SURGICAL OUTCOMES IN CONCURRENT SICKLE CELL AND DIABETIC RETINOPATHY.

PURPOSE: To report the clinical features and outcomes in eyes that underwent vitreoretinal surgery for complications of concurrent sickle cell retinopathy and diabetic retinopathy. METHODS: Retrospective, consecutive case series of all eyes that underwent vitreoretinal surgery for complications secondary to concurrent sickle cell retinopathy and diabetic retinopathy between January 01, 2014, and December 31, 2021. RESULTS: The study included 20 eyes of 14 patients. Indications for surgery included tractional retinal detachment in 12 eyes (60%), combined tractional retinal detachment/rhegmatogenous retinal detachment in 6 eyes (30%), and vitreous hemorrhage in 2 eyes (10%). Pars plana vitrectomy was performed in all eyes. One eye received a scleral buckle at the same time as pars plana vitrectomy. There was no change in mean best-corrected visual acuity at the last follow-up examination (1.5 [20/678]) when compared with mean preoperative best-corrected visual acuity (1.6 [20/762], P = 0.83). Preoperative best-corrected visual acuity correlated with postoperative best-corrected visual acuity at the last follow-up examination in eyes with retinal detachment (r = 0.49, P = 0.04). Single operation anatomic success was achieved in 11 of 17 eyes (65%) with retinal detachment. CONCLUSION: Functional and anatomic outcomes after surgery in eyes with concurrent sickle cell retinopathy and diabetic retinopathy are relatively poor.

SCLERAL SUTURE FIXATION FOR DISLOCATED SILICONE PLATE HAPTIC INTRAOCULAR LENS.

PURPOSE: To describe results in two cases of a dislocated silicone plate haptic intraocular lens managed with vitrectomy and repositioning with scleral suture fixation. METHODS: Small case series. RESULTS: Two patients presenting with dislocated silicone plate haptic intraocular lens underwent a 23-gauge vitrectomy with a "handshake" maneuver to pass a 9-0 prolene suture through the positioning holes to allow scleral fixation. Best-corrected visual acuity was returned to predislocation Level 2 and 8 months after the vitrectomy. CONCLUSION: Silicone plate haptic intraocular lens can be managed with scleral suture fixation using this adapted technique, avoiding removal and exchange techniques. These are the first reported cases of silicone plate haptic intraocular lens managed with scleral suture repositioning.

Rescuing an Akreos 4-Point Haptic Intraocular Lens: A Novel Surgical Technique.

PURPOSE: To present a surgical technique that allows rescue (repositioning) of a dislocated Akreos AO model intraocular lens using scleral sutures. METHODS: The surgical technique is described with supplemental video. RESULTS: The technique was used in 4 eyes of 3 patients with 2 to 18 months of follow-up information. The intraocular lens was well positioned, and the visual acuity (as limited by other disease) was good, without adverse events. CONCLUSION: Scleral suture techniques for repositioning of the Akreos AO intraocular lens offer a suitable alternative to intraocular lens exchange.

Scleral Suture Fixation of Dislocated Posterior Chamber Intraocular Lens: Modification for Tapered Haptics.

PURPOSE: To present a surgical modification to a previously published technique that allows repositioning and scleral fixation of one-piece acrylic intraocular lenses with tapered haptics. METHODS: A retrospective review of three consecutive cases. RESULTS: Our technique modification enables repositioning using scleral suture fixation of one-piece intraocular lenses with tapered haptics by looping the haptic at its proximal, notched junction to the optic with the polypropylene suture. The suture knot is internalized which effectively suspends the intraocular lens and allows for better adjustment of the intraocular lens centration. Two cases were endocapsular dislocations; the third case was dislocated extracapsularly due through a posterior capsule rupture. All showed adequate lens centration at 3 months of follow-up. One case had suffered a vitreous hemorrhage a month postoperatively that is clearing. CONCLUSION: Repositioning using scleral fixation of one-piece intraocular lenses with tapered haptics is possible with a minor technique modification. This offers an alternative to intraocular lens exchange.

ACUTE- AND DELAYED-ONSET ENDOPHTHALMITIS AFTER OPEN GLOBE INJURIES: Clinical Features and Visual Acuity Outcomes.

