Identifying the content for an item bank and computerized adaptive testing system to measure the impact of age-related macular degeneration on health-related quality of life.

PURPOSE: We are developing an age-related macular degeneration (AMD) health-related quality of life (HRQoL) item bank, applicable to Western and Asian populations. We report primarily on content generation and refinement, but also compare the HRQoL issues reported in our study with Western studies and current AMD-HRQoL questionnaires. METHODS: In this cross-sectional, qualitative study of AMD patients attending the Singapore National Eye Centre (May-December 2019), items/domains were generated from: (1) AMD-specific questionnaires; (2) published articles; (3) focus groups/semi-structured interviews with AMD patients (n = 27); and (4) written feedback from retinal experts. Following thematic analysis, items were systematically refined to a minimally representative set and pre-tested using cognitive interviews with 16 AMD patients. RESULTS: Of the 27 patients (mean ± standard deviation age 67.9 ± 7.0; 59.2% male), 18 (66.7%), two (7.4%), and seven (25.9%) had no, early-intermediate, and late/advanced AMD (better eye), respectively. Whilst some HRQoL issues, e.g. activity limitation, mobility, lighting, and concerns were similarly reported by Western patients and covered by other questionnaires, others like anxiety about intravitreal injections, work tasks, and financial dependency were novel. Overall, 462 items within seven independent HRQoL domains were identified: Activity limitation, Lighting, Mobility, Emotional, Concerns, AMD management, and Work. Following item refinement, items were reduced to 219, with 31 items undergoing amendment. CONCLUSION: Our 7-domain, 219-item AMD-specific HRQoL instrument will undergo psychometric testing and calibration for computerized adaptive testing. The future instrument will enable users to precisely, rapidly, and comprehensively quantify the HRQoL impact of AMD and associated treatments, with item coverage relevant across several populations.

MACULAR SENSITIVITY AND CAPILLARY PERFUSION IN HIGHLY MYOPIC EYES WITH MYOPIC MACULAR DEGENERATION.

PURPOSE: To evaluate the interrelationship between macular sensitivity and retinal perfusion density (PD) in eyes with myopic macular degeneration (MMD). METHODS: One hundred and thirty-eight highly myopic eyes from 82 adult participants were recruited. Macular sensitivity was evaluated using the Microperimeter MP-3. Retinal PD was measured using the PLEX Elite 9000 swept source optical coherence tomography angiography. Macular sensitivity values between different categories of MMD and its relationship with optical coherence tomography angiography measurements were evaluated using multivariable linear mixed models, adjusting for age and axial length. RESULTS: Macular sensitivity reduced with increasing severity of MMD (ß ≤ -0.95, P < 0.001), whereas the best-corrected visual acuity was not associated with MMD severity (P > 0.04). Persons who were older (ß = -0.08, P < 0.001), with longer axial length (ß = -0.32, P = 0.005), presence of macular diffuse choroidal atrophy (ß = -2.16, P < 0.001) or worse MMD (ß = -5.70, P < 0.001), and presence of macular posterior staphyloma (ß ≤ -2.98, P < 0.001) or Fuchs spot (ß = -1.58, P = 0.04) were associated with reduced macular sensitivity. Macular sensitivity was significantly associated with deep retinal PD in MMD (ß = 0.15, P = 0.004) but not with superficial retinal PD (P = 0.62). CONCLUSION: There was a strong correlation between reduced macular sensitivity and increasing MMD severity, even in mild MMD independent of the best-corrected visual acuity. Furthermore, macular sensitivity was correlated with deep retinal PD, suggesting a vasculature-function relationship in MMD.

Nursing management of the critical thinking and care quality of ICU nurses: A cross-sectional study.

