PEDIATRIC RETINAL DETACHMENT IN AN ASIAN POPULATION WITH HIGH PREVALENCE OF MYOPIA: Clinical Characteristics, Surgical Outcomes, and Prognostic Factors.

PURPOSE: To evaluate the clinical characteristics and surgical outcomes of pediatric retinal detachments (RDs) in an Asian population. METHODS: Retrospective review of 171 eyes of 152 pediatric patients with rhegmatogenous RD over a 20-year period. RESULTS: Myopia was the most common risk factor in our population. At 6 months, primary anatomical success was 60.7%, and overall anatomical success was 86.7%. A total of 46.8% had best-corrected visual acuity of 20/40 or better, and 81.6% had best-corrected visual acuity of 20/200 or better. In primary RDs, high myopia (≤-6D) patients had a lower primary anatomical success compared to patients with moderate myopia (≤-2D) (59.3 vs. 100% P = 0.03). Increasing age and absence of proliferative vitreoretinopathy were associated with anatomical and visual success. Pars plana vitrectomy as the primary procedure was associated with decreased odds of anatomical success. A longer duration of symptoms, cataract, and a larger RD extent were associated with poorer functional outcome. CONCLUSION: Myopia was the commonest risk factor for pediatric RD in our population. Good anatomical and functional outcome can be achieved with surgery. Increasing age at presentation and absence of proliferative vitreoretinopathy was associated with anatomical and functional success. High myopia was associated with poorer anatomical and functional outcome.

SCLERAL BUCKLING VERSUS VITRECTOMY IN THE MANAGEMENT OF MACULA-OFF PRIMARY RHEGMATOGENOUS RETINAL DETACHMENT: A COMPARISON OF VISUAL OUTCOMES.

PURPOSE: To compare visual outcomes between pars plana vitrectomy (PPV) with or without scleral buckling (SB) and SB alone in the management of uncomplicated macula-off primary rhegmatogenous retinal detachment. METHODS: Case-control study of 723 patients with uncomplicated macula-off primary rhegmatogenous retinal detachment seen at the Singapore National Eye Centre from 2005 to 2011. The primary outcome measure was the proportion of eyes achieving functional success, defined as logMAR best-corrected visual acuity of ≤0.3 logMAR at 6 months postoperatively. Multivariable logistic regression analysis was performed adjusting for the following preoperative covariates: age, gender, race, lens status, number of tears found, presence of proliferative vitreoretinopathy, operative procedure, logMAR best-corrected visual acuity, and duration of symptoms. RESULTS: Three hundred and eight eyes underwent SB alone, and 415 eyes underwent PPV ± SB. In the SB group, 133 eyes (43.2%) achieved functional success compared with 116 eyes (28.0%) in the PPV ± SB group. This difference was statistically significant on both univariate (P < 0.001) and multivariable analyses (OR: 1.51, 95% CI: 1.03-2.21, P = 0.03). CONCLUSION: Scleral buckling alone may achieve visual outcomes that are at least comparable with PPV ± SB in the management of macula-off primary rhegmatogenous retinal detachment.

Prognostic factor analysis of vitrectomy for retinal detachment associated with myopic macular holes.

