of positioning, and quality of life measured by the National Eye Institute Visual Function Questionnaire 25. Results: A total of 185 participants (45 men [24.3%]; 156 white [84.3%]; 9 black [4.9%]; 10 Asian [5.4%]; median age, 69 years [interquartile range, 64-73 years]) were randomized. Macular hole closure was observed in 90 (85.6%) who were advised to position face forward and 88 (95.5%) advised to position facedown (adjusted odds ratio, 3.15; 95% CI, 0.87-11.41; P = .08). The mean (SD) improvement in best-corrected visual acuity at 3 months was 0.34 (0.69) logMAR (equivalent to 1 Snellen line) in the face-forward group and 0.57 (0.42) logMAR (equivalent to 3 Snellen lines) in the facedown group (adjusted mean difference, 0.22 [95 % CI, 0.05-0.38]; equivalent to 2 Snellen lines); 95% CI, 0.05-0.38; P = .01). The median National Eye Institute Visual Function Questionnaire 25 score was 89 (interquartile range, 76-94) in the facedown group and 87 (interquartile range, 73-93) in the face-forward group (mean [SD] change on a logistic scale, 0.08 [0.26] face forward and 0.11 [0.25] facedown; adjusted mean [SD] difference on a logistic scale, 0.02; 95% CI, -0.03 to 0.07; P = .41). Conclusions and Relevance: The results do not prove that facedown positioning following surgery is more likely to close large macular holes compared with facing forward but do support the possibility that visual acuity outcomes may be superior. Trial Registration: Isrctn.org Identifier: 12410596.

Dye extrusion technique (DE-TECH): occult retinal break detection with subretinal dye extrusion during vitrectomy for retinal detachment repair.

OBJECTIVE: To investigate the effectiveness of a new technique for the identification of occult retinal breaks in vitrectomy retinal detachment repair. Dye Extrusion Technique involves injection of sub retinal dye and extrusion through the unidentified breaks using perfluorocarbon liquid. METHOD: Retrospective case note analysis. MAIN OUTCOME MEASURES: rate of break detection, rate of use of local retinopexy, and short-term gas tamponade alone; SECONDARY OUTCOMES: anatomical success at 3 months with no long-term tamponade, final visual acuity, progression of proliferative vitreoretinopathy. RESULTS: Thirty-eight percent of eyes had proliferative vitreoretinopathy of grade C1 or worse. Twenty-five percent underwent primary retinal detachment repair surgery. The remainder underwent repeat operations for previously failed surgery. Breaks were found in 89% of eyes and 81% underwent only local retinopexy and gas tamponade. The overall anatomical success rate was 85% (40/47) which included four cases in which the retina was fully attached awaiting removal of silicone oil. No cases had unexplained loss of vision. No progression of proliferative vitreoretinopathy was noted. CONCLUSIONS: Results suggest that Dye Extrusion Technique may be an effective technique for the identification of occult retinal breaks and may facilitate simple techniques of detachment repair. No evidence of retino-toxicity from the use of trypan blue was found but the study had limited power to detect adverse effects.

Beneficial visual outcome of vitrectomy and delamination surgery for tractional complications of diabetic retinopathy in a cohort of black patients.

BACKGROUND/AIMS: Poor visual outcomes have recently been reported in black patients undergoing vitrectomy and delamination surgery for complications of proliferative diabetic retinopathy. We therefore investigated the outcome of surgery on a similar cohort of black patients and examined for potential predictors of visual success. METHODS: A single-centre retrospective case review of consecutive black patients who underwent vitrectomy and delamination surgery for complications of PDR between July 2010 and September 2017. The primary outcome measure was change in visual acuity (VA) at 6 months post-operatively. Multiple linear regression analysis was performed to evaluate determinants of change in VA. RESULTS: A total of 44 eyes of 44 patients were included. Mean age was 53.7 (range: 24.3-75.8) years. In all, 43% were male. A total of 52% had adjunctive pre-operative anti-VEGF therapy. Mean pre-operative VA was 1.49 logMAR ± 0.73 (range 0.18 to 2.6 logMAR). Mean change in VA at 6 months was a gain of 0.59 ± 0.94 logMAR (range 1.9 logMAR acuity loss to 2.5 logMAR acuity gain). Four cases required further surgery to treat rhegmatogenous detachment. The acuity of 68% improved by 0.3 or more logMAR. Silicone oil was used as primary tamponade in 7%. Pre-operative VA and use of silicone oil significantly predicted VA decline at 6 months (p = 0.001 and p = 0.007). CONCLUSIONS: The majority of our cohort derived visual benefit from vitrectomy and delamination for PDR-related complications. Improvement in VA was comparable to outcomes from the UK National Ophthalmic Database report. Silicone oil should be avoided these patients if possible.