AIM: To explore the effectiveness of a digital learning management system in enhancing intensive care unit nurses' critical care knowledge and critical thinking tendency. BACKGROUND: Learning intensive care unit knowledge and skills is essential for the continuing education of nurses, and impacts patient health outcomes. Enhancing intensive care unit nurses' critical care abilities is a medical care quality concern in clinical practice. METHODS: A cross-sectional study was conducted with 212 participants to investigate the effects of a digital learning system on care quality. RESULTS: After the implementation of the digital learning system, intensive care unit nurses' critical care knowledge and critical thinking skills increased significantly. High-level nurses had higher critical thinking scores. All participants associated critical care knowledge with improved quality of care. CONCLUSION: The digital learning management system enhanced intensive care unit nurses' critical care knowledge. Optimizing nursing care safety and quality requires that nursing staff to be at an adequate level, which improves their critical care ability. IMPLICATIONS FOR NURSING MANAGEMENT: A well-designed digital learning management system with structured classes may allow intensive care unit nurses to learn effectively and can be used for continuing education. These results are of interest to nursing management staff who want to invest in the continued professional development of intensive care unit nurses to improve critical care knowledge, critical thinking skills, care quality, and health care value.

DIABETIC MACULAR ISCHEMIA: Correlation of Retinal Vasculature Changes by Optical Coherence Tomography Angiography and Functional Deficit.

PURPOSE: To examine the relationship between macular microvasculature parameters and functional changes in persons with diabetic retinopathy (DR). METHODS: Cross-sectional study of 76 eyes with varying levels of DR. Optical coherence tomography angiography (OCTA) quantified superficial and deep perifoveal vessel densities and foveal avascular zone areas. Retinal sensitivity was measured using microperimetry. Optical coherence tomography angiography parameters and retinal sensitivity were correlated. RESULTS: Deep perifoveal vessel density decreased with increasing severity of DR (adjusted mean 51.93 vs. 49.89 vs. 47.96, P-trend = 0.005). Superficial and deep foveal avascular zone area increased with increasing DR severity (adjusted mean: 235.0 µm vs. 303.4 µm vs. 400.9 µm, P-trend = 0.003 [superficial]; 333.1 µm vs. 513.3 µm vs. 530.2 µm, P-trend = 0.001 [deep]). Retinal sensitivity decreased with increasing DR severity (adjusted mean: 25.12 dB vs. 22.34 dB vs. 20.67 dB, P-trend = 0.003). Retinal sensitivity correlated positively with deep perifoveal vessel density (Pearson's ρ = 0.276, P = 0.020) and inversely with superficial foveal avascular zone area (Pearson's ρ = -0.333, P = 0.010). CONCLUSION: Alterations in retinal microvasculature can be observed with OCTA with increasing severity of DR. These changes are correlated with reduced retinal sensitivity. Optical coherence tomography angiography is useful to detect and quantify the microvasculature properties of eyes with diabetic macular ischemia.

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.

CHARACTERIZATION OF THE CHOROIDAL VASCULATURE IN MYOPIC MACULOPATHY WITH OPTICAL COHERENCE TOMOGRAPHIC ANGIOGRAPHY.

PURPOSE: To characterize the choriocapillaris (CC) in highly myopic eyes with myopic maculopathy, using optical coherence tomographic angiography. METHODS: Prospective, clinic-based study of 42 eyes of 38 patients with high myopia (≤-6 diopters and axial length ≥26.5 mm). Myopic maculopathy was graded from fundus photographs according to the Meta-Analysis for Pathologic Myopia classification. Macular 3 × 3 mm en face optical coherence tomographic angiographic images were obtained with swept-source optical coherence tomographic angiography and graded for CC flow impairment as follows: 1) intact CC, 2) focal (<1 mm), and 3) extensive (>1 mm). RESULTS: Of the 42 eyes, 17 (39.5%) had tessellated fundus, 20 (46.5%) had diffuse, and 6 (14.0%) had patchy atrophy. Choriocapillaris flow impairment was observed in all eyes with diffuse and patchy atrophy. Even in eyes with tessellated fundus only, CC signal voids were seen in 3 eyes (17.6%). With increasingly severe myopic maculopathy, the pattern of CC flow impairment changed from predominantly focal to predominantly extensive. CONCLUSION: Choriocapillaris flow impairment was observed in many highly myopic eyes, even in those with mild fundus changes, and worsened with increasing severity of myopic maculopathy. Longitudinal studies are needed to assess whether CC flow impairment predicts the risk of myopic maculopathy progression.

COMPARISON OF OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHIC CHANGES AFTER ANTI-VASCULAR ENDOTHELIAL GROWTH FACTOR THERAPY ALONE OR IN COMBINATION WITH PHOTODYNAMIC THERAPY IN POLYPOIDAL CHOROIDAL VASCULOPATHY.

