Unexplained visual loss in retinal detachment repair: comparing gas, silicone oil and heavy silicone oil by multivariable regression.

PURPOSE: To measure the proportion of unexplained and all causes of visual loss following primary rhegmatogenous-retinal-detachment (RRD) repair, comparing gas tamponade (SF6, C2F6, C3F8), silicone oil (SO, 1000cs and 5000cs) and heavy silicone oil (Densiron). METHODS: Retrospective, continuous, comparative study from 01/1/2017-31/5/2021. All primary RRDs were included after successful removal of SO and Densiron. Primary failures were excluded. Visual loss was defined as reduction of ≥0.30 logMAR units. Multivariable binary-logistic and linear regression models to compare tamponade, and all cases of unexplained visual loss and logMAR gain were performed. Covariates included age, ocular co-morbidities, pre-op vision, macula-status, high-myopia, giant-retinal-tear (GRT), perfluorocarbon-use, combined buckle/PPV, PVR-C, retinectomy, tamponade agent and post-operative lens status. RESULTS: Of 1,012 primary RRDs, we found an incidence of unexplained visual loss in 15/1012 (1.5%, SF6:1/341[0.3%], C2F6:4/338[1.2%], C3F8:2/239[0.8%], Densiron:0/33[0.0%], SO-1000cs:5/43[11.6%] and SO-5000cs:3/18[16.7%]), and visual loss of all causes in 57/1012 (5.6%, SF6:13/341[3.8%], C2F6:14/338[4.1%], C3F8:15/239[6.3%], Densiron:2/33[6.1%], SO-1000cs:9/43[20.9%] and SO-5000cs:4/18[22.2%]). On multivariable binary-logistic regression, we report that macula-on RRD (Odds-Ratio[OR]5.7,95% Confidence-interval[CI]1.2-28.2, p=0.032), GRT (OR35.0,CI 2.0-617.3, p=0.015), combined buckle/PPV (OR37.7,CI 2.0-711.4, p=0.015), SO1000cs (OR86.6,CI 5.6-1,348.0), p=0.001) and 5000cs (OR37.2,CI 1.3-1,101.5, p=0.036) (Reference-tamponade:SF6) were associated with unexplained visual loss. Duration of oil tamponade was not linked to increase in unexplained visual loss (p=0.569). CONCLUSIONS: Correlation between SO in detachment repairs and unexplained visual loss has been established, however incidence with HSO has not been compared to other agents. This study demonstrates that although SO was linked with risk-adjusted increased unexplained visual loss relative to gas tamponade, no such association was found for Densiron, on multivariable analysis.

REMOVAL OF DROPPED HEAVY SILICONE OIL BUBBLE USING AIR.

PURPOSE: To report a new ?rescue" technique for the removal of a dropped heavy silicone oil (HSO) bubble, after failed aspiration with a short, 23-gauge cannula and suction pump. METHODS: If the HSO bubble is dropped during standard, 23-gauge, transconjunctival extraction with a suction pump, filtered air can be injected into the HSO bubble to make it rise. Extraction can then be resumed with the suction pump, resulting in complete removal of HSO. RESULTS: This technique has been used approximately ten times over the last 18 months with a 100% success rate and no complications. CONCLUSION: We present a safe, simple, and cost-effective ?rescue" method for the removal of a dropped HSO bubble using air. With the rise in popularity of HSO and the development of new heavy tamponades, safe and effective techniques for their removal are becoming increasingly important.

Outcomes of Heavy Silicone Oil (Densiron) compared to Silicone Oil in primary rhegmatogenous retinal detachment: a multivariable regression model.