Aggregations of retinal pigment epithelial cells on inferior retinal blood vessels, a clinical sign of early proliferative vitreoretinopathy.

PURPOSE: To determine the relationship between 'pigment clusters' on blood vessels (BvRPE) on the inferior retina in patients with rhegmatogenous retinal detachment, and existing proliferative vitreoretinopathy (PVR). METHODS: A prospective observational non-comparative study of consecutive patients presenting with rhegmatogenous retinal detachment to a tertiary referral university department was performed. The retina was inspected preoperatively for the detection of BvRPE. A relationship with existing PVR was determined. RESULTS: A total of 103 patients were recruited, 70 men and 32 women, mean age 56.7 years, with 57 left eyes. Mean duration of follow up was 9.2 months. Nineteen patients (18.4%) had BvRPE, and 20 had RPE clusters off blood vessels (nine had both). In those with the sign of BvRPE the mean number of RPE clusters on blood vessels was 5.7 (SD 5.8). The mean number of clock hours affected was 2.32 (SD = 1.58). Eight had B grade PVR and three C grade PVR. Patients with BvRPE were more likely to have PVR grades B or C than those without the sign (P = 0.002). The mean number of operations in those with the sign was 1.32 (SD = 0.58) and was statistically similar to those without BvRPE. Visual outcome was statistically similar in those with and without the sign. CONCLUSION: Patients with rhegmatogenous retinal detachment may demonstrate 'pigment clusters' on blood vessels in the inferior retina (BvRPE). This is likely to be a specific feature found in PVR and an early sign of activation of retinal pigment epithelial cells.

The management of macular hole retinal detachment and macular retinoschisis in pathological myopia; a UK collaborative study.

PURPOSE: To study UK practice patterns for the management of retinal detachment secondary to macular hole (MHRD) and macular retinoschisis (MRS) in pathological myopia (PM). To review the anatomical and visual outcomes of the surgically managed cases. METHODS: A prospective observational case series for the management of MHRD was undertaken in association with the British Ophthalmological Surveillance Unit (BOSU). The results were combined with retrospective data, collected by the COllaboration of British RetinAl Surgeons (COBRA), on the management of both MHRD and MRS in PM in the UK. A total of 20 cases of MHRD and 53 cases of MRS (27 surgical cases and 26 cases managed conservatively) are reported in this combined study. RESULTS: MHRD: Mean baseline best corrected visual acuity (BCVA) was 1.60 logMAR. All cases underwent pars plana vitrectomy (PPV). Mean post-operative BCVA was 1.49 logMAR (p = 0.674). The macular hole was closed in 5/20 (25%) cases, open/flat in 10/20 (50%) cases and open/elevated in 4/20 cases (20%). MRS: Mean baseline BCVA was 0.87 logMAR in the surgical group and 0.45 logMAR in the conservatively managed group (p = 0.002). All eyes that had surgical intervention underwent PPV. Mean post-operative BCVA was 0.68 logMAR (p = 0.183). Anatomical outcomes demonstrated a persistent MRS in 2/27 (7.4%) cases, partial resolution in 7/27 (25.9%) cases and complete resolution in 16/27 (59.2%) cases. CONCLUSIONS: PPV is the only surgical procedure performed for the management of MHRD and MRS amongst the study participants. Success rates and visual outcomes are limited for MHRD and consistent with the current literature for MRS.

