Fluid-Fluid Exchange and External Needle Drainage with Minimal Gas Vitrectomy Associated with Retinal Displacement.

PURPOSE: To determine if fluid-fluid exchange (endo-drainage) or external needle drainage can result in retinal displacement following minimal gas vitrectomy (MGV) with no fluid-air exchange for rhegmatogenous retinal detachment (RRD) repair. METHODS: Two patients with macula off RRD underwent MGV with and without segmental buckle. First case had minimal gas vitrectomy with segmental buckle (MGV-SB), along with endo-drainage, while the second case had MGV only with external fluid drainage. At the completion of surgery, the patient was immediately log rolled to face down for 6 hours followed by positioning to the break. RESULTS: Both patients achieved retinal reattachment and post-operative wide-field fundus autofluorescence imaging demonstrated a low integrity retinal attachment (LIRA) with retinal displacement. CONCLUSIONS: Iatrogenic fluid drainage techniques such as fluid-fluid exchange or external needle drainage during MGV (without fluid-air exchange) may result in retinal displacement. Allowing the retinal pigment epithelial pump to reabsorb the fluid naturally may reduce the risk of retinal displacement.

Pathophysiology of outer retinal corrugations: Imaging dataset and mechanical models.

This article presents high-resolution swept-source optical coherence tomography (SS-OCT) imaging data used to elaborate a mechanical model that elucidates the formation of outer retinal corrugations (ORCs) in rhegmatogenous retinal detachments (RRD). The imaging data shared in the repository and presented in this article is related to the research paper entitled "Outer Retinal Corrugations in Rhegmatogenous Retinal Detachment: The Retinal Pigment Epithelium-Photoreceptor Dysregulation Theory" (Muni et al., AJO, 2022). The dataset consists of 69 baseline cross-sectional SS-OCT scans from 66 patients that were assessed for the presence of ORCs and analyzed considering the clinical features of each case. From the 66 cases, we selected SS-OCT images of 4 RRD patients with visible ORCs and no cystoid macular edema (CME) to validate the mechanical model. We modelled the retina as a composite material consisting of the outer retinal layer (photoreceptor layer) and the inner retinal layer (the part of the retina that excludes the photoreceptor layer) with thicknesses T o and T i and elastic modulus E o and E i , respectively. The thickness of the outer and inner retinal layers and the relative increase in the length of the outer retinal layer (γ) were measured from the SS-OCT images. Measurements from the SS-OCT images of patients with RRD demonstrated a 30% increase (γ=0.3) in the length of the outer retinal layer and a 400% increase in the thickness of the outer retinal layer (To). Using the mathematical model, Eo/Ei ranged between 0.05 to 0.5 to result in ORCs with a similar frequency to those observed in the SS-OCT scans.

En Face OCT in Diagnosis of Persistent Subretinal Fluid and Outer Retinal Folds after Rhegmatogenous Retinal Detachment Repair.

PURPOSE: To evaluate the role of en face OCT as a diagnostic tool for the detection of persistent subretinal fluid (PSRF) and outer retinal folds (ORFs) after successful rhegmatogenous retinal detachment (RRD) repair. DESIGN: Observational post hoc analysis of 2 prospective surgical trials. PARTICIPANTS: All patients with gradable (signal strength ≥ 5 and no segmentation error) 6 × 6-mm2 macular cube scans obtained using spectral-domain OCT (Carl Zeiss Meditec) between 1 and 2 months after surgery were included in this study. METHODS: The scans were assessed for the presence or absence of PSRF or ORFs using en face OCT and cross-sectional B scans by 2 masked graders, with any disagreements adjudicated by a third senior masked grader. MAIN OUTCOME MEASURES: The sensitivity, specificity, and predictive accuracy (using area under the curve [AUC]) of en face OCT were compared with those of cross-sectional OCT, which is considered the gold standard. RESULTS: Two hundred twenty-three patients were included in this study. The Cohen kappa between the graders in the diagnosis of PSRF and ORFs using en face OCT was 0.84 and 0.86, respectively. The sensitivity of en face OCT was 100% (95% confidence interval [CI], 100%-100%) in the diagnosis of PSRF and 98.8% (95% CI, 96.5%-101.1%) in the diagnosis of ORFs. Similarly, the specificity of en face OCT was 98.7% (95% CI, 96.8%-100.5%) and 84.2% (95% CI, 78.1%-90.2%) in the diagnosis of PSRF and ORFs, respectively. The AUC was 0.99 for PSRF and 0.91 for ORFs. CONCLUSIONS: En face OCT has good sensitivity, specificity, and predictive accuracy (using AUC) in the diagnosis of PSRF and ORFs. En face OCT is an efficient screening tool for postoperative anatomic abnormalities, such as PSRF and ORFs, after RRD repair. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Morphologic Stages of Rhegmatogenous Retinal Detachment Assessed Using Swept-Source OCT.

