Assessment of Microvascular Changes After Rhegmatogenous Retinal Detachment Repair Using Wide-Field Swept-Source Optical Coherence Tomography Angiography.

BACKGROUND AND OBJECTIVE: Our objective was to evaluate retinal microvascular changes and visual outcomes following rhegmatogenous retinal detachment (RRD) repair using wide-field swept-source optical coherence tomography angiography (WF SS-OCTA). PATIENTS AND METHODS: The study included 116 eyes of 111 patients with macula-off (n = 68) or macula-on (n = 48) RRD treated with a single successful procedure, 79 fellow eyes, and 183 eyes of control patients imaged with WF SS-OCTA (3 ×3, 6 ×6, and 12 ×12 mm images). Mixed-effects multiple linear regression models were used for statistical analysis. RESULTS: Vessel density (VD) and vessel skeletonized density (VSD) of the superficial capillary plexus (3 ×3 mm scans) and full-thickness retina (12 ×12 mm) were significantly reduced in RRD eyes compared to fellow and control eyes. Decreased VSD and VD in all layers (3 ×3 mm and 6 ×6 mm) were significantly associated with greater preoperative extent of retinal detachment (P < 0.05) and poorer postoperative best-corrected visual acuity (BCVA) in RRD eyes (P < 0.05). Macula-off status was associated with increased foveal avascular zone irregularity (12 ×12 mm, P = 0.02). CONCLUSIONS: Decreased VD on WF SS-OCTA is associated with poorer postoperative BCVA following RRD repair. [Ophthalmic Surg Lasers Imaging Retina 2024;55:310-317.].

The Cost of Standard and Complex Pars Plana Vitrectomy for Retinal Detachment Repair Exceeds Its Reimbursement.

OBJECTIVE: To measure the total costs and reimbursements associated with standard and complex pars plana vitrectomy using time-driven activity-based costing (TDABC). DESIGN: Economic analysis at a single academic institution. SUBJECTS: Patients who underwent standard or complex pars plana vitrectomy (PPV; Current Procedural Terminology codes 67108 and 67113) at the University of Michigan in the calendar year 2021. METHODS: Process flow mapping for standard and complex PPVs was used to determine the operative components. The internal anesthesia record system was used to calculate time estimates, and financial calculations were constructed from published literature and internal sources. A TDABC analysis was used to determine the costs of standard and complex PPVs. Average reimbursement was based on Medicare rates. MAIN OUTCOME MEASURES: The primary outcomes were the total costs for standard and complex PPVs and the resulting net margin at current Medicare reimbursement levels. The secondary outcomes were the differential in surgical times, costs, and margin for standard and complex PPV. RESULTS: Over the 2021 calendar year, a total of 270 standard and 142 complex PPVs were included in the analysis. Complex PPVs were associated with significantly increased anesthesia time (52.28 minutes; P < 0.001), operating room time (51.28 minutes; P < 0.0001), surgery time (43.64 minutes; P < 0.0001), and postoperative time (25.95 minutes; P < 0.0001). The total day-of-surgery costs were $5154.59 and $7852.38 for standard and complex PPVs, respectively. Postoperative visits incurred an additional cost of $327.84 and $353.86 for standard and complex PPV, respectively. The institution-specific facility payments were $4505.50 and $4935.14 for standard and complex PPV, respectively. Standard PPV yielded a net negative margin of -$976.93, whereas complex PPV yielded a net negative margin of -$3271.10. CONCLUSIONS: This analysis demonstrated that Medicare reimbursement is inadequate in covering the costs of PPV for retinal detachment, with a particularly large negative margin for more complex cases. These findings demonstrate that additional steps may be necessary to mitigate adverse economic incentives so that patients continue to have timely access to care to achieve optimal visual outcomes after retinal detachment. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Rhegmatogenous Retinal Detachment: Variations in Clinical Presentation and Surgical Outcomes by Socioeconomic Status and Race.

