PRIMARY SCLERAL BUCKLING FOR PEDIATRIC RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To evaluate the anatomical outcomes of primary scleral buckling (SB) procedures for pediatric rhegmatogenous retinal detachments. METHODS: Retrospective consecutive case series. One hundred and four eyes of 99 consecutive nonselected pediatric patients undergoing primary SB were identified. Baseline factors recorded were demographics, presenting clinical examination findings, previous ocular surgery, predisposing factors. Intraoperative factors recorded were the type of buckle, number and distribution of retinal breaks, number of retinal quadrants detached, macular status (involved vs. uninvolved), the use of subretinal fluid drainage, and surgical complications. Anatomical reattachment rate at last follow-up. Subgroup analysis was carried out to identify any predisposing factors for failure of primary surgery, effect of age on outcome, intraoperative pathology, effect of posterior versus anterior SB, and redetachment and secondary-procedure complications specific to SB. RESULTS: The initial surgery was segmental SB alone in 87 eyes (83.6%). Retinal reattachment was achieved with 1 operation in 73% (76 of 104 eyes). Of the 28 cases that redetached, 14 eyes underwent a repeat SB procedure (success rate of this second operation: 85.7% [12 of 14 eyes]), 13 eyes underwent vitrectomy (success rate of this second operation: 38.4% [5 of 13 eyes]), and 1 case was not reoperated. Overall, the final success rate was 94% (98 of 104 eyes). Factors associated with a statistically significant increased risk of failure included more than one break; three or more quadrants of detachment; horseshoe tears; no breaks seen on preoperative examination; Stickler syndrome. CONCLUSION: In selected cases, primary SB is an effective treatment for pediatric, rhegmatogenous retinal detachment.

Endoscopic vitrectomy.

PURPOSE OF REVIEW: To update on the recent developments and surgical applications of intraocular endoscopy, and highlight its role in the modern era of microincision vitreoretinal surgery. RECENT FINDINGS: Recent progress in our understanding of the unique intraocular illumination properties of endoscopy, specifically the use of reflected (coaxial) versus conventional transmitted (dissociated) light, is redefining its role in vitreoretinal surgery. Indications for endoscope-enabled intraoperative viewing during pars plana vitrectomy include posterior segment disease with significant anterior segment opacity, difficult-to-access retroirideal diseases involving the sclerotomy, pars plana, pars plicata, ciliary sulcus, ciliary body, or peripheral lens, and complex anterior retinal detachments, particularly in diseases in children. The recent introduction of 23-gauge endoscope that works with standard microcannulas increases its utility. SUMMARY: Endoscopic vitrectomy, particularly with the recent advent of 23-gauge technology, expands our surgical armamentarium, making it a useful complement to conventional viewing systems.

Microplasmin (ocriplasmin) in pediatric vitreoretinal surgery: update and review.

PURPOSE: To discuss the potential role of microplasmin (ocriplasmin) as a surgical adjunct to vitrectomy in pediatric vitreoretinopathies. METHODS: Literature review of the laboratory and clinical evidence to date for the use of both autologous plasmin enzyme as an adjunct to vitrectomy and more recently recombinant microplasmin (ocriplasmin) as monotherapy for focal vitreomacular traction in adults. RESULTS: Autologous plasmin enzyme is currently being used as a surgical adjunct to vitrectomy, with supporting Levels 2 and 3 published evidence in a range of pediatric vitreoretinopathies including Stage 5 retinopathy of prematurity and congenital X-linked retinoschisis. The availability of autologous plasmin enzyme is limited. In recent Phase 3 clinical trials, intravitreal ocriplasmin versus sham injection resulted in resolution of focal vitreomacular traction in 27% versus 10% (P < 0.001, n = 652). CONCLUSION: Ocriplasmin may potentially be used as a surgical adjunct to vitrectomy in place of autologous plasmin enzyme. A Phase 2, randomized, placebo-controlled surgical trial is under way to assess this.

Risk of iatrogenic peripheral retinal breaks in 20-G pars plana vitrectomy.

PURPOSE: To estimate the frequency and risk factors for entry site and other peripheral iatrogenic retinal breaks in eyes undergoing standard 20-G 3-port pars plana vitrectomy. DESIGN: Single-center, retrospective, interventional case series. PARTICIPANTS: A total of 645 eyes undergoing pars plana vitrectomy at Moorfields Eye Hospital during the period June 1, 2005, to June 1, 2006, for indications excluding rhegmatogenous retinal detachment. METHODS: Case note review. Exclusion criteria were preexisting retinal breaks or rhegmatogenous retinal detachment, previously vitrectomized eyes, and iatrogenic breaks posterior to the equator. MAIN OUTCOME MEASURES: Frequency, anatomic location, and risk factors associated with iatrogenic peripheral retinal breaks and rate of postoperative rhegmatogenous retinal detachment. RESULTS: Iatrogenic peripheral retinal breaks occurred in 98 of 645 eyes (15.2%) intraoperatively. Eleven of 645 cases (1.7%) experienced postoperative rhegmatogenous retinal detachment caused by undetected or new peripheral retinal breaks. Breaks were most common during surgery for tractional retinal detachment (22.2%), macular hole (18.1%), dislocated intraocular lens implants (16.7%), and epiretinal membrane (13.9%). Overall, breaks were more common in the superior retina (P<0.01), with 41.5% occurring in the 10 and 2 o'clock positions. Eyes requiring surgical induction of a posterior vitreous detachment had 2.9 times greater odds of developing iatrogenic peripheral retinal breaks (95% confidence interval, 1.8-4.7, P<0.001) than eyes with preexisting posterior vitreous detachment. Similarly, phakic eyes had 2.4 times higher odds (95% confidence interval, 1.42-3.96, P = 0.001) of break formation. CONCLUSIONS: Iatrogenic peripheral retinal breaks caused by vitrectomy are more common than previously indicated. Approximately 4 in 10 breaks are related to traction at sclerotomy entry sites. Eyes undergoing surgery for tractional retinal detachment seemed to have the highest risk for break formation. Similarly, phakic eyes and eyes that require induction of a posterior vitreous detachment have more than double the risk for break formation.