PURPOSE: To describe the sequential morphologic changes after rhegmatogenous retinal detachment (RRD) utilizing a novel, objective, and clinically relevant staging system based on swept-source OCT (SS-OCT) and determine its association with the duration of fovea-off and postoperative visual acuity (VA). DESIGN: Prospective cohort study. SUBJECTS: Consecutive patients with primary fovea-involving RRD referred to St. Michael's Hospital, Toronto, Canada, from January 2020 to April 2022. METHODS: All patients underwent SS-OCT and ultrawide-field SS-OCT at baseline. Primary RRDs with breaks above the 8- and 4-o'clock meridians were included. Patients with vision loss for ≥ 3 months, proliferative vitreoretinopathy grade C or worse, a demarcation line, previous vitrectomy, or other retinal pathology were excluded. The staging was based on an assessment of outer retinal morphology on successive SS-OCT scans from the peripheral break to the most posterior aspect of the RRD, following its direction of progression. MAIN OUTCOME MEASURES: Sequential outer retinal morphologic changes observed using SS-OCT and associated VA at 3 months after surgery. RESULTS: Forty-nine eyes were included. The mean age (standard deviation [SD]) was 61.2 (15.2) years. The mean presenting logarithm of the minimum angle of resolution (SD) acuity was 1.09 (0.75). All stages observed on a high-definition horizontal 51-line scan were reported. Outer retinal changes occurred in 5 stages: (1) separation of the neurosensory retina from the retinal pigment epithelium (42/49, 85.7%); (2) thickening of inner and outer segments of photoreceptors (45/49, 91.8%); (3) outer retinal corrugation formation: (3a) low-frequency (44/49, 93.6%) and (3b) high-frequency outer retinal corrugations (42/49, 85.7%); (4) loss of the definition of outer retinal corrugations, with concurrent thickening of inner and outer segments (26/49, 53.1%); and (5) patchy (moth-eaten) or complete loss of inner and outer segments (17/49, 34.7%). The mean duration of fovea-off by stage in the parafovea (SD) was 2 (1.4), 2.3 (1.2), 11.4 (8.1), and 12 (13.3) days for stages 3a, 3b, 4, and 5, respectively. There was a statistically significant association between increasing stage of RRD and longer duration of foveal involvement (P = 0.001) and, most importantly, between increasing stage and worse VA at 3 months after surgery (P = 0.011). CONCLUSIONS: This novel staging system describes the sequential morphologic changes in RRD using SS-OCT. Increasing stage of RRD was associated with worse VA at 3 months after surgery. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

IMMEDIATE SUBRETINAL FLUID DISPLACEMENT FROM THE BUOYANT FORCE OF A SMALL GAS BUBBLE IN PNEUMATIC RETINOPEXY: INSIGHTS INTO THE POTENTIAL MECHANISM OF RETINAL DISPLACEMENT AFTER RETINAL DETACHMENT REPAIR.

