A randomised controlled trial of adjunctive triamcinolone acetonide in eyes undergoing vitreoretinal surgery for open globe trauma - the ASCOT study.

Background: Eyes sustaining open globe trauma are at high risk of severe visual impairment. Proliferative vitreoretinopathy is the most common cause of retinal detachment and visual loss in eyes with open globe trauma. There is evidence from experimental studies and pilot clinical trials that the use of adjunctive steroid medication triamcinolone acetonide can reduce the incidence of proliferative vitreoretinopathy and improve outcomes of surgery for open globe trauma. Objective: The Adjunctive Steroid Combination in Ocular Trauma or ASCOT study aimed to investigate the clinical effectiveness of adjunctive triamcinolone acetonide given at the time of vitreoretinal surgery for open globe trauma. Design: A phase 3 multicentre double-masked randomised controlled trial randomising patients undergoing vitrectomy following open globe trauma to either adjunctive triamcinolone acetonide or standard care. Setting: Hospital vitreoretinal surgical services dealing with open globe trauma. Participants: Patients undergoing vitrectomy surgery who had sustained open globe trauma. Interventions: Triamcinolone acetonide 4 mg/0.1 ml into the vitreous cavity and 40 mg/1 ml sub-Tenon's or standard vitreoretinal surgery and postoperative care. Main outcome measures: The primary outcome was the proportion of patients with at least 10 letters of improvement in corrected visual acuity at six months. Secondary outcomes included retinal detachment secondary to proliferative vitreoretinopathy, retinal reattachment, macula reattachment, tractional retinal detachment, number of operations, hypotony, elevated intraocular pressure and quality of life. Health-related quality of life was assessed using the EuroQol Five Domain and Visual Function Questionnaire 25 questionnaires. Results: A total of 280 patients were randomised; 129 were analysed from the control group and 130 from the treatment group. The treatment group appeared, by chance, to have more severe pathology on presentation. The primary outcome (improvement in visual acuity) and principal secondary outcome (change in visual acuity) did not demonstrate any treatment benefit for triamcinolone acetonide. The proportion of patients with improvement in visual acuity was 47% for triamcinolone acetonide and 43% for standard care (odds ratio 1.03, 95% confidence interval 0.61 to 1.75, p = 0.908); the baseline adjusted mean difference in the six-month change in visual acuity was -2.65 (95% confidence interval -9.22 to 3.92, p = 0.430) for triamcinolone acetonide relative to control. Similarly, the secondary outcome measures failed to show any treatment benefit. For two of the secondary outcome measures, stable complete retinal reattachment and stable macular retinal reattachment, outcomes for the treatment group were significantly worse for triamcinolone acetonide at the 5% level (respectively, odds ratio 0.59, 95% confidence interval 0.36 to 0.99, p = 0.044 and odds ratio 0.59, 95% confidence interval 0.35 to 0.98, p = 0.041) compared with control in favour of control. The cost of the intervention was £132 per patient. Health economics outcome measures (Early Treatment Diabetic Retinopathy Study, Visual Function Questionnaire 25 and EuroQol Five Dimensions) did not demonstrate any significant difference in quality-adjusted life-years. Conclusions: The use of combined intraocular and sub-Tenon's capsule triamcinolone acetonide is not recommended as an adjunct to vitrectomy surgery for intraocular trauma. Secondary outcome measures are suggestive of a negative effect of the adjunct, although the treatment group appeared to have more severe pathology on presentation. Future work: The use of alternative adjunctive medications in cases undergoing surgery for open globe trauma should be investigated. Refinement of clinical grading and case selection will enable better trail design for future studies. Trial registration: This trial is registered as ISRCTN 30012492, EudraCT number 2014-002193-37, REC 14/LNO/1428, IRAS 156358, Local R&D registration CHAD 1031. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (12/35/64) and will be published in full in Health Technology Assessment; Vol. 27, No. 12. See the NIHR Journals Library website for further project information.

Despite advances in surgical techniques, eye trauma remains a leading cause of blindness and visual impairment. The main cause of trauma is a scarring process within the eye ­ proliferative vitreoretinopathy. There is good evidence from laboratory work and small-scale clinical studies that the addition of a steroid medication, triamcinolone acetonide, given in and around the eye at the time of surgery for eye trauma, can reduce the incidence of proliferative vitreoretinopathy scarring and improve the outcomes of surgery. The Adjunctive Steroid Combination in Ocular Trauma or ASCOT study was a multicentre clinical trial designed to test the use of triamcinolone acetonide as an addition to surgery to improve outcomes in eyes with 'open globe' penetrating injuries. A total of 280 patients were recruited and randomised to receive standard surgery or surgery with the additional steroid (triamcinolone acetonide). No benefit was found from the addition of the steroid medication. The addition of steroid medication was not good value for money. Secondary outcome measures suggested that triamcinolone acetonide may have had a negative effect on outcomes, although this may have been due to the presence of more severe cases amongst the patients allocated to receive the additional steroid (triamcinolone acetonide). The use of adjunctive triamcinolone acetonide in eye trauma cases undergoing surgery is therefore not recommended. Future studies with different additional medications and/or more targeted case selection are indicated to improve outcomes for eyes experiencing penetrating trauma.