PURPOSE: To measure the visual outcomes, proliferative vitreoretinopathy (PVR) and retinectomy rates following primary rhegmatogenous retinal detachment (RRD) repair, comparing silicone oil (SO) and heavy SO (Densiron). METHODS: Retrospective, continuous comparative study from January 2017 to May 2021 of all primary RRD. Multivariable linear (logMAR gain) and binary-logistic (PVR-C and retinectomy rate) regression models to compare tamponade were performed. Covariates included age, gender, ocular co-morbidities, high myopia, macula-status, giant-retinal-tear (GRT), pre-op vision, PVR-C, oil type, perfluorocarbon-use, combined scleral buckle/vitrectomy, combined phaco-vitrectomy, 360-degrees-endolaser and oil duration. Cases with trauma or less than six-month follow-up were excluded. RESULTS: A total of 259 primary RD were analysed. There were 179 SO patients and 80 Densiron patients that had six-month primary re-detachment in 18 (10.1%) and 8 (10.0%) respectively (p = 1.000). No difference in logMAR gain was detected between tamponade choice on multivariable linear regression. Subsequent glaucoma surgery was 5 (2.8%) and 4 (5.0%) for SO and Densiron patients respectively (p = 0.464). On multivariate binary-logistic regression we found no difference in development of PVR-C between oil tamponades. However, SO had significantly higher subsequent retinectomy rate compared to Densiron (odds ratio 15.3, 95% CI 1.9-125.5, p = 0.011). Duration of oil tamponade was not linked to differences in logMAR gain, PVR-C formation or increased retinectomy rate. CONCLUSIONS: We report no difference in primary anatomical success, number of further RRD surgeries, subsequent glaucoma surgery, visual outcomes, PVR-C between both tamponades on multivariable models. Densiron oil was found to be more retinectomy sparing relative to SO.

Vitreoretinal specialists compared with residents on outcomes of primary laser retinopexy in preventing retinal detachment in 958 eyes.

OBJECTIVE: Retinal tears are the most common vitreoretinal (VR) emergency and retinopexy aims to reduce the risk of rhegmatogenous retinal detachment (RRD). Currently retinal laser is a required competence by the Royal College of Ophthalmologists for residents. We report 6-month detachment rate and repeat retinopexy rate of VR specialists compared with residents. METHODS AND ANALYSIS: A retrospective, consecutive study of 958 eyes undergoing primary laser retinopexy (slit lamp or indirect laser) from January 2017-2020 was divided into training level by operator: specialty training (ST) 2-3, ST4-5, ST6-7 and VR specialists. RESULTS: We report an overall 6-month RRD rate in 32/958 (3.3%) (ST2-3: 9/221 (4.1%), ST4-5: 15/373 (4.0%), ST6-7: 2/72 (2.8%) and VR specialists: 6/292 (2.1%)). We additionally report a repeat retinopexy rate of 189/958 (19.7%), (ST2-3: 44/221 (19.9%), ST4-5: 80/373 (21.4%), ST6-7: 16/72 (22.8%) and VR specialists: 49/292 (16.8%)]). Multivariable Cox survival regression analysis showed significant risk factors for developing RRD include male gender (p=0.018), high myopia (≤-6.00 Dioptres, p=0.004), ST2-3 (p=0.022) and ST4-5 (p=0.040) (relative to VR specialists) and by ST6-7, no significance was found (p=0.151). Significantly higher repeat retinopexy rates were associated with horseshoe tears (relative to round holes, p<0.001) and high myopia (p=0.026) with no difference between different training levels. CONCLUSION: There was a decreasing trend in RRD rate following primary retinopexy with increase in training. Although junior residents had a higher RRD rate than VR specialists, it was still favourable relative to other large case series. While there was no difference in subsequent laser retinopexy rate between training levels, the retreatment rate was associated with the type of tear and high myopia.

Primary retinopexy in preventing retinal detachment in a tertiary eye hospital: a study of 1157 eyes.