PURPOSE: To demonstrate how a small gas bubble injected into the vitreous cavity in pneumatic retinopexy for rhegmatogenous retinal detachment causes immediate displacement of subretinal fluid and to gain insights into the potential mechanism of retinal displacement. METHODS: Three patients with rhegmatogenous retinal detachment who underwent pneumatic retinopexy were enrolled and prospectively followed. All patients underwent ultra-widefield fundus photography at baseline and at 1 to 2 minutes after intravitreal gas injection. RESULTS: In all cases, the ultra-widefield fundus photograph demonstrated immediate displacement of subretinal fluid, suggesting that the buoyant force applied to the retina by the bubble was responsible for the displacement of subretinal fluid. The results were extrapolated to determine the buoyant force applied by a small and large gas bubble as in pneumatic retinopexy and pars plana vitrectomy. We determined that the buoyant force applied with a larger bubble in pars plana vitrectomy was substantially greater, and this may lead to retinal displacement. CONCLUSION: Intravitreal gas applies significant buoyant force to the detached retina and subretinal fluid that leads to substantial and rapid displacement of subretinal fluid. Understanding the affect of the buoyant force of the gas bubble on the detached retina can provide insight into possible mechanisms of retinal displacement.

MINIMAL GAS VITRECTOMY WITH SCLERAL BUCKLE TO MINIMIZE RETINAL DISPLACEMENT IN RHEGMATOGENOUS RETINAL DETACHMENT WITH INFERIOR BREAKS.

PURPOSE: To present a novel technique, minimal gas vitrectomy with scleral buckle, as a means of potentially minimizing retinal displacement compared with standard vitrectomy or vitrectomy/scleral buckle for select cases. METHODS: A patient with right macula-off retinal detachment and retinal breaks at 7 o'clock and 10 o'clock underwent a 23-gauge pars plana vitrectomy, localization, and cryopexy of the breaks along with an inferior temporal segmental scleral buckle. No air-fluid exchange was performed. Suturing of sclerotomies, anterior chamber paracentesis of 0.3 mL, and intravitreal injection of 0.6 mL pure sulfur hexafluoride were then performed. The patient was advised to perform the steamroller maneuver with initial face-down positioning for 6 hours. RESULTS: The patient achieved retinal reattachment, and postoperative wide-field fundus autofluorescence imaging demonstrated high-integrity retinal attachment with no retinal displacement. CONCLUSION: The minimal gas vitrectomy with scleral buckle technique has the potential to minimize retinal displacement in cases with inferior break(s) by using a small volume expansile gas tamponade and localized scleral buckle compared with standard vitrectomy or vitrectomy/scleral buckle with a full gas fill.

A paradigm shift in retinal detachment repair: The concept of integrity.

The management of rhegmatogenous retinal detachment has rapidly evolved over recent decades. A range of surgical techniques exist, all of which can achieve retinal reattachment in most cases. In recent years there have also been vast technical advances in retinal imaging that have introduced novel ways of visualizing and studying the retinal macro and microstructural anatomy following retinal detachment repair. Recent clinical trial data demonstrates that functional and patient-reported outcomes of retinal reattachment differ with surgical technique, accompanied by differences in anatomic biomarkers of retinal recovery or 'integrity'. We discuss recent insights into the physiology of retinal reattachment gleaned from multimodal imaging, which shed light on the pathophysiology of various post-operative anatomic abnormalities. The ideal scenario is to achieve retinal reattachment as soon as possible, without retinal displacement, outer retinal folds or discontinuity of the external limiting membrane, ellipsoid zone and interdigitation zone, with an intact foveal bulge. To this end, we present an in-depth contemporary account of current concepts and mechanisms involved during retinal reattachment surgery, supported by clinical data and mathematical modelling, awareness of which can help the vitreoretinal surgeon achieve better post-operative outcomes. In this review we substantiate the case for a paradigm shift in rhegmatogenous retinal detachment repair; beyond the emphasis on single-operation reattachment rates, and instead striving to maximize functional outcomes using minimally invasive techniques. This can only be achieved if vitreoretinal surgeons embrace all of the available techniques, with individualized selection of surgical approach and the resolute goal of optimizing the 'integrity' of retinal reattachment.

Pneumatic retinopexy as a treatment for rhegmatogenous retinal detachment in pediatric patients meeting PIVOT criteria.