Diagnostic value of lumbar puncture for the etiological assessment of uveitis: a retrospective cohort of 188 patients.

AIM: To assess the relevance of lumbar puncture (LP) for the etiological diagnosis of uveitis and to establish predictive factors associated with its contributory use. METHODS: We performed a retrospective study of patients with de novo uveitis who were referred to our tertiary hospital for etiological diagnosis of uveitis, between January 2003 and July 2018. We included patients who underwent a LP as part of the etiological assessment of uveitis. LP was considered as contributory if it led to the etiological diagnosis or to correct the initially suspected diagnosis. RESULTS: One hundred eighty eight of the 1211 patients referred for evaluation (16%) had an LP, among these patients, 93 (49.4%) had abnormal results including 69 (36.7%) patients with hypercellularity, 69 (36.7%) with hyperproteinorachia, and 28 (14.9%) with oligoclonal bands and/or increased IgG index. LP was considered as contributing to the diagnosis in only 31 (16.4%) cases, among which there were 10 (5.3%) contributions to the etiological diagnosis and 21 (11.2%) modifications in the diagnosis classification. Multivariate analysis established that African ethnicity (p < 0.001), bilateral uveitis (p = 0.01), presence of macular edema or retinal serous detachment (p = 0.048), presence of retinal vasculitis (p < 0.001), presence of neurological signs or symptoms (p = 0.01), and contributing cerebral MRI (p < 0.001) were all significantly associated with a contributory LP. LP did not lead to any therapeutic modification. CONCLUSION: LP direct contribution to the diagnosis was rare and most often detected non-specific abnormalities. LP should be performed only in cases of neurological clinical signs or symptoms, suspicion of multiple sclerosis, Vogt-Koyanagi-Harada, or syphilis.

The clinical effectiveness and safety of prophylactic retinal interventions to reduce the risk of retinal detachment and subsequent vision loss in adults and children with Stickler syndrome: a systematic review.

BACKGROUND: Stickler syndrome, also known as hereditary progressive arthro-ophthalmopathy, is an inherited progressive disorder of the collagen connective tissues. Manifestations include short-sightedness, cataracts, retinal problems leading to retinal detachment and possible blindness. This is principally the case among individuals with type 1 Stickler Syndrome. It is the most commonly identified inherited cause of retinal detachment in childhood. However, there is no consensus regarding best practice and no current guidelines on prophylactic interventions for this population. OBJECTIVES: The aim of this systematic review was to assess the evidence for the clinical effectiveness and safety of primary prophylactic interventions for the prevention of retinal detachment in previously untreated eyes without retinal detachment in patients with Stickler syndrome. The primary outcome of interest was retinal detachment post prophylaxis. DATA SOURCES: A systematic search was made of 11 databases of published and unpublished literature, which included MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing and Allied Health Literature and The Cochrane Library. There was no restriction by language or date. The references of all included studies were checked for further relevant citations and authors of studies with potentially relevant data were also contacted. REVIEW METHODS: Two reviewers double-screened all titles and abstracts of the citations retrieved by the search to identify studies that satisfied the inclusion criteria. Both reviewers also independently extracted and quality assessed all included studies. A narrative synthesis was performed. RESULTS: The literature search identified 1444 unique citations, of which four studies satisfied the inclusion criteria. The two principal studies were both retrospective cohort studies with control groups in populations with type 1 Stickler syndrome. One study evaluated 360° cryotherapy (n = 204) and the other focal or circumferential laser treatment (n = 22). Both studies reported a statistically significant difference in the rate of retinal detachment per eye between the groups receiving prophylaxis and the controls. However, both studies were subject to a high risk of bias. The results of the two supporting studies of Wagner-Stickler patients were either relatively inconsistent or unreliable. No study reported any major or long-term complications associated with the interventions. Despite the weaknesses of the evidence, the rate of retinal detachment in the intervention groups, especially the cryotherapy group, was lower than the rate either experienced in the study control groups or reported in other studies of untreated Stickler syndrome populations not exposed to prophylaxis. CONCLUSIONS: Only 360° cryotherapy and focal and circumferential laser treatment have been evaluated for the type 1 Stickler syndrome population, and then only by a single retrospective, controlled, cohort study in each case. Both of these studies report a significant difference between intervention and control groups (principally no treatment) and no major or long-term side effects or complications. However, there is a high risk of bias within these two studies, so the relative effectiveness of either intervention is uncertain. FUTURE WORK: A service priority is to determine reliably the prevalence of Stickler syndrome, i.e. how many individuals have type 1 or type 2 Stickler syndrome, and their risk of retinal detachment and subsequent blindness. A non-randomised, prospective cohort comparison study, in which eligible participants are treated, followed-up and analysed in one of three study arms, for no treatment, laser therapy or cryotherapy, would potentially offer further certainty in terms of the relative efficacy of both prophylaxis versus no prophylaxis and cryotherapy versus laser therapy than is possible with the currently available data. Alternatively, continued follow-up and analysis of existing study data, and data collection from relevant sample populations, are required to assess the long-term risks of blindness, retinal detachment and prophylaxis. FUNDING: This study was funded by the National Institute for Health Research Health Technology Assessment programme.