PURPOSE: The purpose of the study was to report the clinical features and best-corrected visual acuity outcomes in patients with acute- and delayed-onset endophthalmitis after open globe injuries. METHODS: The study included a retrospective, comparative, consecutive case series of patients with endophthalmitis after open globe injury between January 2016 and October 2020 at the Bascom Palmer Eye Institute. RESULTS: Acute-onset endophthalmitis accounted for 16 of 20 cases (80%), and all cases were diagnosed at the initial examination. Delayed-onset endophthalmitis cases, occurring more than 2 weeks after injury, accounted for 4 of 20 cases (20%) and were because of Zone 1 wound leaks and infections. Factors associated with endophthalmitis included presence of a retained intraocular foreign body (11/20 [55%]) and delay of presentation >24 hours (15/20 [75%]) ( P < 0.001 and 0.002, respectively). The mean presenting best-corrected visual acuity was logMAR 1.64 (20/800), and the mean best-corrected visual acuity at the last follow-up was logMAR 1.22 (20/300). CONCLUSION: In patients with open globe injury-related endophthalmitis, visual acuity outcomes are generally poor. Despite intravitreal antibiotics at primary closure, delayed-onset endophthalmitis cases may develop in the setting of compromised Zone 1 wound integrity.

DIRECT MACULAR HOLE MANIPULATION RESULTS IN HIGH SUCCESS RATE IN SECONDARY MACULAR HOLE REPAIR.

PURPOSE: To investigate closure rates and functional outcomes of surgery for refractory and recurrent macular holes (MHs) in a real-world setting. METHODS: Retrospective review of secondary MH surgeries. RESULTS: A total of 72 eyes from 72 patients were included. Eyes had a mean of 1.51 surgeries before inclusion into this study with a mean MH size of 762 µ m and a mean baseline logarithm of the minimum angle of resolution best-corrected visual acuity of 1.11 (∼20/260 Snellen). Closure rates were 89.3% for tissue transplantation, 77.3% for internal limiting membrane (ILM) flaps, 92.9% for MH manipulation, and 12.5% for repeat ILM peeling ( P < 0.05). Best-corrected visual acuity changes in logarithm of the minimum angle of resolution from baseline to postoperative month six were +0.29 for ILM peeling alone (15 Early Treatment Diabetic Retinopathy Study letters worse), -0.39 for MH manipulation (20 Early Treatment Diabetic Retinopathy Study letters improved), -0.23 for tissue transplantation (13 Early Treatment Diabetic Retinopathy Study letters improved), and -0.2 for ILM flaps (10 Early Treatment Diabetic Retinopathy Study letters improved; P < 0.05). CONCLUSION: Secondary MH closure is possible using various surgical techniques with acceptable anatomical closure rates. Repeat ILM peeling is associated with the lowest closure rates and poorest functional results. To distinguish between techniques would require a large sample size of approximately 750 eyes.

INTRAOCULAR INFLAMMATION INCIDENCE AFTER INTRAVITREAL BROLUCIZUMAB INJECTION FOR EXUDATIVE AGE-RELATED MACULAR DEGENERATION.

PURPOSE: We evaluated the clinical outcomes of intraocular inflammation (IOI) of eyes with neovascular age-related macular degeneration (AMD) injected with brolucizumab in our tertiary referral center. METHODS: A retrospective case series for which clinical records of all eyes that received intravitreal brolucizumab at Bascom Palmer Eye Institute between December 1, 2019, and April 1, 2021, were reviewed. RESULTS: There were 345 eyes of 278 patients who received 801 brolucizumab injections. IOI was detected in 16 eyes of 13 patients (4.6%). In those patients, baseline Logarithm of Minimu Angle of Resolution (logMAR) best-corrected visual acuity was 0.32 0.2 (20/42), while it was 0.58 0.3 (20/76) at IOI presentation. The mean number of injections among eyes experiencing IOI was 2.4, and the interval between the last brolucizumab injection and IOI presentation was 20 days. There was no known case of retinal vasculitis. Management of IOI included topical steroids in seven eyes (54%), topical and systemic steroids in five eyes (38%), and observation in one eye (8%). Best-corrected visual acuity returned to baseline and inflammation resolved in all eyes by the last follow-up examination. CONCLUSION: Intraocular inflammation after brolucizumab injection for neovascular AMD was not uncommon. Inflammation resolved in all eyes by the last follow-up visit.

COST ANALYSIS OF SCLERAL BUCKLE, PARS PLANA VITRECTOMY, AND PARS PLANA VITRECTOMY WITH SCLERAL BUCKLE FOR RETINAL DETACHMENT REPAIR.