OBJECTIVE: To report the results of pneumatic retinopexy (PnR) as the initial treatment in pediatric patients with rhegmatogenous retinal detachment (RRD) fulfilling The Pneumatic Retinopexy versus Vitrectomy for the Management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial (PIVOT) criteria. DESIGN: A retrospective multicentre study. PARTICIPANTS: Pediatric patients who underwent outpatient PnR as the initial treatment for RRD from January 2006 to July 2019 who met PIVOT criteria. METHODS: Patients underwent anterior chamber paracentesis followed by intravitreal injection of sulfur hexafluoride (SF6) gas. Either laser retinopexy was performed following retinal reattachment or cryopexy was performed at the time of the initial procedure. RESULTS: A total of 20 eyes of 20 consecutive patients met inclusion criteria and were included in this study. Mean (± standard deviation [SD]) follow-up time was 42.2 ± 38.0 months. Mean patient age was 14.4 years (range, 9-18). There were 17 males and 3 females. The mean (± SD) logMar visual acuity improved from 0.73 ± 0.82 (Snellen equivalent approximately 20/100) to 0.37 ± 0.46 (Snellen equivalent approximately 20/50; p = 0.02) at 3 months and to 0.40 ± 0.54 (Snellen equivalent approximately 20/50; p = 0.05) at last follow-up. Primary reattachment rate was 85% (17/20) at 3 months and 75% (15/20) at last follow-up visit. CONCLUSIONS: PnR may be an effective treatment option for RRD in pediatric patients meeting PIVOT criteria.

Real-Time In Vivo Assessment of Retinal Reattachment in Humans Using Swept-Source Optical Coherence Tomography.

PURPOSE: To assess the in vivo physiology of retinal reattachment in humans using swept-source optical coherence tomography (SS-OCT) in real time. DESIGN: Prospective case series. METHODS: Fifteen consecutive patients with fovea-involving rhegmatogenous retinal detachment were undergoing pneumatic retinopexy. SS-OCT was performed at presentation and frequent intervals immediately after pneumatic retinopexy. The primary outcome was longitudinal assessment of early postoperative SS-OCT to establish stages of reattachment. RESULTS: Most patients (93.3%, 14/15) achieved successful reattachment at the median follow-up duration of 13 weeks (interquartile range 7.5-18.0). Reattachment occurred in 5 specific stages: 1) redistribution of fluid and approach of the neurosensory retina toward the retinal pigment epithelium occurred in 100% (15/15); 2) reduction in cystoid macular edema and improvement of outer retinal corrugations was achieved in 100% (15/15); 3) initial contact of the neurosensory retina to the retinal pigment epithelium occurred completely in 66.7% (10/15); 4) deturgescence of the inner and outer segments of the photoreceptors occurred in 66.7% (10/15); and 5) recovery of photoreceptor integrity occurred in 3 specific substages: 5A) external limiting membrane recovery (10/15, 66.6%); 5B) ellipsoid zone recovery (9/15, 60%); and 5C) interdigitation zone/foveal bulge recovery (3/15, 20%). Twenty percent (3/15) had delayed progression through stage 2, characterized by formation of outer retinal folds. Similarly, 33.3% (5/15) developed residual subfoveal fluid blebs (delayed progression to stage 3). CONCLUSIONS: This study characterizes the in vivo physiology of retinal reattachment in humans using high-resolution SS-OCT that occurs in 5 specific stages. Delayed progression through certain stages was characterized by postoperative anatomic abnormalities. Am J Ophthalmol 2021;221:•••-•••. © 2021 Elsevier Inc. All rights reserved.

The Productivity Requirements of Implementing a Medical Scribe Program.