PURPOSE: Retinopexy is the most common vitreo-retinal procedure performed in the eye emergency department and significantly reduces the risk of a rhegmatogenous retinal detachment (RRD). There are various indications for retinopexy, with the most common being horseshoe-tears (HST). Multiple treatment techniques exist, ranging from slit-lamp laser-retinopexy, indirect laser-retinopexy or cryopexy. We report on our primary retinopexy 6-month RRD rate, repeat retinopexy rate and compare outcomes of different indications and treatment modalities. METHODS: Retrospective consecutive case series of 1157 patients attending Birmingham and Midlands Eye Centre, UK between January 2017 and 2020. RESULTS: The RRD rate at 6 months was 3.9%, with 19.1% requiring subsequent retinopexies. Multivariate Cox survival regression analysis showed that significant risk factors for RRD following primary retinopexy included male gender (p = 0.012), high myopia (≤ - 6.00D, p = 0.004), HST (compared to round holes, p = 0.026) and primary cryopexy (compared to slit-lamp laser, p = 0.014). HST was the most common indication for retinopexy (812 [70.2%]) in which 118 (14.5%) had multiple tears. Slit-lamp laser was used in 883 (76.3%) of cases. The rate for subsequent epiretinal membrane peel surgery was 3 (0.3%) and was higher in eyes that required multiple retinopexy procedures (p = 0.035). CONCLUSION: With our large cohort of patients over three years, we provide additional evidence on the RRD and subsequent retinopexy rate after primary retinopexy. Further retinopexy is a common occurrence, particularly in high-risk retinal tears such as HST. Strict monitoring and prompt follow-up after retinopexy is important to prevent progression to RRD and should be of priority in the clinicians post-retinopexy management plan, particularly in those with associated risk factors.

Effect of demographics and ethnicity on laser retinopexy in preventing retinal detachment in a tertiary eye hospital in 812 eyes.

PURPOSE: To investigate different baseline characteristics, clinical indications, repeat retinopexy rate, and 6-month detachment rate of primary laser retinopexy across different ethnicities. METHOD: Retrospective, single-centre, consecutive comparative study, looking at all patients who had primary laser retinopexy between January 2017 and 2020. Multivariate Cox survival [reporting hazard ratio (HR)] and binary logistic regression (reporting odds ratio) analyses were performed to investigate differences between ethnicities with age, gender, operator level (vitreoretinal or general ophthalmologist) and high myopia status (≤-6.0 Dioptres) as covariates. RESULTS: We report on 812 patients in three ethnicities: Black [69 (8.5%)], South Asian [SA, 156 (19.2%)] and White [587 (72.3%)] with overall 6-month detachment rate of 31 (3.8%). Rate for subsequent retinopexies was Black: 12 (17.4%), SA: 15 (9.6%) and White: 131 (22.3%), p = 0.002. Multivariate Cox survival regression analysis found no difference in detachment rate between ethnicities. South Asian (SA) had lower repeat retinopexy rate than White patients [HR, 0.40 (95% confidence interval [CI], 0.22-0.71, p = 0.002)]. Multivariate binary logistic regression found that Black and SA patients compared with White, have the following: (i) higher proportion of round holes relative to horseshoe tears [OR, 2.31 (95% CI, 1.19-4.49, p = 0.014) and OR, 2.06 (95% CI, 1.25-3.40), p = 0.004, respectively] and (ii) higher proportion of high myopia [OR, 2.99 (95% CI, 1.20-7.46, p = 0.019) and OR, 2.35 (95% CI, 1.11-4.96), p = 0.025, respectively]. Ethnic minorities were younger than White patients: SA [43, interquartile range (IQR), 28-61], Black (49, IQR, 35-57) and White (61, IQR, 54-67 years, p < 0.001) and had more indirect and 360 retinopexy compared with slit lamp (p < 0.001). CONCLUSION: We demonstrate a significant difference in baseline characteristics, retinal tear morphology and treatment course between the ethnic groups. Further studies are necessary to investigate the genetic and biological differences that may influence these variations and may help to allow for more targeted health care.

The Effect of Supervision and Out-of-Hours Surgery on the Outcomes of Primary Macula-On Retinal Detachments Operated by Vitreoretinal Fellows: A Review of 435 Surgeries.

