SF 6 COMPARED WITH C 2 F 6 FOR INFERIOR RHEGMATOGENOUS RETINAL REPAIR : The Manchester Pseudophakic Retinal Detachment Study.

PURPOSE: To compare SF 6 relative with C 2 F 6 in the anatomical and functional outcomes following pars plana vitrectomy for uncomplicated primary pseudophakic rhegmatogenous retinal detachment with inferior causative breaks. METHODS: This is a retrospective, comparative study on eyes with pseudophakic rhegmatogenous retinal detachment with inferior causative breaks that had small-gauge pars plana vitrectomy repair using SF 6 and C 2 F 6 tamponade between 2011 and 2020 at a tertiary centre in the United Kingdom. Primary outcome was single surgery anatomical success, and the secondary outcome was best-corrected visual acuity. Propensity score matching, using preoperative findings as covariates to account for relevant confounders, was performed. RESULTS: From 162 pseudophakic rhegmatogenous retinal detachment eyes with inferior causative breaks, the median (interquartile range) follow-up was 82 (52-182) days. The single surgery anatomical success was 156 (96.3%) overall: 47 of 47 (100.0%) and 109 of 115 (94.8%) in the SF 6 and C 2 F 6 groups, respectively ( P = 0.182). Relative to the SF 6 group, the C 2 F 6 group had a higher mean number of tears (SF 6 : 3.1[2.0], C 2 F 6 : 4.5[2.7], P = 0.002) and greater retinal detachment extent (SF 6 : 5.3[2.9], C 2 F 6 : 6.2[2.6] clock hours, P = 0.025). Following propensity score matching analysis, 80 eyes were matched with 40 in each group to homogenize preoperative factors. No significant difference was found in single surgery anatomical success and best-corrected visual acuity between the groups following propensity score matching. CONCLUSION: Primary pars plana vitrectomy with gas tamponade leads to a high single surgery anatomical success rate in uncomplicated pseudophakic rhegmatogenous retinal detachment with inferior causative breaks with no additional benefit associated with long-acting tamponade when comparing C 2 F 6 with SF 6 .

AUTOLOGOUS RETINAL TRANSPLANT FOR REFRACTORY SEROUS RETINAL DETACHMENT SECONDARY TO OPTIC DISK PIT: A NOVEL SURGICAL APPROACH.

PURPOSE: To present a new technique to treat refractory retinal detachment secondary to optic disk pit. METHODS: An interventional case report. RESULTS: A 25-year-old man with congenital optic disk pit had two failed vitrectomies involving laser around the optic disk, internal limiting membrane peel and flap to plug the disk pit, and gas tamponade to reattach the retina. With all options running out, a further vitrectomy with autologous retinal transplant and silicone oil tamponade was performed to treat the refractory serous retinal detachment; the silicone oil was removed at 6 weeks after the last procedure. The retina remained successfully attached at 6 months postsurgery with the patient maintaining his baseline visual acuity. CONCLUSION: The use of autologous retinal transplant is a new approach to treat refractory retinal detachment secondary to congenital optic disk anomalies, and adds to our options of dealing with this complex condition when first-line approaches have failed.

The use of fluorinated gases and quantification of carbon emission for common vitreoretinal procedures.

PURPOSE: To report the contribution to carbon dioxide equivalent mass [CO2EM] of various types of VR surgery performed across three tertiary referral centres, according to their indication and fluorinated gas used. We secondarily reported on the difference in tamponade choice, and CO2EM between the different centres. MATERIALS: Retrospective, continuous, comparative multicentre study of all procedures using fluorinated gases between 01/01/17-31/12/20 at the Manchester Royal Eye Hospital and Birmingham and Midland Eye Centre, and between 01/01/19-31/12/2020 at the University Hospitals Coventry and Warwickshire. RESULTS: Across 4877 procedures, the use of fluorinated gases produced 284.2 tonnes (71.2 tonnes annually) CO2EM; an annual consumption of 30,330 l of gasoline. Rhegmatogenous-retinal-detachment (RRD) and macular hole repair had the highest CO2EM by indication, accounting for 191.4 tonnes CO2EM (67.3%) and 28.6 tonnes CO2EM (10.1%); a mean 60.0 kg and 32.0 kg of CO2EM produced per surgery respectively. The use of fluorinated gases and their respective CO2EM contributions were significantly different across all three centres (p < 0.001) for all indications. SF6, despite being used in 1883 procedures (38.6%), contributed to 195.5 tonnes CO2EM (68.8%). Relative to C2F6, procedures using C3F8 and SF6 produced 1.9 and 4.4 times more CO2EM. CONCLUSION: We demonstrated that SF6 causes significantly higher carbon emissions relative to C2F6 and C3F8 with RRD and macular hole repair having the greatest environmental impact. We also reported large variations between different large VR centres in fluorinated gas use, and therefore in carbon emission contributions depending on indications for surgery. Evidence-based protocols might help in making VR surgery "greener".