BACKGROUND: Economic analyses of medical scribes have been limited to individual, specialty-specific clinics. OBJECTIVE: To determine the number of additional patient visits various specialties would need to recover the costs of implementing scribes in their practice at 1 year. DESIGN: Modeling study based on 2015 data from the Centers for Medicare & Medicaid Services (CMS) and National Ambulatory Medical Care Survey. Scribe costs were based on literature review and a third-party contractor model. Revenue was calculated from direct visit billing, CPT (Current Procedural Terminology) billing, and data from the National Ambulatory Medical Care Survey. DATA SOURCES: 2015 data from CMS and the National Ambulatory Medical Care Survey. TARGET POPULATION: Health care providers. TIME HORIZON: 1 year. PERSPECTIVE: Office-based clinic. OUTCOME MEASURES: The number of additional patient visits a physician must have to recover the costs of a scribe program at 1 year. RESULTS OF BASE-CASE ANALYSIS: An average of 1.34 additional new patient visits per day (295 per year) were required to recover scribe costs (range, 0.89 [cardiology] to 1.80 [orthopedic surgery] new patient visits per day). For returning patients, an average of 2.15 additional visits per day (472 per year) were required (range, 1.65 [cardiology] to 2.78 [orthopedic surgery] returning visits per day). The addition of 2 new patient (or 3 returning) visits per day was profitable for all specialties. RESULTS OF SENSITIVITY ANALYSIS: Results were not sensitive to most inputs, with the exception of hourly scribe cost and inclusion of CPT revenue. LIMITATION: Use of Medicare data and failure to account for indirect costs, downstream revenue, or changes in documentation quality. CONCLUSION: For all specialties, modest increases in productivity due to scribes may allow physicians to see more patients and offset scribe costs, making scribe programs revenue-neutral. PRIMARY FUNDING SOURCE: University of Chicago Medicine's Center for Healthcare Delivery Science and Innovation and the Bucksbaum Institute.

Hyperbaric Oxygen Therapy for Large Composite Grafts: An Alternative in Pediatric Facial Reconstruction.

BACKGROUND: Management of pediatric facial defects can be challenging, as reattachment of large composite grafts is usually unsuccessful. Hyperbaric oxygen therapy (HBO) has been researched to augment composite graft survival, but clinical use for this application remains anecdotal. The authors present their successful experience managing select cases with large composite grafts and HBO as an adjunct. METHODS: A retrospective chart review identified children presenting with facial defects and managed operatively with large composite grafts (≥1.5 × 1.5 cm) and HBO therapy. Records were reviewed for defect characteristics, management details, and outcomes at last follow-up. RESULTS: Nine children (avg. 8.4 years, range 1.6-15.1) presented with ear or nose defects secondary to dog bites (n=7), falls (n=1), or congenital causes (n=1). Three experienced ear amputations, and six suffered nasal avulsions of varying degrees. All avulsed ears were reattached. Three cases of nose avulsions were reattached; the other three underwent secondary reconstruction with composite ear grafts. HBO was initiated immediately and continued for 8-10 days. All grafts survived at least 80% with no postoperative complications. At last follow-up (avg. 30.1 months; 0.8-63.9), all patients demonstrated good cosmetic results with minimal residual deformity. CONCLUSION: When reconstruction of pediatric facial defects warrants a large chondrocutaneous graft, immediate postoperative HBO therapy can increase survival. Particularly when reattaching amputated segments, if successful, this approach offers an anatomically ideal result without donor site morbidity. If unsuccessful, it does not "burn bridges" and decreases the extent of secondary reconstruction. The authors present their HBO protocol along with a review of available literature.

Childhood leukemia survivors exhibit deficiencies in sensory and cognitive processes, as reflected by event-related brain potentials after completion of curative chemotherapy: A preliminary investigation.

Objective: The purpose of this study was to characterize post-chemotherapy sensory, memory, and attention abilities in childhood survivors of acute lymphoblastic leukemia (ALL) to better understand how treatment affects cognitive functioning. Methods: Eight ALL survivors and eight age-matched, healthy children between the ages of 5-11 years participated in the study. Among the ALL survivors, a median of 63 days (range 22-267 days) elapsed between completion of chemotherapy and this assessment. Sounds were presented in an oddball paradigm while recording the electroencephalogram in separate conditions of passive listening and active task performance. To assess different domains of cognition, we measured event-related brain potentials (ERPs) reflecting sensory processing (P1 component), working memory (mismatch negativity [MMN] component), attentional orienting (P3a), and target detection (P3b component) in response to the sounds. We also measured sound discrimination and response speed performance. Results: Relative to control subjects, ALL survivors had poorer performance on auditory tasks, as well as decreased amplitude of the P1, MMN, P3a, and P3b components. ALL survivors also did not exhibit the amplitude gain typically observed in the sensory P1 component when attending to the sound input compared to when passively listening. Conclusions: Atypical responses were observed in brain processes associated with sensory discrimination, auditory working memory, and attentional control in pediatric ALL survivors indicating deficiencies in all cognitive domains compared to age-matched controls. Significance: ERPs differentiated aspects of cognitive functioning, which may provide a useful tool for assessing recovery and risk of post-chemotherapy cognitive deficiencies in young children. The decreased MMN amplitude in ALL survivors may indicate (N-methyl D-aspartate) NMDA dysfunction induced by methotrexate, and thus provides a potential therapeutic target for chemotherapy-associated cognitive impairments.