PURPOSE: During bank holidays and weekends (BHWE), many primary macula-on retinal detachments (RD) across the United Kingdom are performed unsupervised out-of-hours by experienced vitreoretinal (VR) fellows. We aimed to determine whether first-year (F1) and second-year (F2) fellows could safely operate out-of-hours independently with remote supervision on primary macula-on RDs. METHODS: This is a retrospective consecutive series of 435 patients attending the Birmingham and Midlands Eye Centre from January 2017 to July 2020. We evaluated (i) 6-month re-detachment rate and (ii) visual outcomes of F1, F2, and consultants during office hours and BHWE as well as the effects of supervision versus non-supervision. RESULTS: For the re-detachment rate, no difference was found between surgeon grade (p = 0.821), whether supervised (p = 1.000), whether BHWE (p = 1.000), unsupervised BHWE and supervised mid-week (p = 0.757), and unsupervised F1 and F2 (p = 1.000), with non-significance maintained on multivariate regression. No difference was detected in the level of supervision (15.7%) between fellow grades during BHWE (p = 0.761) or mid-week (p = 0.295) or between surgeon grade and logMAR letters gained pre-postoperatively (p = 0.834). CONCLUSION: Safe VR services can be provided by experienced VR fellows during office hours, BHWE, supervised, or unsupervised, with similar primary success and visual outcomes to consultants in this patient subgroup. Initial intensive supervision and feedback and a gradual increase in independence is fundamental for VR fellows to gain confidence and become safe independent surgeons.

Optic Disc Pit Maculopathy - Case Series, Clinical Approach, and Management.

PURPOSE: The purpose of this study was to analyze the diagnostic and therapeutic approach of five cases with optic disc pit (ODP) maculopathy. MATERIALS AND METHODS: This was a retrospective study of five patients diagnosed with ODP maculopathy. Four of these cases had unilateral involvement, whereas one case had bilateral findings. The medical notes of these individuals were reviewed in order to record the presenting symptoms, clinical signs, visual acuity (VA), imaging, management, and the final visual outcome on their last follow-up appointment. RESULTS: The first patient (53-year-old female) underwent a left pars plana vitrectomy (PPV) combined with inner retinal fenestration, endolaser, and perfluoropropane (C3F8) gas tamponade and her VA improved from 6/24 to 6/9 Snellen. A focal retinal laser treatment was carried out on our second patient leading to decrease of the subretinal fluid but had a poor visual outcome due to the underlying secondary glaucoma from iris melanoma treatment in the past. The third patient was an asymptomatic 7-year-old girl in which the maculopathy resolved spontaneously without any surgical intervention with a final VA of 6/5. The fourth and fifth patients were asymptomatic with good vision in both eyes and were, therefore, only monitored with follow-ups. CONCLUSION: ODP maculopathy remains a challenging clinical entity for a vitreoretinal surgeon. The current management for ODP maculopathy involves surgical procedures with PPV being a common treatment of choice. Spontaneous resolution of ODP maculopathy has also been reported. Our study highlights the contrasting management that can be adopted in the treatment of ODP maculopathy, and there is not one definite treatment for this condition.

Management of retinal detachment in retinoblastoma with globe conserving treatment.

PURPOSE: To investigate the features and outcomes of retinoblastoma (Rb) patients complicated by development of retinal detachment (RD) following systemic chemotherapy with or without local focal consolidation treatment and without external beam radiotherapy (EBRT). METHODS: A retrospective study of all Rb patients between April 2002 and April 2012 at a tertiary hospital center (Birmingham Children's Hospital and Birmingham Midlands Eye Centre, United Kingdom). All eyes that had developed RD during or after systemic treatment with or without local focal consolidation treatment were included in the study. The time interval between the type of treatment of Rb, development of RD and relevant surgical intervention were analyzed. Patients with exudative RD were treated conservatively through observation and patients with rhegmatogenous RD were treated with scleral buckling. Final anatomical retinal reattachment rate and visual acuity outcomes were analyzed. RESULTS: A total of 258 patients were treated for Rb over the 10-year period. One hundred sixty-nine patients were managed with globe conserving treatment. Ten (5.92%) eyes of 10 patients were complicated with RD. Five eyes were exudative or presumed exudative type of RD while the other five eyes were rhegmatogenous or presumed rhegmatogenous RD. In the exudative group, two patients achieved visual acuity (VA) of 0.2 Single Kays (20/32 Snellen), and the other two patients achieved 0.85 and 0.86 Crowded Kays (20/142 and 20/145 Snellen), respectively, after the RD had resolved. The last patient in the group had to be enucleated due to tumor recurrences. The median time for the exudative RD to resolve is 15 weeks (range, 4-36 weeks). In the rhegmatogenous group, 3 of the 4 operated patients achieved retinal reattachment. The final postoperative VA ranged between 0.05 Crowded Kays to 1.84 Crowded Kays (20/22 to 20/1384 Snellen). The other patient was treated conservatively as no retinal breaks were found with previous cryotherapy and thermotherapy. The final VA in this patient was hand movement, and the RD did not reattach. The median time for the rhegmatogenous RD to reattach is 6 weeks (range, 4-8 weeks). There were no intra- and postoperative complications. CONCLUSIONS: With long-term conservative management through observation, exudative Rb after systemic treatment of Rb will tend to resolve by itself. However, supplementary local treatment with cryoretinopexy or laser photocoagulation during the systemic treatment of Rb can lead to an increased risk of rhegmatogenous RD. In these cases, most rhegmatogenous RD are successfully repaired with non-drainage scleral buckling and cryoretinopexy.