Risk factors for visual impairment in patients with sickle cell disease in London.

PURPOSE: Dramatically improved health care in recent years has increased the life expectancy of patients with sickle cell disease (SCD) as well as the prognosis for its ocular complications. We sought to identify risk factors for visual impairment in patients with SCD in London 4 decades after Goldberg's seminal studies. METHODS: Patients 16 years and older with SCD (genotypes HbSS, HbSC, HbSß-thalassemia) attending hematology and ophthalmology services were offered ocular examination. Retinopathy was graded according to the Goldberg classification. Visual impairment was defined as corrected distance visual acuity of 20/40 or poorer. RESULTS: In total, 182 eyes of 182 patients (mean ± SD age, 37.2 ± 12.8 years; female, 65.9%) were included. Women were significantly older than men (mean ± SD age, 38.8 ± 13.1 vs 34.2 ± 11.8 years; p = 0.0174). There was no difference in mean age of each genotype group (p>0.15). Risk factors for sight-threatening proliferative sickle retinopathy (PSR) were age over 35 years (odds ratio [OR] 2.01; 95% confidence interval [CI] 1.05-3.89; p = 0.0359) and HbSC genotype (OR 4.06; 95% CI 2.07-7.98; p<0.0001). Although visual impairment was related to the presence of sight-threatening PSR (OR 7.23; 95% CI 1.50-35.0; p = 0.0138), it was not related to hemoglobin genotype (p>0.50). CONCLUSIONS: We present the largest study of ocular findings in SCD in the United Kingdom. Sight-threatening PSR is a risk factor for visual impairment, but hemoglobin genotype status is not.

Morphision: a method for subjective evaluation of metamorphopsia in patients with unilateral macular pathology (i.e., full thickness macular hole and epiretinal membrane).

BACKGROUND: Lack of clinical tests to quantify spatial components of distortion in patients with full thickness macular holes (FTMH) and epiretinal membranes (ERM). AIM: To develop a test for subjective evaluation of visual distortion in the central visual field around fixation in patients with unilateral FTMH or ERM. SETTINGS AND DESIGN: Prospective case-control study carried out at tertiary referral center. MATERIALS AND METHODS: Twenty-five patients with unilateral macular disease (13 macular epiretinal membranes, 12 full-thickness macular holes), and nine controls (without ocular pathology) underwent ophthalmological examination with logMAR ETDRS visual acuity, near vision and contrast sensitivity assessed. Macular optical coherence tomography and metamorphopsia assessment using Morphision test was also carried out. This test consists of a set of modified Amsler charts for detection, identification, and subjective quantification of visual distortion in the central visual field around fixation. Morphision test content and construct validity, and reliability (test-retest method) were evaluated. Sixteen patients completed an unstructured survey on test performance and preference. RESULTS: Every patient with unilateral FTMH or ERM identified a particular chart using Morphision test (content validity). None of the normal subjects without symptoms of metamorphopsia identified any distortion (construct validity). Test-retest showed a 100% consistency for frequency and 67% for amplitude. The mean amplitude difference between measurements was 0.02 degrees (SD = 0.038). The coefficient of repeatability was 0.075. There was a correlation between Morphision amplitude score and visual acuity and contrast sensitivity, individually. CONCLUSIONS: Morphision test allowed detection and subjective quantification of metamorphopsia in the clinical setting in our patients with unilateral macular epiretinal membranes and full thickness macular holes.

Macular displacement following rhegmatogenous retinal detachment repair.

AIMS: To investigate the incidence of macula displacement and symptoms of distortion following rhegmatogenous retinal detachment (RRD) repair, quantify the displacement where seen and further characterise the nature of the displacement. METHODS: Consecutive patients undergoing primary RRD repair were assessed postoperatively with fundus autofluorescence and optical coherence tomography imaging, and the extent of macula displacement quantified using a novel means. Findings were examined for correlations with symptoms and pre-operative features. RESULTS: Macula displacement was evident postoperatively in 72% of 32 consecutive fovea-involving detachments treated with vitrectomy and gas. It was also evident in 5/17 foveal-sparing cases treated with vitrectomy and gas and in two of two patients with fovea-involving detachments treated with vitrectomy and oil. There was a significant correlation between the presence of macula displacement and symptoms of distortion in the early postoperative period (p=0.013). Symptomatic patients described bending of lines with or without objects appearing smaller or narrower in the operated eye. Quantifying the displacement demonstrated that the extent of displacement was associated with distance from the optic disc (p=0.005) and the extent of retinal detachment. CONCLUSIONS: Displacement of the macula is common following RRD repair and heterogeneous in nature. Most affected patients are symptomatic in the early postoperative period.