PURPOSE: To compare the cost and utility of scleral buckle (SB), pars plana vitrectomy (PPV), and PPV with SB (PPV/SB) for moderately complex rhegmatogenous retinal detachment repair. METHODS: Cost-utility analysis using data from the Primary Retinal Detachment Outcomes Study. The model estimated costs, lifetime utility, and lifetime cost per quality-adjusted life year for treatment of moderately complex rhegmatogenous retinal detachment with SB, PPV, or PPV/SB. Data from the Centers for Medicare and Medicaid Services were used to calculate costs in hospital and ambulatory surgery center settings. RESULTS: Total costs (2020 US dollars) for repair of a moderately complex rhegmatogenous retinal detachment in hospital (ambulatory surgery center) settings were $5,975 ($3,774) for the SB group, $8,125 ($5,082) for the PPV group, and $7,551 ($4,713) for the PPV/SB group. The estimated lifetime quality-adjusted life years gained were 5.4, 4.7, and 4.7 in the SB, PPV, and PPV/SB groups, respectively. The cost per quality-adjusted life year for hospital and ambulatory surgery center settings was $1,106 a ($699) for the SB group, $1729 ($1,081) for the PPV group, and $1,607 ($1,003) for the PPV/SB group. CONCLUSION: Scleral buckle, PPV, and PPV/SB yielded very favorable cost-utility results for the repair of moderately complex rhegmatogenous retinal detachment, with slightly better results for SB, compared with current willingness to pay standards.

CLINICOPATHOLOGIC CORRELATION OF PRERETINAL TISSUES IN MYOPIC TRACTION MACULOPATHY.

PURPOSE: To evaluate histopathologic features of preretinal tissues removed from eyes with myopic traction maculopathy (MTM). METHODS: We retrospectively studied preretinal tissue specimens from eyes with MTM removed during pars plana vitrectomy. A control group of six idiopathic epiretinal membranes was studied for comparison. RESULTS: Six MTM specimens were studied histopathologically. Outer retinal schisis-like thickening was present in 100% of preoperative optical coherence tomography images; four of the six eyes had subfoveal neurosensory retinal detachment. Postoperative optical coherence tomography images demonstrated complete resolution of the schisis-like appearance in all eyes; a full-thickness macular hole occurred in two of the six eyes. Histopathologic examination disclosed fibrocellular tissue that was strongly positive for glial fibrillary acidic protein, weak to moderately positive for cytokeratin, and weakly positive for smooth muscle actin and CD68. There were no apparent histopathologic or immunohistochemical differences between preretinal tissues from eyes with MTM and idiopathic epiretinal membranes from control eyes. CONCLUSION: The outer retinal schisis-like thickening, commonly associated with subretinal fluid, that characterizes MTM is associated with preretinal tissues that are histopathologically indistinguishable from idiopathic epiretinal membranes. These findings suggest that anteroposterior traction caused by axial elongation rather than a uniquely abnormal cellular process is the etiologic mechanism of MTM.

The Assessment of Blood Flow Velocities in Retinal Collaterals in Diabetic Retinopathy.

PURPOSE: Diabetic retinopathy (DR) is a microvascular disease characterized by capillary dropout and resultant retinal ischemia which then leads to retinal vascular remodeling. Our goal was to assess blood flow velocities in retinal collateral vessels in healthy and diabetic subjects with various stages of DR. METHODS: In our pilot study, we enrolled five eyes of five healthy subjects (H), five eyes of four subjects with diabetes and no retinopathy (DM), three eyes of three subjects with mild non-proliferative diabetic retinopathy (MDR), and five eyes of four subjects with proliferative diabetic retinopathy (PDR). Following routine ophthalmic examination, all subjects were imaged using a retinal function imager (RFI; Optical Imaging Inc., Rehovot, Israel). The built-in software of the RFI was used to identify and segment retinal collaterals with measurement of the blood flow velocities (BFV). One-way ANOVA was performed for BFV, followed by Newman-Keuls post hoc test. The level of significance was set at 5%. RESULTS: The total number of collateral segments involved in the study was 30, 31, 21, and 39 in the H, DM, MDR, and PDR groups, respectively. The BFVs in the collaterals were significantly lower in PDR (H: 1.86 ± 0.67, DM: 1.91 ± 0.71, MDR: 1.71 ± 0.53, PDR: 1.37 ± 0.58 mm/s). The PDR group showed a statistically significant difference in the comparisons to all groups (p = 0.012, p = 0.008, and p = 0.043 for the H, DM, and MDR groups, respectively), while no other comparisons between the groups were significant. CONCLUSION: We observed decreased BFV in retinal collaterals in PDR that may be due to the extensive capillary dropout and retinal ischemia. Further studies are needed for the noninvasive functional assessment of retinal microvascular changes in DR to better understand the underlying pathophysiology.