Optical coherence tomographic assessment of dynamic macular changes in patients with Vogt-Koyanagi-Harada disease.

To determine the relationship between visual acuity and three-dimensional optical coherence tomographic (3D-OCT) findings of the macula in eyes with Vogt-Koyanagi-Harada (VKH) disease. Twelve eyes of six patients (three men and three woman, average age 53.2 years) in the acute phase of VKH disease were examined with a 3D-OCT instrument. All of the eyes had a serous macular detachment. The height of the sensory retinal detachment (SRD) and the sensory retinal thickness (SRT) were measured by OCT before treatment (acute stage) and at the convalescent stage. The correlation between the retinal morphology and visual acuity was evaluated. The height of the SRD and the SRT were 612.5 ± 371.2 and 136. 7 ± 22.0 µm, respectively. The initial visual acuity was significantly worse in eyes with a higher SRD (P = 0.014, r = 0.68) but the correlation between initial visual acuity and SRT was not significant. The recovery of visual acuity was attained in 50.7 ± 44.1 days and the complete resolution of the SRD was attained in 30.5 ± 23.2 days. The final visual acuity was attained several days after the complete resolution of the SRD in all four eyes of patients over 60 years of age, but the recovery of visual acuity often preceded the complete resolution of the SRD. The OCT images provided a noninvasive indicator of the severity of the disease and dynamic changes in the macular morphology, reflecting the effect of treatment in association with the improvement in visual acuity. Monitoring the SRD by 3D-OCT may guide the tapering of systemic corticosteroid treatment.

Combined or sequential surgery for management of rhegmatogenous retinal detachment with macular holes.

PURPOSE: To describe the anatomical success and visual outcome in patients with rhegmatogenous retinal detachment and coexisting macular holes using two different management strategies. METHODS: Nonrandomized, prospective interventional case series where patients either had combined surgery, i.e., vitrectomy, internal limiting membrane peel, retinopexy to the peripheral breaks, and gas tamponade; or sequential, i.e., vitrectomy, retinopexy to the peripheral breaks, and gas tamponade with macular hole surgery if indicated, as a secondary procedure. RESULTS: Five patients (Group 1) had combined surgery and 7 (Group 2) had sequential treatment. All retinas were reattached irrespective of surgical approach. In Group 1, best-corrected visual acuity improved in all patients from 1.8/60 to 9.2/60 Snellen (P = 0.06). In Group 2, there was improvement in best-corrected visual acuity in all patients from 3.3/60 to 12.9/60 Snellen (P = 0.05). After comparison of the logarithm of the minimum angle of resolution, postoperative best-corrected visual acuity improvement was not significantly different between both groups (P = 0.68). CONCLUSION: The results of this study suggest that good anatomic and visual outcome can be achieved using either approach. Visual acuity improved in all patients from both groups. In sequential surgery some of the macular holes may close spontaneously. However, combined surgery offers the clinical and cost benefit of a single procedure.

Resources involved in managing retinal detachment complicated by proliferative vitreoretinopathy.