PURPOSE: To describe the anatomic and functional outcomes in a cohort of subjects undergoing vitrectomy for retinal detachment (RD) resulting from myopic macular hole (MH) and to analyze the prognostic and surgical factors predicting retinal reattachment and MH closure. DESIGN: Retrospective case series. PARTICIPANTS: All patients who underwent vitrectomy for RD resulting from myopic MH between 2000 and 2009 at our center. METHODS: Case records were reviewed at 6 months after surgery. Retinal reattachment and complete anatomic success, defined as retinal reattachment with MH closure, were assessed. Multivariate logistic regression models, including age, gender, duration of symptoms, spherical equivalent refraction (SE), internal limiting membrane peeling, tamponade choice, and concurrent scleral buckling, were constructed to assess associations with covariates. MAIN OUTCOME MEASURES: Retinal reattachment and complete anatomic success (retinal reattachment with MH closure). RESULTS: In total, 114 subjects were analyzed. Most were women (n = 79 [69.3%]), and the mean age was 57.5±13.3 years. The mean SE was -9.88±6.37 diopters. At 6 months, 98 subjects (86.0%) demonstrated retinal reattachment, of whom 93 subjects required only 1 operation. Complete anatomic success was achieved in 61 subjects (53.5%), of whom 55 needed only 1 operation. Subjects with retinal reattachment had better best-corrected visual acuity (BCVA; mean BCVA, 1.22±0.81 logarithm of the minimum angle of resolution [logMAR] units) than those without (mean BCVA, 1.98±1.26 logMAR units; P < 0.001), and subjects with complete anatomic success had better BCVA (mean BCVA, 1.05±0.87 logMAR units) than those without (mean BCVA, 1.62±0.87 logMAR units; P < 0.001). In multivariate analyses, increasing age and the use of perfluoropropane (C3F8) tamponade were predictive of anatomic success (per 1-year increase: odds ratio [OR], 1.049; 95% confidence interval [CI], 1.002-1.099; P = 0.04; and for tamponade: OR, 10.71; 95% CI, 1.08-106.29; P = 0.04). CONCLUSIONS: Vitrectomy is effective in the repair of RD resulting from MH in myopic eyes, with retinal reattachment achieved more frequently than MH closure. Retinal reattachment and MH closure are important for improving visual outcomes. Greater age at presentation and use of C3F8 are associated with a greater likelihood of anatomic success.

Trends and factors related to outcomes for primary rhegmatogenous retinal detachment surgery in a large asian tertiary eye center.

PURPOSE: To describe trends and outcomes of vitreoretinal surgery for primary rhegmatogenous retinal detachment in a large Asian tertiary eye center. METHODS: Retrospective review of 1,530 eyes with primary retinal detachment between 2005 and 2011 managed at the Singapore National Eye Center by one of the following: scleral buckling (SB), pars plana vitrectomy (PPV), and combined SB and PPV (SB + PPV). Anatomical and functional outcomes were assessed. RESULTS: There was a trend toward PPV and PPV + SB as the primary reattachment procedure from 2005 to 2011. The primary anatomical success rate for PPV (78.6%) was worse than that for SB (88.8%) or SB + PPV (89.0%, P = 0.000). Final anatomical success rates were similar for all 3 procedures: SB 97.7%, PPV 95.2%, and SB + PPV 96.4%. Better functional success was achieved in the SB group (86.1%) than both the PPV (72.5%) and SB + PPV groups (77.5%, P = 0.000), partly attributable to the less complex nature of retinal detachments in the SB group. Older age and proliferative vitreoretinopathy were related to the poor functional outcomes in both phakic and pseudophakic eyes. CONCLUSION: There was an increasing trend toward PPV and PPV + SB as the primary retinal reattachment surgery from 2005 through to 2011. High rates of anatomical and functional outcomes were achieved with SB, PPV, and SB + PPV, proliferative vitreoretinopathy and older age were negatively correlated with the functional success in both phakic and pseudophakic eyes.

Evaluation of an international benchmarking initiative in nine eye hospitals.