PURPOSE: To compare changes in optical coherence tomography angiography in eyes with polypoidal choroidal vasculopathy after treatment with anti-vascular endothelial growth factor monotherapy or combined with photodynamic therapy. METHODS: This is a longitudinal case-controlled study. The authors performed optical coherence tomography angiography at baseline and Month 3 in patients with treatment-naive polypoidal choroidal vasculopathy undergoing monotherapy (n = 10) or combination therapy (n = 13). We analyzed flow signal within the outer retina and choriocapillaris using automated segmentation. The authors analyzed the presence of pachyvessels using a 10.4-µm segment through Haller layer. The changes in each layer were compared between treatments. RESULTS: At Month 3, both groups showed similar improvement in best-corrected visual acuity and central retinal thickness. However, flow signal within the polypoidal choroidal vasculopathy complex was decreased in more eyes after combination therapy than after monotherapy (84.6% vs. 40.0%, P = 0.04). Patchy reduction in flow signal within the choriocapillaris layer was noted in 15.4% and 10.0% after combination therapy and monotherapy, respectively (P = 0.61). Significant reduction in pachyvessel caliber was seen only after combination therapy but not after monotherapy (75.0% vs. 0.0%, P = 0.01). CONCLUSION: Longitudinal optical coherence tomography angiography demonstrates more significant reduction in lesion flow and pachyvessels in the short term after combination therapy than after monotherapy, although visual and structural OCT showed similar improvement.

CHOROIDAL VASCULAR HYPERPERMEABILITY AS A PREDICTOR OF TREATMENT RESPONSE FOR POLYPOIDAL CHOROIDAL VASCULOPATHY.

PURPOSE: To investigate the influence of choroidal vascular hyperpermeability (CVH) and choroidal thickness on treatment outcomes in eyes with polypoidal choroidal vasculopathy (PCV) undergoing anti-vascular endothelial growth factor monotherapy or combination therapy of photodynamic therapy and anti-vascular endothelial growth factor injections. METHODS: The authors performed a prospective, observational cohort study involving 72 eyes of 72 patients with polypoidal choroidal vasculopathy (mean age 68.6 years, 51% men) treated with either monotherapy (n = 41) or combination therapy (n = 31). Each eye was imaged with color fundus photography, fluorescent angiography, indocyanine green angiography, and spectral domain optical coherence tomography. Indocyanine green angiography images were used to evaluate CVH, and spectral domain optical coherence tomography was used to measure central choroidal thickness. Changes in visual acuity over 12 months, and number of anti-vascular endothelial growth factor injections were investigated. RESULTS: Choroidal vascular hyperpermeability was present in 31 eyes (43.1%). Visual acuity change over 12 months was numerically better in the CVH group compared with the CVH (-) group (-0.099 and -0.366 logarithm of the minimal angle of resolution unit in the CVH (-) and CVH (+) groups, respectively, multivariate P = 0.063) and significantly better in a matched pair analysis (P = 0.033). Furthermore, in the combination therapy group, the number of injection was significantly lower in the CVH (+) group compared with the CVH (-) group (4.68 vs. 2.58 injections/year in the CVH (-) and CVH (+) groups; P = 0.0044). There was no significant relationship between treatment response and choroidal thickening. CONCLUSION: The presence of CVH is associated with better visual outcome in eyes with polypoidal choroidal vasculopathy and lower injection number in combination therapy. Thus, CVH, but not choroidal thickness, should be further evaluated as a potential biomarker for selecting patients for combination therapy.

Case Series: Bilateral Rhegmatogenous Retinal Detachments in Atopic Dermatitis.