Intravitreal Fluocinolone Acetonide (ILUVIEN) Implant for the Treatment of Refractory Cystoid Macular Oedema After Retinal Detachment Repair.

Cystoid macular oedema (CMO) is one of the most frequent postoperative macular complications to cause partial visual recovery after successful retinal detachment (RD) repair. Refractory CMO is difficult to treat and many strategies have been employed with varying degrees of success. We report for the first time the use of ILUVIEN implant to treat refractory CMO after successful RD repair. A 65-year-old female presented with right eye full-thickness macular hole and underwent pars plana vitrectomy, internal limiting membrane peeling and cryotherapy with gas tamponade with 12% C3F8. She subsequently developed right eye macula-on RD and proliferative vitreoretinopathy and required multiple procedures for successful retinal reattachment. Later, she developed CMO that responded to intravitreal triamcinolone injections and intravitreal dexamethasone 0.7-mg implants but recurrence of CMO continued to be a problem. After receiving ILUVIEN intravitreal implant, her visual acuity improved and CMO resolved without recurrence for 13 months. Refractory CMO after RD repair is difficult to treat and in a quarter of cases will not improve without treatment. Our case shows that a single ILUVIEN implant maintained anatomical dry fovea and improved vision. This also demonstrates that ILUVIEN is an effective management strategy to reduce the need for repeated treatments.

Long-term refractive stability following combined astigmatic keratotomy and phakoemulsification.

BACKGROUND: To determine whether combined astigmatic keratotomy and cataract surgery induces a sustained reduction in astigmatism. METHODS: Patients who had previously undergone combined cataract surgery and astigmatic keratotomy for naturally occurring astigmatism were identified and their notes reviewed. Mean final follow-up was 34 months (30-42 months). Fourteen eyes of 11 patients were eligible for study. Arcuate corneal incisions had been employed using the Buzard nomogram. Using power vector analysis, the post-operative refractive change at 6 months and final follow-up was determined. RESULTS: The mean preoperative manifest cylindrical refractive error was 2.88 D (1.50-5.50 D). The mean postoperative manifest cylindrical refractive error was 1.89 and 1.79 D at 6 months and final follow-up, respectively. Power vector analysis demonstrated a significant postoperative reduction in refractive blur at 6 months and final follow-up (P = 0.006, P = 0.004, respectively): mean preoperative blur strength was 2.90 D and mean postoperative blur strength was 1.33 and 1.25 D at 6 months and final follow-up, respectively. Sustained postoperative reduction in astigmatism was noted in 12 of 14 eyes at final follow-up. CONCLUSIONS: Astigmatic keratotomy is a well-established treatment for astigmatism. In this series, the refractive benefit from combined astigmatic keratotomy and cataract surgery is maintained for several years. No surgical complications were observed.

Periocular pseudo-rheumatoid nodules commonly affect the orbital rim.