Development of a structured year-end sign-out program in an outpatient continuity practice.

BACKGROUND: In an effort to prevent medical errors, it has been recommended that all healthcare organizations implement a standardized approach to communicating patient information during transitions of care between providers. Most research on these transitions has been conducted in the inpatient setting, with relatively few studies conducted in the outpatient setting. OBJECTIVES: To develop a structured transfer of care program in an academic outpatient continuity practice and evaluate whether this program improved patient safety as measured by the documented completion of patient care tasks at 3 months post-transition. DESIGN: Graduating residents and the corresponding incoming interns inheriting their continuity patient panels were randomized to the pilot structured transfer group or the standard transfer group. The structured transfer group residents were asked to complete written and verbal sign-outs with their interns; the standard transfer group residents continued the current standard of care. PARTICIPANTS: Thirty-two resident-intern pairs in an academic internal medicine residency program in New York City. MAIN MEASURES: Three months after the transition, study investigators evaluated whether patient care tasks assigned by the graduating residents had been successfully completed by the interns in both groups. In addition, follow-up appointments, continuity of care and house officer satisfaction with the sign-out process were evaluated. KEY RESULTS: Among patients seen during the first 3 months, the clinical care tasks were more likely to be completed by interns in the structured group (73 %, n = 49) versus the standard group (46 %, n = 28) (adjusted OR 3.21; 95 % CI 1.55-6.62; p = 0.002). This was further enhanced if the intern who saw the patient was also the assigned primary care provider (adjusted OR 4.26; 95 % CI 1.7-10.63; p = 0.002). CONCLUSIONS: A structured outpatient sign-out improved the odds of follow-up of important clinical care tasks after the year-end resident clinic transition. Further efforts should be made to improve residents' competency with regard to sign-outs in the ambulatory setting.

In vivo, Pikfyve generates PI(3,5)P2, which serves as both a signaling lipid and the major precursor for PI5P.

Mutations that cause defects in levels of the signaling lipid phosphatidylinositol 3,5-bisphosphate [PI(3,5)P(2)] lead to profound neurodegeneration in mice. Moreover, mutations in human FIG4 predicted to lower PI(3,5)P(2) levels underlie Charcot-Marie-Tooth type 4J neuropathy and are present in selected cases of amyotrophic lateral sclerosis. In yeast and mammals, PI(3,5)P(2) is generated by a protein complex that includes the lipid kinase Fab1/Pikfyve, the scaffolding protein Vac14, and the lipid phosphatase Fig4. Fibroblasts cultured from Vac14(-/-) and Fig4(-/-) mouse mutants have a 50% reduction in the levels of PI(3,5)P(2), suggesting that there may be PIKfyve-independent pathways that generate this lipid. Here, we characterize a Pikfyve gene-trap mouse (Pikfyve(ß-geo/ß-geo)), a hypomorph with ~10% of the normal level of Pikfyve protein. shRNA silencing of the residual Pikfyve transcript in fibroblasts demonstrated that Pikfyve is required to generate all of the PI(3,5)P(2) pool. Surprisingly, Pikfyve also is responsible for nearly all of the phosphatidylinositol-5-phosphate (PI5P) pool. We show that PI5P is generated directly from PI(3,5)P(2), likely via 3'-phosphatase activity. Analysis of tissues from the Pikfyve(ß-geo/ß-geo) mouse mutants reveals that Pikfyve is critical in neural tissues, heart, lung, kidney, thymus, and spleen. Thus, PI(3,5)P(2) and PI5P have major roles in multiple organs. Understanding the regulation of these lipids may provide insights into therapies for multiple diseases.