BACKGROUND: Benchmarking has become very popular among managers to improve quality in the private and public sector, but little is known about its applicability in international hospital settings. PURPOSE: The purpose of this study was to evaluate the applicability of an international benchmarking initiative in eye hospitals. METHODOLOGY: To assess the applicability, an evaluation frame was constructed on the basis of a systematic literature review. The frame was applied longitudinally to a case study of nine eye hospitals that used a set of performance indicators for benchmarking. Document analysis, nine questionnaires, and 26 semistructured interviews with stakeholders in each hospital were used for qualitative analysis. FINDINGS: The evaluation frame consisted of four areas with key conditions for benchmarking: purposes of benchmarking, performance indicators, participating organizations, and performance management systems. This study showed that the international benchmarking between eye hospitals scarcely met these conditions. The used indicators were not incorporated in a performance management system in any of the hospitals. Despite the apparent homogeneity of the participants and the absence of competition, differences in ownership, governance structure, reimbursement, and market orientation made comparisons difficult. Benchmarking, however, stimulated learning and exchange of knowledge. It encouraged interaction and thereby learning on the tactical and operational levels, which is also an incentive to attract and motivate staff. PRACTICE IMPLICATIONS: Although international hospital benchmarking seems to be a rational process of sharing performance data, this case study showed that it is highly dependent on social processes and a learning environment. It can be useful for diagnostics, helping local hospitals to catalyze performance improvements.

25-years Trends and Risk factors related to Surgical Outcomes of Giant Retinal Tear-Rhegmatogenous Retinal Detachments.

To describe the 25-year surgical trends, long-term outcomes and risk factors affecting the outcomes of giant retinal tear-related rhegmatogenous retinal detachments (GRT-RRD). Patients' demographics, pre-operative characteristics, risk factors, operative procedures and post-operative outcomes were collected and divided into three groups - Group A: 1991 to 2015 (overall); Group B: 1991 to 2005, and Group C: 2006 to 2015. Functional and anatomical successes were monitored over a 5-year period. Multivariate logistic regression analysis was performed to identify the risk factors related to functional and anatomical success.127 eyes of 127 patients were included in the study. At 5th year, 69.4% patients had visual acuity (VA) < logMAR 1.0 with 87.5% primary anatomical success rate. While the functional outcome remained the same between group B and C, there was an increase in the anatomical success from 89.7% to 100%, albeit not statistically significant. Patients with worse presenting VA, 150 degrees or more of giant retina tear, macula-detached status and presence of PVR were associated with VA of> logMAR 1.0 (all p < 0.05). The types of surgery (TPPV vs combined SB/TPPV), number of breaks, lens extraction and additional cryotherapy were not associated with the functional or anatomical success. In conclusion, the GRT-RRD functional and structural outcomes were comparable between 1991-2005 and 2006-2015, albeit a statistically insignificant improvement of anatomical outcome over the past 25 years. Worse presenting VA, 150 degrees or more of giant retinal tear, detached macula and presence of PVR were associated with poorer visual outcome.

Bietti's crystalline dystrophy in Asians: clinical, angiographic and electrophysiological characteristics.

This article describes nine Chinese patients with Bietti's crystalline dystrophy, including two families, one consisting of three siblings and the other a pair of sisters. All patients had the classic refractile deposits located in all layers of the retina, with varying degrees of pigment epithelium atrophy. However, paralimbal crystals were not seen in the anterior corneal stroma. We describe clinical, angiographical and electrophysiological characteristics, and also review the literature on Bietti's crystalline dystrophy. All patients had full eye examination, including best corrected visual acuity, biomicroscopy, applanation tonometry and dilated funduscopy. Fluorescein angiography and indocyanine green angiography were performed, together with visual fields and electrophysiologic studies. All nine of our patients were phenotypically heterogeneous, with varying age and symptoms at presentation, as well as different degrees of progression. Age was not found to be a predictor of severity. The differences in disease severity, even within sibling groups, suggested that perhaps other factors were at play in phenotypic expression. We found that in early ICGA, all stages of BCD had delayed choroidal filling, which has not been previously described. We also observed a relative derangement of inner choroidal circulation as evidenced by late hypofluorescence on the ICGA. However, it is as yet unclear whether this circulatory disturbance is due to primary involvement of the posterior ciliary arteries, or secondary to choroidal and/or retinal pigment epithelial atrophy. While the FA and ICGA findings were similar, we found that the true extent of the atrophic areas was better delineated by ICGA. ICGA was also superior in outlining the degree and extent of choroidal vascular compromise.