SIGNIFICANCE: Bilateral occurrence of rhegmatogenous retinal detachment is a potentially blinding condition seen most commonly in patients with atopic dermatitis. Poor control of the skin condition may lead to simultaneous or sequential retinal detachment and even development of complications such as proliferative vitreoretinopathy. PURPOSE: The purpose of this study was to highlight the importance of the dermatologist's role in aggressive treatment of atopic dermatitis to prevent this potentially blinding condition. CASE REPORTS: A retrospective review of three patients with poorly controlled atopic dermatitis at the Singapore National Eye Centre with bilateral rhegmatogenous retinal detachment was conducted. Two patients presented with sequential rhegmatogenous retinal detachments, and one patient had simultaneous bilateral retinal detachments. At presentation, all three were experiencing atopic dermatitis flares and were either on low-dose oral or topical steroids only. Post-retinal detachment surgery, all eyes except one achieved good visual acuity. The patients were referred to a dermatologist and treated with therapeutic doses of systemic steroids and immunomodulators for their dermatitis flare. CONCLUSIONS: This case series draws attention to the importance of the eye care provider's comanagement of such patients with atopic dermatitis. Aggressive control of facial atopic dermatitis with consideration of immunomodulators or short-term systemic steroids during flares to control facial eczema and eye rubbing may reduce this potentially blinding ocular complication.

Randomized controlled trial evaluating a novel community eye care programme for elderly individuals with visual impairment.

IMPORTANCE: The novel intervention was effective at improving compliance to appropriate tertiary eye care after community eye screening. BACKGROUND: Elderly individuals from low socio-economic background with visual impairment (VI) often do not attend tertiary care, even if significant eye diseases are detected while in the community. We evaluate a novel incentive care scheme (ICS) to improve compliance to appropriate follow-up after community eye screening. DESIGN: Randomized controlled trial in a population-based setting was conducted. PARTICIPANTS: A total of 140 elderly individuals with VI (visual acuity <6/12, mean age ± SD = 66.6 ± 8.9 years, 46.4% female) were included. METHODS: Participants were randomized to either ICS (N = 72) or usual care (UC; N = 68). ICS incorporated patient education, social support and financial assistance to assist individuals in attending tertiary eye care. UC comprised of a standard referral letter and advice. MAIN OUTCOME MEASURE: Primary outcome included compliance to eye care referral. Secondary outcomes included best-corrected visual acuity and vision-related quality of life assessed at baseline and 3 months. RESULTS: Participants receiving the ICS intervention had higher rates of compliance to tertiary eye care attendance compared to UC (31.9% vs. 16.2%, respectively, P = 0.027). While we observed an overall significant improvement in best-corrected visual acuity at 3 months in both groups (P < 0.05), we found no significant differences in Rasch-transformed vision-related quality of life scores between groups (all P > 0.05). Identified barriers for tertiary healthcare access included patient attitudes and financial- and health-related barriers. CONCLUSION AND RELEVANCE: Our pilot RCT found that ICS improved adherence to appropriate tertiary eye care referrals after community eye screening in elderly people with VI.

CHARACTERIZATION AND DIFFERENTIATION OF POLYPOIDAL CHOROIDAL VASCULOPATHY USING SWEPT SOURCE OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY.

PURPOSE: To determine the correlation and agreement between swept-source optical coherence tomography angiography (SS-OCT-A) with fluorescein angiography (FA), indocyanine green angiography (ICGA) and spectral domain OCT (SD-OCT) in characterizing polypoidal choroidal vasculopathy (PCV) and in differentiating eyes with typical age-related macular degeneration (t-AMD). METHODS: This study included 32 and 54 eyes with t-AMD and PCV, respectively, who underwent SS-OCT-A, SD-OCT, fluorescein angiography, and indocyanine green angiography. The images from these four techniques were compared. RESULTS: On SS-OCT-A, flow signals with vascular network configuration were detected in 81.2% and 77.8% of eyes with t-AMD and PCV, respectively. 40.4% of polyps were detected as flow signals with polypoidal configuration. Compared with indocyanine green angiography, SS-OCT-A had sensitivity and specificity of 83.0% and 57.1%, respectively, for vascular network, and 40.5% and 66.7% for polyps. Longitudinal changes were in agreement between SS-OCT-A and SD-OCT in 90% of eyes. 88.2% of eyes with dry retina on SD-OCT had persistent vascular net on SS-OCT-A. In two cases with reactivation of PCV, SS-OCT-A was more sensitive at detecting recurrence than SD-OCT. CONCLUSION: Swept-source optical coherence tomography angiography is effective at detecting vascular network that correlate to conventional angiography in eyes with t-AMD and PCV. Swept-source optical coherence tomography angiography is inferior to indocyanine green angiography in detecting polyps and cannot replace indocyanine green angiography for differentiating PCV from t-AMD; however, SS-OCT-A may be more sensitive than SD-OCT in detecting early recurrence.