PURPOSE: To describe the typical presenting clinical characteristics and histopathology for periocular pseudo-rheumatoid nodules. METHODS: Clinical case-note and histopathological review for patients presenting to the Orbital Clinic at Moorfields Eye Hospital between 1994 and 2002. RESULTS: Four females with biopsy-proven periocular pseudo-rheumatoid nodules presented between the ages of 22 and 33 years (mean 26.8 years), having a 4-month to 3-year history of newly formed (or recurrent) subcutaneous nodules-these overlying the superotemporal orbital rim and rarely tender. One patient had insulin-dependent diabetes for 22 years and one patient had bilateral disease. The masses were excised in all patients, with a minor recurrence in one, not requiring further treatment; one patient defaulted from follow-up. CONCLUSIONS: Periocular pseudo-rheumatoid nodules appear to typically present in young females, possibly more commonly with type I diabetes mellitus, and form a rather characteristic slowly growing, firm, occasionally slightly tender, subdermal nodule overlying the superolateral rim of the orbit. Surgical excision improves the condition in many cases, although spontaneous regression might also occur.

Vitrectomy-phacoemulsification-vitrectomy for the management of aqueous misdirection syndromes in phakic eyes.

OBJECTIVE: To describe vitrectomy-phacoemulsification-vitrectomy, a sequential 3-step surgical approach, in the management of malignant glaucoma/aqueous misdirection syndromes in phakic eyes. DESIGN: Retrospective, noncomparative, interventional case series. PARTICIPANTS: Five eyes (4 angle-closure glaucoma and 1 open-angle glaucoma) of 5 patients with mean age of 66 years (range, 56-78). Four patients presented with aqueous misdirection syndrome and 1 patient presented for cataract extraction, having previously had malignant glaucoma in the fellow eye after phacoemulsification surgery. INTERVENTION: The operation performed had three steps: vitrectomy, phacoemulsification, and vitrectomy. Step 1: Preliminary vitrectomy involved limited core vitrectomy to "debulk" the vitreous and soften the eye. Step 2: Phacoemulsification was performed in a standard manner. Step 3: Residual vitrectomy, zonulohyaloidectomy and peripheral iridectomy (if not already present) were performed to create a free communication between the posterior and anterior segments. MAIN OUTCOME MEASURES: Intraocular pressure, visual acuity, biomicroscopic anterior chamber depth, and complications. RESULTS: The time interval between the onset of malignant glaucoma and surgery ranged from 2 weeks to 3 months. All 4 patients with aqueous misdirection syndrome had relief of the aqueous misdirection postoperatively with anterior chamber deepening. Intraocular pressures on day 1 ranged from 6 to 28 mmHg (mean 15.6, mmHg), and at the last visit ranged from 8 to 30 mmHg (mean, 20.4 mmHg). One eye developed an early choroidal serosanguinous effusion requiring drainage. CONCLUSIONS: The vitrectomy-phacoemulsification-vitrectomy approach was effective in this pilot series in the management of aqueous misdirection syndromes and malignant glaucoma in phakic eyes.

Pooled cataract waiting lists: views of hospital consultants, general practitioners and patients.

In the National Health Service general practitioners (GPs) usually refer patients to named consultants; thus, waiting times for a particular procedure can vary greatly even within a single centre. An alternative is to pool the waiting list, with patients treated in turn by the consultant available. We sought opinions on this strategy, from patients, GPs, and consultants, in relation to cataract surgery. Questionnaires were sent to 776 consultant ophthalmologists; telephone interviews were conducted with 50 randomly selected Birmingham GPs; and 85 Birmingham patients listed for cataract surgery were asked whether they would change consultant to be operated on sooner. 503 (64%) of the consultants responded. Of consultants, 30% favoured pooled lists and 67% were against. Of patients, 82% favoured pooled lists and 18% were against. Of GPs, 92% favoured pooled lists and 8% were against. Some consultants thought that pooled lists were suitable for routine cases but not for more complex cases. 82% of patients expressed willingness to change consultant in order to get an earlier operation. In units with surgeons whose cataract-surgery practices are similar, pooled lists are one way to maximize theatre use and equalize waiting times for routine cases. The model could be applied to other routine surgical procedures such as hip replacement, herniorrhaphy and prostatectomy.