Cost Evaluation of Early Vitrectomy versus Panretinal Photocoagulation and Intravitreal Ranibizumab for Proliferative Diabetic Retinopathy.

PURPOSE: To evaluate costs and cost-utility of early vitrectomy (pars plana vitrectomy [PPV]) compared with panretinal photocoagulation (PRP) and intravitreal ranibizumab (IVR) for proliferative diabetic retinopathy (PDR) without diabetic macular edema. DESIGN: A decision analysis model of cost-utility. PARTICIPANTS: There were no participants. METHODS: A decision analysis was based on results from the Diabetic Retinopathy Clinical Research Network Protocol S comparing treatment of PRP with IVR (0.3 mg) in PDR without incident macular edema to model the total 2-year costs and outcomes for each treatment scenario. These values were compared with the 2-year hypothetical costs of early PPV for PDR. Centers for Medicare and Medicaid Services data were used to calculate associated modeled costs in a hospital/facility-based and nonfacility setting. Cost-utility was calculated on the basis of the preserved visual utility and estimated life years remaining. In addition, costs for lifetime treatment were modeled for all scenarios and used to calculate lifetime quality-adjusted life years (QALY) costs for each scenario. Sensitivity analyses were performed to evaluate the impact of the model's assumptions. MAIN OUTCOME MEASURES: Cost of treatment, utility, and cost per QALY. RESULTS: The modeled cost per QALY of treatment for PDR for 2 years of utility in the facility (nonfacility) setting was $163 988 ($102 559) in the PRP group, $436 992 ($326 424) in the IVR group, and $181 144 ($107 965) in the PPV group. Sensitivity analysis showed that both IVR and PPV groups would have equivalent costs per QALY over the first 2 years if 78% (facility) and 80% (nonfacility) of patients in the PPV group required additional treatment with IVR (at the dose of 10.1 injections as in Protocol S). Beyond 2 years, the cost per QALY in the facility (nonfacility) setting was calculated as $61 695 ($21 752) in the PRP group, $338 348 ($239 741) in the IVR group, and $63 942 ($22 261) in the PPV group. CONCLUSIONS: Early PPV as a strategy for treatment of PDR without macular edema demonstrates cost-utility similar to management with PRP and more favorable cost-utility compared with IVR in the short term. This advantage over IVR continues when lifetime costs are factored.

Cost-Utility of Evaluation for Posterior Vitreous Detachment and Prophylaxis of Retinal Detachment.

PURPOSE: To evaluate the costs and cost-utility of examination for posterior vitreous detachment (PVD) and treatment of associated pathology, and of managing various other peripheral retinal disorders to prevent retinal detachment (RD). DESIGN: A decision analysis model of cost-utility. PARTICIPANTS: There were no participants. METHODS: Published retrospective data on the natural course of PVD, retinal tears, and lattice degeneration were used to quantitate the visual benefits of examination and treatment. Center for Medicare and Medicaid Services data were used to calculate associated modeled costs in a hospital/facility-based and nonfacility/ambulatory surgical center (ASC)-based setting. Published standards of utility for a given level of visual acuity were used to derive costs and quality-adjusted life years (QALYs). MAIN OUTCOME MEASURES: Cost of evaluation and treatment, utility of defined health states, QALY, and cost per QALY. RESULTS: The modeled cost of evaluation of a patient with PVD and treatment of associated pathology in the facility/hospital (nonfacility/ASC)-based setting was $65 to $190 ($25-$71) depending on whether a single or 2-examination protocol was used. The cost per QALY saved was $255 to $638/QALY ($100-$239/QALY). Treatment of a symptomatic horseshoe tear resulted in a net cost savings of $1749 ($1314) and improved utility, whereas treatment of an asymptomatic horseshoe tear resulted in $2981/QALY ($1436/QALY). Treatment of asymptomatic lattice degeneration in an eye in which the fellow eye had a history of RD resulted in $4414/QALY ($2187/QALY). CONCLUSIONS: Evaluation and management of incident acute PVD (and symptomatic horseshoe tears) offer a low cost and a favorable cost-utility (low $/QALY) as a result of the minimization of the cost and morbidity associated with the development of RD, thus justifying current practice standards.