Intraocular avastin (bevacizumab) for neovascularisation of the iris and neovascular glaucoma.

INTRODUCTION: The aim of this study was to determine the effectiveness of intraocular injections of bevacizumab for neovascularisation of the iris and neovascular glaucoma. CLINICAL PICTURE: Three patients with neovascularisation of the iris due to various causes were recruited. TREATMENT: Patients were treated with intraocular bevacizumab. OUTCOME: Neovascularisation of the iris was noted to have completely regressed as early as 3 days after the injection and in all the patients (100%) within 8 days after injection. They were followed up for at least 1 month with no clinical evidence of recurrence. Visual acuity remained stable or improved, and the intraocular pressure was controlled in all the 3 patients' eyes. Vitreous haemorrhage also cleared. No signs of inflammation or complications were observed. CONCLUSION: Intraocular injection of bevacizumab is effective and safe for patients with neovascularisation of the iris and neovascular glaucoma with or without vitreous haemorrhage.

Can long-term corticosteriods lead to blindness? A case series of central serous chorioretinopathy induced by corticosteroids.

INTRODUCTION: Long-term, high-dose corticosteroid therapy is well-known to cause systemic and ocular complications. A lesser known complication is chronic central serous chorioretinopathy (CSCR). Although idiopathic central serous chorioretinopathy (CSCR) is known to be mild with spontaneous recovery and minimal effects on the final visual acuity, chronic CSCR as a complication of long- term steroid therapy behaves differently, and may cause irreversible visual impairment. CLINICAL PICTURE: Three cases of chronic, recurrent CSCR were precipitated by longterm corticosteroids prescribed for post-renal transplant immunosuppressive therapy, postpituitary surgery and pemphigus vulgaris. TREATMENT AND OUTCOME: Two cases resolved with tapering of corticosteroids while one case was treated by focal laser photocoagulation. Two eyes had severe impairment of vision as a result of subretinal scar formation while the other 4 eyes had mild reduction of visual acuity from retinal epithelium pigment atrophy. CONCLUSION: Long-term corticosteroid therapy can be complicated by severe, chronic and recurrent CSCR and occasionally peripheral exudative retinal detachment. This may result in subretinal fibrosis and permanent loss of vision.

Characterization of Bietti crystalline dystrophy patients with CYP4V2 mutations.

PURPOSE: Mutations of the CYP4V2 gene, a novel family member of the cytochrome P450 genes on chromosome 4q35, have recently been identified in patients with Bietti crystalline dystrophy (BCD). The aim of this study was to investigate the spectrum of mutations in this gene in BCD patients from Singapore, and to characterize their phenotype. METHODS: Nine patients with BCD from six families were recruited into the study. The 11 exons of the CYP4V2 gene were amplified from genomic DNA of patients by polymerase chain reaction and then sequenced. Detailed characterization of the patients' phenotype was performed with fundal photography, visual field testing, fundal fluorescein angiography, and electroretinography (ERG). RESULTS: Three pathogenic mutations were identified; two mutations, S482X and K386T, were novel and found in three patients. The third mutation, a previously identified 15-bp deletion that included the 3' splice site for exon 7, was found in all nine patients, with six patients carrying the deletion in the homozygous state. Haplotype analysis in patients and controls indicated a founder effect for this deletion mutation in exon 7. Clinical heterogeneity was present in the patients. Compound heterozygotes for the deletion in exon 7 seemed to have more severe disease compared to patients homozygous for the deletion. There was good correlation between clinical stage of disease and ERG changes, but age did not correlate with disease severity. CONCLUSIONS: This study identified novel mutations in the CYP4V2 gene as a cause of BCD. A high carrier frequency for the 15-bp deletion in exon 7 may exist in the Singapore population. Phenotype characterization showed clinical heterogeneity, and age did not correlate with disease severity.