The impact of 360-laser barricade on outcomes of vitrectomy for pseudophakic retinal detachment; The Manchester Pseudophakic Retinal Detachment Study.

PURPOSE: To investigate the anatomical and functional outcomes and specifically, the effect of 360-degree barrier-laser, in pars plana vitrectomy (PPV) for primary pseudophakic rhegmatogenous retinal detachment (PRD). METHODS: We conducted a single-centre retrospective, continuous and comparative study on eyes that had undergone PPV with focal-retinopexy (laser or cryotherapy) versus 360-laser for PRD repair between 2011-2020 at a single tertiary vitreoretinal centre in the UK. Primary outcomes were single surgery anatomical success (SSAS) rate and final postoperative visual acuity (VA). Multivariable regression covariates for primary re-detachment included age, gender, onset-of-detachment, pre-operative VA, ocular co-morbidities, macula-status, majority inferior (vs superior) PRD, number-of-tears and PRD extent (in clock-hours), 360-laser barricade, and perfluorocarbon liquid (PFCL) use. For VA gain, primary re-detachment was added as a covariate. RESULTS: We included 467 eyes with a mean follow-up of 388 (161) days. The SSAS was 444/467 (95.1%) overall, and 351/370 (94.9%) and 93/97 (95.9%) in focal-retinopexy and 360-laser groups, respectively (p = 0.798). Compared to the focal-retinopexy group, the 360-laser group had significantly worse post-operative VA but similar logMAR gain (p = 0.812). A multivariable binary logistic regression found that only PFCL use was linked with increased primary re-detachment (OR:5.32 [p = 0.048]) and 360-laser did not contribute to increased SSAS. A multivariable linear regression analysis showed that poor logMAR gain was significantly associated with better pre-operative logMAR, ocular co-morbidities, greater PRD extent, use of 360-laser and primary re-detachment. However, when excluding macula-off RD (n = 211), 360-laser was no longer significant (p = 0.088). CONCLUSIONS: Prophylactic 360-laser does not seem to impact on SSAS and functional outcomes following PPV for primary PRD.

Environmental Effect of Fluorinated Gases in Vitreoretinal Surgery: A Multicenter Study of 4,877 Patients.

PURPOSE: To investigate the direct contribution to carbon emissions of fluorinated gases used in all vitreoretinal (VR) procedures utilizing gas tamponade and assess the respective carbon footprint of the three different gas delivery systems. DESIGN: A multicenter, retrospective, environmental impact study. METHODS: All VR procedures using fluorinated gases between 2017 to 2020 at the Manchester Royal Eye Hospital (MREH) and Birmingham and Midland Eye Centre (BMEC) (the second and third largest VR centers in the UK), and between 2019 to 2020 at the University Hospitals Coventry and Warwickshire (UHCW) were included. CO2 equivalent mass (CO2EM) was calculated from the mass of each gas used, according to the Intergovernmental Panel on Climate Change. RESULTS: A total of 4877 (1883 SF6 [38.6%], 2096 C2F6 [43.0%], and 897 C3F8 [18.4%]) procedures were analyzed. UHCW and BMEC utilized single-use 30 mL and 75 mL cannisters, respectively. MREH used four cylinders of each gas over 4 years (2 kg SF6, 1 kg C2F6, 1 kg C3F8). Mean CO2EM per patient was: MREH 111.8 kg, BMEC 7.5 kg, and UHCW 2.7 kg. For MREH and BMEC, the CO2EM was 73.4 metric tons annually (if all cases were performed with i) 30 mL: 3.7 tons and ii) cylinders: 148.0 tons, x 40-fold difference), equating to 599,400 (30,500-1.2 million) km travelled by a passenger car. The current use of SF6 in VR surgery accounts for 0.11% of total SF6 use; if 30 mL cylinders were exclusively used in the UK, this could be lowered to 0.01%. CONCLUSIONS: This study highlights the significant waste associated with large gas cylinders and demonstrated that 30 mL cannisters can lead to a marked reduction in carbon emissions, even after accounting for the increased carbon footprint involved in their manufacture and disposal.

Environmental effect of air versus gas tamponade in the management of rhegmatogenous retinal detachment VR surgery: A multicentre study of 3,239 patients.