PURPOSE: To report the differences in cost of treatment and outcome in retinal detachment (RD) cases with and without proliferative vitreoretinopathy (PVR). METHODS: Analysis of clinical trial databases of RD observed in 190 eyes of 190 patients. Eyes were classified as no PVR, developing PVR, or established PVR. For each eye, total cost of treatment undertaken on Moorfields Eye Hospital vitreoretinal unit, final retinal status, and best-corrected visual acuity were recorded. RESULTS: Management of patients who developed PVR involved approximately double the resources of RD without PVR. Eyes with pre-exiting PVR had similar resource input to those with RD without PVR. Patients who developed PVR had a mean of 3.7 operations (including subsequent cataract surgery) compared to 1.8 and 2.1 respectively for noncomplicated RD and pre-existing PVR. Anatomic success and visual outcome was significantly worse in eyes with PVR. CONCLUSIONS: Treatment of eyes that developed PVR after initial surgery cost significantly more than eyes with no PVR or established PVR (P < 0.01). Improvements in the management of RD aimed at preventing PVR and advances in PVR treatment may have significant financial as well as clinical benefits.

Opportunities for maloccurrence in delivery of specialized care in the managed care environment.

Two patients lost eyes because of complications of retinal detachment in managed care situations. In both cases the eyes might have been saved had the patients been treated earlier by highly qualified subspecialists.

[Scleral compression in assessment of the stage of proliferative vitreoretinopathy and type of subretinal contents in retinal detachment]. / Sklerokompressiia v otsenke stadii proliferativnoi vitreoretinopatii i kharaktera subretinal'nogo soderzhimogo pri otsloike setchatki.

The authors analyse intraocular changes occurring in detachment of the retina using sclero-compression data. A total of 447 eyes of 417 patients with detachment of the retina complicated by proliferative vitreoretinopathy of various severity were examined. Four main types of compression chorioretinal relationships are distinguished permitting a preoperative differential diagnosis of stages of concomitant proliferative vitreoretinopathies and of the type of subretinal contents in detachment of the retina. The diagnosis of proliferative vitreoretinopathy in detachment of the retina is based on international classification, though it does not fully reflect all specific features of the disease. Basing on the data of analysis of compression chorioretinal relationships, the authors supplement the known classification as regards the interpretation of the minimal stage A which is considered more extensively and the moderate stage B of proliferative vitreoretinopathy. The described assessment of intraocular changes in detachment of the retina permits not only a correction of the routine assessment of stages of this condition, but is practically valuable. The authors suggest four basic approaches to the choice of the optimal surgical strategy, based on the disease characteristics, stage of proliferative vitreoretinopathy, and type of compression chorioretinal relationships.

Incidencia, manejo y evolución de la diálisis temporal inferior de retina / Incidence, management and evolution of the temporal dialysis inferior of retina

La diálisis temporal inferior de la retina (DTIR) es una entidad frecuente. No se ha podido determinar de forma precisa su etiología. Se realizó un estudio retrospectivo a 3 años en el Hospital de la Luz, en el cual se revisaron expedientes de 36 pacientes (46 ojos) con DTIR. La incidencia fue de 11.78 por ciento con predominio en el sexo masculino. En el 69 por ciento de los casos se consideró de etiología idiopática, siendo unilateral en 72 por ciento y bilateral en 28 por ciento. El síntoma principal fue la disminución de agudeza visual aun cuando se conserva una visión aceptable al momento de diagnóstico. La degeneración microquística fue la principal lesión periférica asociada, se encontró en 15.2 por ciento de los ojos afectados y en el 11 por ciento de los ojos contralaterales. En el 93 por ciento de los casos se realizó cirugía presentando una evolución satisfactoria en el 80.4 por ciento con pocas complicaciones. La DTIR resalta como una lesión frecuente con alta prevalencia en México y quizá en otros países con características reciales similares.

[Acute vitreous hemorrhage--possibilities for differential diagnostic, echographic assessment]. / Akute Glaskörpereinblutung--Möglichkeiten der differentialdiagnostischen, echographischen Abklärung.

In acute vitreal hemorrhage, echography is the method of choice for evaluation of the vitreous body. Echography ist capable of providing information on the localization, the density, and the mobility, and in certain diseases, also on the cause of the hemorrhage. The echographic findings (standardized echography) recorded in 216 patients with acute vitreal hemorrhage examined within 14 months (Jan. 1988 to Feb. 1989) were evaluated. In 91 patients (42%) diabetic retinopathy was known: in such cases echography can disclose proliferative changes and traction-detachment of the retina. In 58 patients (27%) echography revealed a posterior vitreous detachment, while in 17 patients (8%) an additional retinal detachment was found. In 39 patients (18%) a degenerative, disciform lesion of the macula was revealed as the cause of the hemorrhage, in 5 patients (2%) a malignant melanoma of the choroid, and in 2 patients a (large) retinal tear. In 5 patients, apart from the vitreous opacities no changes in the posterior segment could be found.