Vision-Related Quality of Life Associated with Unilateral and Bilateral Ocular Conditions.

PURPOSE: To present ophthalmic patient time-tradeoff vision utilities for quantifying vision-related quality-of-life when the fellow eye still has good vision. These utilities are important for performing reliable cost-utility analyses. DESIGN: Consecutive time-tradeoff vision utilities were obtained from ophthalmic patients with good vision (20/20-20/25) in one eye and vision ranging from 20/20 to no light perception in the fellow eye over a 15-year period from 2000 through 2014. PARTICIPANTS: Five hundred eighty-six ophthalmic participant interviews from Wills Eye Hospital, New York Eye and Ear Hospital, and ophthalmology office practices in Pennsylvania and New Jersey. METHODS: Participants underwent a full ophthalmic examination, after which time-tradeoff vision utilities were obtained by personal interview by the authors using a standardized, validated instrument. MAIN OUTCOME MEASURES: Time-tradeoff vision utilities. RESULTS: Mean time-tradeoff vision utilities were as follows in participants with good vision (20/20-20/25) in at least one eye and the following visions in the fellow eyes: no light perception, 0.79; counting fingers to light perception, 0.87; 20/200 to 20/400, 0.88; 20/60 to 20/100, 0.88; 20/30 to 20/50, 0.87; and 20/20 to 20/25, 0.94. CONCLUSIONS: In people with good vision (20/20-20/25) in one eye, the associated mean time-tradeoff vision utility is a remarkably consistent 0.87 to 0.88 when vision in the fellow eye ranges from 20/30 to light perception. Vision of 20/20 to 20/25 in the fellow eye results in a significantly higher associated utility of 0.94 (P < 0.01), whereas vision of no light perception in the fellow eye results in a significantly lower utility of 0.079 (P < 0.01). These utilities are important for calculating reliable patient value (quality-adjusted life-year) gains in ophthalmic cost-utility analysis populations in which there is unilateral and bilateral disease involvement.

Treated retinal breaks: clinical course and outcomes.

PURPOSE: To report rates and timing of retreatments, new break formation, and vitreoretinal surgical intervention after initial treatment of retinal breaks, and to identify factors associated with increased rates of additional vitreoretinal interventions. METHODS: Retrospective, consecutive case series of all patients who were diagnosed with a retinal break and underwent laser retinopexy for prophylaxis of retinal detachment at the Bascom Palmer Eye Institute, Miami, FL, from 2013 through 2016 were reviewed. The main outcome measure was if additional laser treatment or vitreoretinal surgical procedure was performed after the initial laser retinopexy. RESULTS: Additional laser retinopexy was performed in 75 (18.7%) of 401 study eyes over 113 sessions: 58 (51.3%) sessions to retreat the original tear and 55 (48.7%) to treat a new tear. Vitreoretinal surgery for retinal detachment after the initial laser retinopexy was performed in 23 (5.7%) eyes. Risk factors associated with vitreoretinal surgery after initial laser treatment included superotemporal location (OR = 3.62; p = 0.008), vitreous hemorrhage (OR = 2.62; p = 0.017), and multiple breaks (OR = 2.60; p = 0.014). CONCLUSIONS: Additional treatment is often performed after the initial treatment of a retinal break. Although progression to retinal detachment is not common, regular follow-up examinations are recommended.

INTERNAL LIMITING MEMBRANE PEELING DURING PARS PLANA VITRECTOMY FOR RHEGMATOGENOUS RETINAL DETACHMENT: Cost Analysis, Review of the Literature, and Meta-analysis.