PURPOSE: To report the potential reduction of carbon emissions by utilising air-tamponade (AT), where possible, instead of fluorinated gases in the management of rhegmatogenous retinal detachment (RRD). We compared the carbon CO2 emissions produced at two large tertiary referral vitreoretinal (VR) centres where RRD are exclusively repaired using fluorinated gases to a tertiary VR mass of each gas used according to the Intergovernmental Panel on Climate Change. MATERIALS AND METHODS: Retrospective, continuous, comparative multicentre study of all procedures using fluorinated gases between 01/01/17-31/12/20 at the Manchester Royal Eye Hospital (MREH) and Birmingham and Midland Eye Centre (BMEC), and between 01/01/19-31/12/2020 at the University Hospitals Coventry and Warwickshire (UHCW). RESULTS: We report on 3,239 (SF6:1,415 [43.7%], C2F6:1,235 [38.1%], C3F8:541 [16.7%], Air:48 [1.5%]) procedures. UHCW and BMEC utilise single use 30ml and 75ml cannisters, respectively and MREH use multi-use gas cylinders. UHCW used AT in 48 (70%) of RRD repairs. Mean equivalent mass CO2/patient was MREH:115.9kg, BMEC:7.9kg and UHCW:1.9kg. If assuming all centres used 30ml cannisters, the mean equivalent mass CO2/patient was MREH:3.5 kg, BMEC:3.1kg and UHCW:1.9kg. AT enabled UHCW to greatly reduce the need for the most environmentally damaging SF6 gas, leading to lower CO2 emissions by 47.0% and 41.1% compared to MREH and BMEC, respectively. CONCLUSION: We demonstrate how AT vs. the fluorinated gases can reduce in carbon footprint in the management of RRD. Further studies are required to determine the most 'environment-friendly' intraocular tamponade without compromising patient outcomes centre that also routinely employs AT in selected RRD cases.

Manchester iStent study: long-term 7-year outcomes.

OBJECTIVES: To determine the efficacy and safety of combined phacoemulsification and single first-generation iStent implantation over 84 months. SUBJECTS/METHODS: Single-surgeon, single-centre, uncontrolled prospective interventional study in real-world settings. Forty-one patients with open-angle glaucoma on at least one antihypertensive drop underwent phaco-iStent surgery. This cohort was monitored over the subsequent 84 months. The primary outcome measure was intraocular pressure (IOP). Secondary outcome measures were number of glaucoma drops, visual acuity, cup-disc-ratio (CDR), mean deviation (MD) and visual field index (VFI). Thirty-one (76%) patients survived to 48 months and 19 (46%) patients to 84 months. RESULTS: At 84 months, we demonstrate an absolute mean reduction of 4.87 mmHg (95% CI 1.62-7.64) for IOP and 0.59 (95% CI 0.03-1.16) for number of glaucoma drops. At the final clinic visit, LogMAR VA improved by 0.21 (95% CI 0.08-0.34), with no significant change in CDR, MD and VFI. Attrition was mainly due to death (27%) and further glaucoma surgery (12%). A single patient suffered from postoperative hyphaema, with no sequalae. Patients at high risk for progression to filtration surgery were defined as those on oral acetazolamide for IOP control, or those fulfilling all the following criteria: IOP ≥ 20 mmHg, CDR ≥ 0.7, MD ≤ -4.0 dB, number of drops ≥ 2. This group is to be considered for surgery as the next step in management according to NICE glaucoma guidelines. These patients (n = 14) demonstrated a more marked final IOP reduction of 6.85 mmHg (95% CI 3.97-9.75) vs 1.62 mmHg (95% CI 0.04-3.22) in their low-risk counterparts (n = 27). Reduction in glaucoma drops was 0.86 (95% CI 0.07-1.64) for the high-risk and 0.56 (95% CI 0.06-1.05) for the low-risk cohort. Further glaucoma surgery was required for 4 (29%) high-risk and 1 (0.5%) low-risk patients over the study period. CONCLUSIONS: Our results strongly suggest that the expected outcome of phaco-iStent surgery is a maintained reduction in intraocular pressure and number of glaucoma medications over 7 years. This is combined with a negligible rate of complications, a sustained improvement in central visual acuity, and a reliable maintenance of peripheral visual function.

Compressive Optic Neuropathy Caused by Orbital Non-Hodgkin's Lymphoma.

Purpose. To present a unique case of Non-Hodgkin's-Lymphoma- (NHL) associated compressive optic neuropathy. Method. An 89-year-old male presenting with acute unilateral visual loss and headache. Results. Patient was initially diagnosed with occult giant cell arteritis; however after visual acuity deteriorated despite normal inflammatory markers, an urgent MRI scan revealed an extensive paranasal sinus mass compressing the optic nerve. Conclusion. Paranasal sinus malignancies occasionally present to the ophthalmologist with signs of optic nerve compression and must be included in the differential diagnosis of acute visual loss.