Day 1 postoperative intraocular pressure spike in vitreoretinal surgery (VDOP1).

PURPOSE: To classify the clinical characteristics that might identify patients who may not require next-day follow-up following routine vitreoretinal intervention. METHODS: Prospective case series. RESULTS: The only statistically significant factors for raised intraocular pressure (IOP) were gas tamponade and preoperative raised IOP. 44.7% (17/38) of patients with preoperative IOP ≥ 20 mmHg had postoperative IOP ≥ 30 mmHg while 8.6% (17/197) of patients with preoperative IOP < 20 mmHg had postoperative IOP ≥ 30 mmHg (p = 0.0001). Phacoemulsification did not increase risk for a postoperative IOP spike. There was a 20-21% risk of postoperative IOP > 30 mmHg for patients with gas tamponade. All patients with no tamponade with IOP > 30 mmHg had preoperative IOP ≥ 20 mmHg. CONCLUSION: Uncomplicated vitreoretinal procedures with preoperative IOP of< 20 mmHg and no gas tamponade are unlikely to have uncontrolled IOP spike at day 1.

Idiopathic bilateral retinal dialyses complicated by posterior retinal tear after blunt trauma.

PURPOSE: The purpose of this study was to present a case of posterior rupture in a previously detached retina after blunt trauma. METHOD: This is a case report. RESULT: A child with idiopathic bilateral retinal dialyzes sustained accidental blunt trauma to the left eye while awaiting surgery. This caused a posterior rupture of the retina in an already preexisting retinal detachment. The right eye underwent uneventful cryopexy and a buckle procedure. The left eye was managed conservatively while awaiting spontaneous posterior vitreous separation. Unfortunately, the retina detached further to involve the macula with progression of proliferative vitreoretinopathy. The child required three subsequent vitrectomies in the left eye to stabilize the retina. CONCLUSION: This case highlights the etiology of retinal dialyzes and the dilemmas in the management of complicated retinal detachment.

Computerized repeating and averaging improve the test-retest variability of ETDRS visual acuity measurements: implications for sensitivity and specificity.

PURPOSE: The goals of this study were to investigate the effectiveness of computerized repeating and averaging of visual acuity measurements in reducing test-retest variability (TRV) and to estimate the increase in sensitivity and specificity that would be achieved in diagnosing visual acuity change. METHODS: Timed, paired ETDRS chart and computerized acuity mean measurement (CAMM) were performed in 100 subjects. CAMM(n) scores were the running mean of consecutive measurements. Bland-Altman methods were used to calculate 95% ranges for TRV. RESULTS: The 95% TRV range of ETDRS measurements and the CAMM score after 6 (CAMM6) measurements were, respectively, 8 and 5.7 ETDRS letters (P = 0.02). CAMM6 offered a pragmatically optimum tradeoff between reduced TRV and test time. A measured change of 5 letters or more in the absence of true change was observed in 13% (95% CI, 8%-21%) with the ETDRS chart and 4% (95% CI, 2%-10%) with CAMM6 measurements. To achieve ≥95% test sensitivity (assuming 95% test specificity), change criteria of 15 and 11 letters must be set with an ETDRS chart and CAMM6, respectively. CAMM6 measurement times were longer (mean 234 seconds vs. 74 seconds) for the ETDRS chart. CONCLUSIONS: Compared with the current gold standard, computerized repeating and averaging of acuity measurements improve specificity and sensitivity when identifying true changes. The 160-second increase in test time should be set against the considerable economic and clinical benefits that may result.