Development and Validation of a Deep Learning System for Diabetic Retinopathy and Related Eye Diseases Using Retinal Images From Multiethnic Populations With Diabetes.

Importance: A deep learning system (DLS) is a machine learning technology with potential for screening diabetic retinopathy and related eye diseases. Objective: To evaluate the performance of a DLS in detecting referable diabetic retinopathy, vision-threatening diabetic retinopathy, possible glaucoma, and age-related macular degeneration (AMD) in community and clinic-based multiethnic populations with diabetes. Design, Setting, and Participants: Diagnostic performance of a DLS for diabetic retinopathy and related eye diseases was evaluated using 494 661 retinal images. A DLS was trained for detecting diabetic retinopathy (using 76 370 images), possible glaucoma (125 189 images), and AMD (72 610 images), and performance of DLS was evaluated for detecting diabetic retinopathy (using 112 648 images), possible glaucoma (71 896 images), and AMD (35 948 images). Training of the DLS was completed in May 2016, and validation of the DLS was completed in May 2017 for detection of referable diabetic retinopathy (moderate nonproliferative diabetic retinopathy or worse) and vision-threatening diabetic retinopathy (severe nonproliferative diabetic retinopathy or worse) using a primary validation data set in the Singapore National Diabetic Retinopathy Screening Program and 10 multiethnic cohorts with diabetes. Exposures: Use of a deep learning system. Main Outcomes and Measures: Area under the receiver operating characteristic curve (AUC) and sensitivity and specificity of the DLS with professional graders (retinal specialists, general ophthalmologists, trained graders, or optometrists) as the reference standard. Results: In the primary validation dataset (n = 14 880 patients; 71 896 images; mean [SD] age, 60.2 [2.2] years; 54.6% men), the prevalence of referable diabetic retinopathy was 3.0%; vision-threatening diabetic retinopathy, 0.6%; possible glaucoma, 0.1%; and AMD, 2.5%. The AUC of the DLS for referable diabetic retinopathy was 0.936 (95% CI, 0.925-0.943), sensitivity was 90.5% (95% CI, 87.3%-93.0%), and specificity was 91.6% (95% CI, 91.0%-92.2%). For vision-threatening diabetic retinopathy, AUC was 0.958 (95% CI, 0.956-0.961), sensitivity was 100% (95% CI, 94.1%-100.0%), and specificity was 91.1% (95% CI, 90.7%-91.4%). For possible glaucoma, AUC was 0.942 (95% CI, 0.929-0.954), sensitivity was 96.4% (95% CI, 81.7%-99.9%), and specificity was 87.2% (95% CI, 86.8%-87.5%). For AMD, AUC was 0.931 (95% CI, 0.928-0.935), sensitivity was 93.2% (95% CI, 91.1%-99.8%), and specificity was 88.7% (95% CI, 88.3%-89.0%). For referable diabetic retinopathy in the 10 additional datasets, AUC range was 0.889 to 0.983 (n = 40 752 images). Conclusions and Relevance: In this evaluation of retinal images from multiethnic cohorts of patients with diabetes, the DLS had high sensitivity and specificity for identifying diabetic retinopathy and related eye diseases. Further research is necessary to evaluate the applicability of the DLS in health care settings and the utility of the DLS to improve vision outcomes.

MYOPIC RETINOSCHISIS IN ASIANS: Structural Features and Determinants of Visual Acuity and Prognostic Factors for Progression.