23-Gauge endoscopic vitrectomy.

Vitreoretinal diseases are exemplified by a wide spectrum of complexities. The purpose of this review is to highlight the potential role of endoscopic vitrectomy in modern microincision vitreoretinal surgery. This is related to the clinically relevant optical properties that are exclusive to endoscopy, namely the ability to bypass anterior segment opacities, visualization of difficult-to-access regions of the retina, the unique surgeon's perspective, and the use of reflected (coaxial) versus transmitted (dissociated) illumination. Indications for endoscopy include posterior pathology with limited-to-no view secondary to anterior segment pathology, difficult-to-assess retroirideal pathologies involving the sclerotomy, pars plana, pars plicata, ciliary sulcus, ciliary body, or peripheral lens, and complex anterior retinal detachments, particularly in pediatric vitreoretinopathies and anterior proliferation. The recent advent of the 23-gauge endoscope significantly increases the utility of endoscopic vitrectomy, making it a potentially important part of the surgical armamentarium alongside conventional viewing systems.

Patient safety in vitreoretinal surgery: quality improvements following a patient safety reporting system.

AIMS: Vitreoretinal (VR) surgery is complex. Most clinical conditions that VR surgeons manage have a high risk for blindness or severe visual impairment. Reporting of patient safety incidents (PSI) in VR surgery was introduced at the Moorfields Eye Hospital (MEH) in the 1990s. We examine the role of PSI reporting in making VR surgery safer at our institution. METHODS: Qualitative review of PSIs from 1997 to 2009 at MEH, London, UK. RESULTS: Over the 13-year study period, 38 789 VR procedures were undertaken and 579 VR PSIs occurring in theatre or inpatient were reported. Mean rate of PSI reporting was 1.49% (range 0.12-3.35). In comparison, the mean rate of PSI reporting over the same period across all National Health Service ophthalmology in England was 0.59% (range 0.36-0.49). Overall, 0.9% of VR PSI resulted in 'Severe' harm, 11.6% in 'Moderate' harm and 87.5% in 'No' or 'Low' harm. 15 (2.6%) of PSIs directly resulted in a change in clinical practice, 13 of which occurred in the first half of the study period. 12 (3.6%) critical incidents were violations of pre-existing protocols and guidelines, eight of which occurred in the second half of the study period. 61 (10.9%) of PSIs fell into nine main error subtypes that contributed to a change in practice. The most common were ocular hypotony (2.9%), medical device failure (2.8%) and delay in VR surgery (1.2%). CONCLUSIONS: VR PSI reporting resulted in a change in clinical practice. Longitudinal analysis suggests an accompanying increase in patient safety.

Cataract progression in macular hole cases: results with vitrectomy or with observation.

PURPOSE: To quantify the difference in progression of nuclear sclerotic cataract using Scheimpflug image analysis in patients with idiopathic full-thickness macular hole who were randomized to have vitrectomy and gas tamponade or to be observed. SETTING: Moorfields Eye Hospital, London, United Kingdom. DESIGN: Prospective randomized placebo-controlled masked clinical trial. METHODS: As part of the Moorfields Macular Hole Study, patients with full-thickness macular hole who were randomized to have vitrectomy and gas tamponade or who were observed were compared. Patients had Scheimpflug image analysis of the crystalline lens to evaluate nuclear sclerosis progression by the single-masked observer at baseline and 3, 6, 9, and 12 months postoperatively. RESULTS: Ninety-eight patients had sufficient baseline data for analysis. At 3 months and 6 months, vitrectomy patients had significant increases in nuclear density compared with baseline (16.6% and 33.9%, respectively) (both P<.0001). In the observation group, nuclear density increased by 1.4% between baseline and 6 months (P = .92). At 6 months, the increase in nuclear density from baseline was 24 times greater in the surgical group than in the observation group (P<.0001). No correlation between the rate of nuclear sclerosis progression and age or baseline nuclear density was found. CONCLUSIONS: Rapid nuclear sclerosis progression was quantifiable by Scheimpflug image analysis in patients having surgery for idiopathic full-thickness macular hole.There was no [corrected] evidence of a correlation between age groups and the rate of cataract progression. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.