PURPOSE: To evaluate the visual and potential economic impact of primary internal limiting membrane (ILM) peeling in primary treatment of rhegmatogenous retinal detachment. METHODS: A PubMed search was performed to extract data regarding the rate of epiretinal membrane formation and the rate of secondary pars plana vitrectomy with membrane peel after repair of rhegmatogenous retinal detachment with or without ILM peeling. Data were aggregated and analyzed in a meta-analysis. This information was used to perform a cost analysis to determine the economic ramifications of primary ILM peeling. RESULTS: Six included studies compared the outcomes of eyes receiving pars plana vitrectomy for rhegmatogenous retinal detachment repair with and without primary ILM peel. The cumulative rate of epiretinal membrane formation was 29% (86/295) in the eyes without ILM peel and 3% (8/289) in the eyes with ILM peel. The cumulative rate of secondary pars plana vitrectomy/membrane peel was 16% (22/141) in the eyes without ILM peel and 0% (0/158) in the eyes with ILM peel. The weighted summary point estimate odds ratio was 0.083 (95% confidence interval 0.042-0.164), indicating a statistically significant protective effect across the 6 studies of ILM peeling and the development of epiretinal membrane. Based on published data, the average dollars saved by conducting a primary ILM peel was $615 in a facility setting and $364 in an ambulatory surgical center. CONCLUSION: Published, mainly retrospective, data suggest that primary ILM peel in rhegmatogenous retinal detachment repair may have a significant reduction in the rate of postoperative epiretinal membrane and may lessen the need for secondary pars plana vitrectomy/membrane peel. Furthermore, from an economic perspective, the reduction in the need for secondary surgery may justify the higher cost with primary ILM peel.

RETINAL DETACHMENT SURGERY IN A PEDIATRIC POPULATION: Visual and Anatomic Outcomes.

PURPOSE: Pediatric retinal detachments (RDs) are unique in etiology, anatomy, and prognosis compared with the adult population. The mechanisms of pediatric RD include tractional (TRD), rhegmatogenous retinal detachment, traumatic, and other types, such as exudative or hemorrhagic. This study examined visual and anatomical outcomes of pediatric RD undergoing surgical repair at a single university referral center. METHODS: A retrospective consecutive case series of patients clinically diagnosed and undergoing surgery for RD between birth and 15 years of age from 2002 to 2013 at a single academic institution. RESULTS: A total of 206 patients (231 eyes) were included in this study, of which 25 (12%) had bilateral RD. Of those patients, 67 (29%) had TRD (retinopathy of prematurity, persistent fetal vasculature, or familial exudative vitreoretinopathy), 51 (22%) had rhegmatogenous retinal detachment (myopia, X-linked retinoschisis, or Stickler syndrome), 60 (26%) had traumatic RD, and 53 (23%) were due to other types of RD, such as Coats disease or coloboma. Presenting best-corrected visual acuity better than 20/200 correlated with better final best-corrected visual acuity (P < 0.0001). Anatomical success was strongly correlated with visual acuity outcome (P < 0.00001) and was significantly more likely in rhegmatogenous retinal detachment versus TRD (78% vs. 39%, P < 0.05). The rates of obtaining a final best-corrected visual acuity > 20/200 were poorer in TRD (10%) compared with rhegmatogenous retinal detachment (39%, P < 0.01) or traumatic RD (28%, P < 0.05). CONCLUSION: Visual and anatomical outcomes varied among categories of RD. Rhegmatogenous retinal detachments were associated with the best outcomes (anatomical success and globe conservation), whereas TRDs generally had poorer visual and anatomical outcomes.

MACULAR HOLE AFTER PARS PLANA VITRECTOMY FOR RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To report the clinical features, possible associations and treatment outcomes of patients with macular hole after pars plana vitrectomy (PPV) (single or multiple) for rhegmatogenous retinal detachment (RD). METHODS: Retrospective consecutive case series from July 2009 to July 2014. RESULTS: In the 15 study patients, the average time from RD surgery to macular hole diagnosis was 119 days (range: 41-398 months). Possible associations include epiretinal membrane (73%, 11/15 patients), macula-off RD (60%, 9/15 patients), recurrent RD (47%, 7/15 patients), and high myopia (56%, 5/9 patients). Single surgery was successful in hole closure in 8/15 patients (Group A) while 7/15 patients underwent multiple surgeries (Group B). Macular hole closure was achieved in 7/8 (87.5%) patients in Group A compared to 4/7 (57.1%) patients in Group B. Improvement of at least two lines of Snellen's visual acuity was achieved in 4/8 (50.0%) and 4/7 (57.1%) patients in Group A and B, respectively. CONCLUSION: In patients with macular hole formation after pars plana vitrectomy for RD, possible associations were epiretinal membrane, macula-off RD, recurrent RD, and high myopia. Even when macular hole closure was achieved, limited visual improvement occurred.

Cost Evaluation of Panretinal Photocoagulation versus Intravitreal Ranibizumab for Proliferative Diabetic Retinopathy.