PURPOSE: To describe microstructural changes and schisis extent in eyes with myopic retinoschisis and to determine their influence on visual acuity at baseline and follow-up. METHODS: In this prospective observational study, 50 eyes of 38 patients with myopic retinoschisis were evaluated using spectral domain optical coherence tomography, and the patients were followed for at least 12 months. The presence of microstructural changes and the extent of retinoschisis at baseline on spectral domain optical coherence tomography, and the association between these parameters and the risk of visual acuity deterioration were analyzed. RESULTS: Median presenting visual acuity and central retinal thickness were 0.31 logMAR (≈20/40) and 395 µm, respectively. Twenty-six eyes (52%) had entire macular area retinoschisis. Common microstructural changes included photoreceptor detachment (24%), foveal ellipsoid zone (EZ) disruption (34%), partial-thickness macular hole (26%), and full-thickness macular hole (16%). Visual acuity was poorer in eyes with photoreceptor detachment, EZ disruption, full-thickness macular hole, and central retinal thickness >300 µm. Eyes with entire macular area retinoschisis had the poorest visual acuity and thickest central retinal thickness, and they were more likely to have photoreceptor detachment, EZ disruption, and retinal detachment. Over a mean follow-up of 31.7 ± 7.7 months, 14 eyes (28%) had worsening visual acuity of ≥2 lines. Ten of these 14 eyes had entire macular retinoschisis at baseline. CONCLUSION: Most eyes with myopic retinoschisis remain stable. However, eyes with extensive retinoschisis involving the entire macular area are more likely to progress and have microstructural abnormalities and poorer vision. Early surgery should be considered for these eyes.

THREE-YEAR RESULTS OF POLYPOIDAL CHOROIDAL VASCULOPATHY TREATED WITH PHOTODYNAMIC THERAPY: Retrospective Study and Systematic Review.

PURPOSE: To evaluate the 3-year outcome in eyes with polypoidal choroidal vasculopathy (PCV) treated with photodynamic therapy with verteporfin. METHODS: Retrospective study and review of the literature. We performed a retrospective study of patients with PCV who were treated with photodynamic therapy between January 2007 and December 2008. Patients were excluded if they had received photodynamic therapy before the study period, but those who received previous treatment with other modalities (thermal laser or intravitreal therapies) were allowed. The main outcome measures were best-corrected visual acuity, repeat photodynamic therapy, and recurrence of PCV at the end of Years 1, 2, and 3. We further conducted a systematic review of the literature using the terms "polypoidal choroidal vasculopathy" and "photodynamic therapy" and compared the visual outcome of studies over 3 years using meta-analytical methods. RESULTS: The retrospective study included 68 eyes. The mean best-corrected visual acuity was 0.73 ± 0.56 logMAR (20/107, Snellen equivalent) at baseline, 0.73 ± 0.70 logMAR (20/107, Snellen equivalent) at 1 year, 0.96 ± 0.76 logMAR (20/182, Snellen equivalent) at 2 years, and 1.07 ± 0.81 logMAR (20/235, Snellen equivalent) at 3 years. The cumulative recurrence rates of PCV were 16.1% (1 year), 34.9% (2 years), and 52.7% (3 years) and eyes with recurrence were more likely to suffer ≥3 lines loss compared with eyes without recurrence (63.2 vs. 17.6%, P = 0.006). The systematic review summarized results from 48 published studies and our retrospective study. The pooled analysis from 29 studies (316 eyes reporting the 3-year visual outcome) reported mean best-corrected visual acuity improvement of 0.115 logMAR at 1 year (n = 1,669), 0.066 logMAR at 2 years (n = 701), and 0.027 logMAR at 3 years (n = 316). Reported recurrence rates were 5.9% to 50.0% after 1 year, 9.1% to 83.3% after 2 years, and 40.0% to 78.6% after 3 years or longer of follow-up. CONCLUSION: The visual outcome in eyes with PCV was stable until 2 years, but the outcome at 3 years worsened, particularly in eyes that experienced recurrence.

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.

Extracapsular cataract extraction training: junior ophthalmology residents' self-reported satisfaction level with their proficiency and initial learning barrier.