PURPOSE: To evaluate costs of panretinal photocoagulation (PRP) vs. intravitreal ranibizumab (IVR) for proliferative diabetic retinopathy (PDR). DESIGN: A Markov-style model of cost-effectiveness and cost utility. PARTICIPANTS: There were no participants. METHODS: Based on results from Diabetic Retinopathy Clinical Research (DRCR) Network Protocol S, we performed a Markov-style analysis to generate the total 2-year costs for each treatment arm. The cost per line-year saved and cost utility were calculated based on the estimated life years remaining. Both treatment arms were assumed to result in 9 lines of vision saved in 20% of patients. Medicare reimbursement data were acquired to determine costs, which were then separately calculated for practice settings of a hospital-based facility as the highest end of the cost range and a nonfacility in the same geographic area as the lowest end. Cost parameters for a prototypical patient's life expectancy also were modeled and calculated. MAIN OUTCOME MEASURES: Inputed cost of therapy, cost per line saved, cost per line-year saved, and cost per quality-adjusted life years (QALY). RESULTS: When PRP was the primary treatment, the 2-year cost in the facility setting was $13 053, with cost per line saved $7252, cost per line-year $240, and cost per QALY $7988. In the nonfacility setting costs were approximately 21% lower. When IVR was the primary treatment, the 2-year cost in the facility setting was $30 328, cost per line saved was $16 849, cost per line-year $575, and cost per QALY $19 150. In the nonfacility setting costs were approximately 15% lower. Extrapolation to lifetime therapy yielded the cost per QALY with PRP treatment of $14 219 to $24 005 and with IVR of $138 852 to $164 360. Cost utility for PRP would be 85% lower than IVR in the facility setting and 90% lower than IVR in the nonfacility setting. CONCLUSIONS: PRP compared with IVR as primary treatment for PDR is less expensive over 2 years, but both fall well below the accepted cost per QALY upper limit. However, over an average lifetime, the cost differential between PRP and IVR increases, and IVR therapy may exceed the typical accepted limit of cost per QALY.

Rates of Reoperation and Retinal Detachment after Macular Hole Surgery.

PURPOSE: To evaluate rates of reoperation and retinal detachment (RD) after macular hole surgery. DESIGN: Retrospective cross-sectional study. PARTICIPANTS: Patients in the insurance claim-based MarketScan databases from 2007 through 2013 with a record of macular hole surgery. METHODS: Patients with macular hole surgery were identified. Cases of definite (the same eye was coded both times) and presumed (the eye laterality was not coded) macular hole reoperations within 2, 3, and 12 months were queried. In addition, cases of postoperative RD within 2, 3, and 12 months were captured. MAIN OUTCOME MEASURES: Rates of macular hole reoperation and postoperative RD, including subgroup analysis based on presence or absence of internal limiting membrane (ILM) peeling. RESULTS: Records of 23465 macular hole surgeries among 20 764 patients were analyzed. Among presumed reoperations, the rates of reoperation were 4.3% (4.1% after ILM peeling and 5.0% after no ILM peeling; P = 0.01) within 2 months of surgery, 5.5% (5.3% after ILM peeling and 6.2% after no ILM peeling; P = 0.03) within 3 months of surgery, and 9.5% (9.0% after ILM peeling and 11.0% after no ILM peeling; P = 0.01) within 12 months of surgery. The rates for definite reoperations were 1.3% (1.2% after ILM peeling and 1.8% after no ILM peeling; P = 0.04) at 2 months, 1.7% (1.6% after ILM peeling and 2.5% after no ILM peeling; P = 0.004) at 3 months, and 4.1% (3.3% after ILM peeling and 7.5% after no ILM peeling; P < 0.001) at 12 months. The cumulative rate of postoperative RD was 1.81±0.09% to 2.18±0.5% after 2 months, 2.27±0.10% to 3.18±0.67% after 3 months, and 3.92±0.16% to 5.70±1.1% after 12 months. Internal limiting membrane peeling was associated negatively with postoperative RD at 2 months (2.3% vs. 1.7%; P = 0.007), 3 months (2.8% vs. 2.1%; P = 0.004), and 12 months (4.7% vs. 3.3%; P < 0.001). CONCLUSIONS: In this sample, reoperations for macular hole were performed at low rates. Internal limiting membrane peeling was associated with lower rates of reoperation and RD.