PURPOSE: To investigate residents' self-reported satisfaction level with their proficiency in extracapsular cataract extraction (ECCE) surgery and the initial barriers to learning the procedure. METHODS: This is a single-centre prospective descriptive case series involving eight first-year ophthalmology residents in Singapore National Eye Center. We recorded the demographics, frequency of review by the residents of their own surgical videos and their satisfaction level with their proficiency at each of the ECCE steps using a 5-point Likert scale. All ECCE surgical videos between October 2013 and May 2014 were collected and analysed for the overall time taken for the surgery and the time taken to perform the individual steps of the procedure. RESULTS: The mean age of the residents was 27.6 ± 1.5 years and 62.5% (5/8) were women. More than half (62.5%, 5/8) reviewed their own surgical videos while 37.5% (3/8) discussed the surgical videos with their peers or supervisors. Of the ECCE steps, the residents were most dissatisfied with their proficiency in performing irrigation and aspiration (87.5%, 7/8), followed by suturing (62.5%, 5/8), intraocular lens insertion (62.5%, 5/8) and tin can capsulotomy (62.5%, 5/8). The average time taken for each ECCE case was 55.0 ± 12.2 min and, of all the steps, most time was spent on suturing (20.5 ± 6.8 min), followed by irrigation and aspiration (5.5 ± 3.6 min) and tin can capsulotomy (3.3 ± 1.8 min). CONCLUSIONS: The first-year ophthalmology residents were most dissatisfied with their proficiency in irrigation/aspiration, suturing and tin can capsulotomy. More training needs to be directed to these areas during teaching sessions in the operating room, wet laboratory or cataract simulation training sessions.

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.

Trends in age-related macular degeneration management in Singapore.

PURPOSE: To describe the trends and patterns of anti-vascular endothelial growth factor (anti-VEGF) therapy and photodynamic therapy (PDT) use for age-related macular degeneration (AMD) in the National Eye Centre in Singapore over a 4-year period. METHODS: Data on the total number of intravitreal anti-VEGF injections and PDT treatment over a 4-year period at the Singapore National Eye Centre were obtained from centralized electronic records. Patients aged 40 years and older treated for AMD were included. Data retrieved included the annual treatment load in terms of number of new patients and total treatment episodes, and treatment burden for patients was studied in terms of number of injections per year and cumulative injection numbers over 3 years. Potential influence on retreatment by choice of drug, use of adjunct PDT, and diagnosis of polypoidal choroidal vasculopathy were further analyzed. RESULTS: From 2009 to 2012, a total of 6157 injections were performed on 1380 unique individual patients. The total number of injections performed per calendar year increased from 962 in 2009 to 2278 in 2012. The number of unique incident cases increased from 287 in 2009 to 446 in 2012. The mean number of injections over the first year increased from 2.62 in 2009 to 3.19 in 2012 (p < 0.001). Choice of anti-VEGF therapy did not significantly alter the cumulative injections required. Patients diagnosed as having polypoidal choroidal vasculopathy had similar injection episodes (p = 0.178), whereas choice of anti-VEGF and adjunct PDT had no effect on the overall treatment. CONCLUSIONS: Anti-VEGF treatment of AMD continues to increase substantially year on year in the past few years, in alignment with experience from other countries. However, the cumulative number of injections per patient remains low, and many patients discontinue treatment within the first year. These data demonstrate that undertreatment remains a significant concern in clinical settings.

Artificial Intelligence, Digital Imaging, and Robotics Technologies for Surgical Vitreoretinal Diseases.

OBJECTIVE: To review recent technological advancement in imaging, surgical visualization, robotics technology, and the use of artificial intelligence in surgical vitreoretinal (VR) diseases. BACKGROUND: Technological advancements in imaging enhance both preoperative and intraoperative management of surgical VR diseases. Widefield imaging in fundal photography and OCT can improve assessment of peripheral retinal disorders such as retinal detachments, degeneration, and tumors. OCT angiography provides a rapid and noninvasive imaging of the retinal and choroidal vasculature. Surgical visualization has also improved with intraoperative OCT providing a detailed real-time assessment of retinal layers to guide surgical decisions. Heads-up display and head-mounted display utilize 3-dimensional technology to provide surgeons with enhanced visual guidance and improved ergonomics during surgery. Intraocular robotics technology allows for greater surgical precision and is shown to be useful in retinal vein cannulation and subretinal drug delivery. In addition, deep learning techniques leverage on diverse data including widefield retinal photography and OCT for better predictive accuracy in classification, segmentation, and prognostication of many surgical VR diseases. CONCLUSION: This review article summarized the latest updates in these areas and highlights the importance of continuous innovation and improvement in technology within the field. These advancements have the potential to reshape management of surgical VR diseases in the very near future and to ultimately improve patient care. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.