BACKGROUND AND OBJECTIVE: To characterize rhegmatogenous retinal detachment (RRD) presentation and repair outcomes by race and socioeconomic status. MATERIALS AND METHODS: Retrospective cohort one-center study of adults with a new RRD repair from 2012 to 2020. Logistic and linear regression analyses were conducted. RESULTS: 61.7% were male, 84.5% White and 9.4% Black (total n = 1092). 95.8% White and 94.2% Black patients had retinal reattachment (P = .234). Macula-off status was more likely with Medicare/Medicaid than private insurance (OR 1.63, 95% CI 1.11 to 2.41, P = .014); and less likely with higher income (OR 0.88, CI 0.81 to 0.96, P = .003). Black patients had worse best visual acuity (BVA) at presentation and follow-up (follow-up -6.93 letters, CI -13.19 to -0.64, P = .031), and higher odds of postoperative ocular hypertension (OHTN) (OR 2.41, CI 1.28 to 4.60, P = .007). CONCLUSIONS: Despite equivalent retinal reattachment rates, Black patients have worse BVA, and are more likely to develop OHTN than White patients. Macula-off status is less likely in patients with higher income or private insurance. [Ophthalmic Surg Lasers Imaging Retina 2022;53:538-545.].

Rhegmatogenous retinal detachment surgery in elderly people over 70 years old: visual acuity, quality of life, and cost-utility values.

BACKGROUND AND PURPOSE: To evaluate the influence of rhegmatogenous retinal detachment (RRD) surgery on elderly patients in terms of visual acuity, vision-related quality of life and its cost-effectiveness. METHODS: Elderly patients over 70 years old, who were diagnosed and underwent RRD surgery at Shanghai First People's Hospital, Shanghai Jiao Tong University, China, from January 1, 2009, through January 1, 2013. The participants received scleral buckling surgery and vitreous surgery with or without scleral buckling under retrobulbar anesthesia. We followed the patients for 1 year and collected best-corrected visual acuity (BCVA), vision-related quality of life, and direct medical costs data. Utility values elicited by time-trade-off were analyzed to determine the quality of life. Quality-adjusted life years (QALYs) gained in life expectancy were calculated and discounted at 3% annually. Costs per QALY gained were reported using the bootstrap method. Further analyses were made for two age groups, age 70-79 and age over 80 years. Sensitivity analyses were performed to test stability of the results. RESULTS: 98 patients were included in the study. The BCVA significantly improved by 0.53±0.44 (Logarithm of the Minimum Angle of Resolution (logMAR)) at the 1-year postoperative time point (p<0.001). Utility values increased from 0.77 to 0.84 (p<0.001), and an average of 0.4 QALYs were gained in the life expectancy. Costs per QALY gained from the RRD surgery were 33,186 Chinese Yuan (CNY) (5,276 US dollars (USD))/QALY; 24,535 CNY (3,901 USD)/QALY for the age group of 70-79 years and 71,240 CNY (11,326 USD)/QALY for the age group over 80 years. CONCLUSIONS: RRD surgery improved the visual acuity and quality of life in the elderly patients over 70 years old. According to the World Health Organization's recommendation, at a threshold of willingness to pay of 115,062 CNY (18,293 USD)/QALY, RRD surgery is cost effective in the elderly patients.

Novel microarchitectural dynamics in rhegmatogenous retinal detachments identified with intraoperative optical coherence tomography.

PURPOSE: To evaluate ultrastructural macular changes during rhegmatogenous retinal detachment repair using intraoperative optical coherence tomography (iOCT). METHODS: A multisurgeon, single-center consecutive case series of 9 eyes undergoing surgical repair for macula-involving rhegmatogenous retinal detachment with iOCT imaging using a custom microscope-mounted spectral domain OCT system. All patients underwent combined vitrectomy/scleral buckle repair. Imaging characteristics were analyzed, including persistence of subclinical intraoperative subretinal fluid and architectural changes associated with intraoperative maneuvers. Clinical characteristics were analyzed. RESULTS: Nine eyes of nine patients were identified that underwent iOCT imaging during macula-involving rhegmatogenous retinal detachment repair. Persistent subclinical subretinal fluid was identified in 100% of eyes after perfluoro-n-octane instillation. Significant alterations to the foveal architecture were detected with iOCT in 100% of cases. Three foveal configurations were noted based on iOCT findings. Stage 1 was characterized by a small area of subfoveal hyporeflectivity (3/9 eyes), Stage 2 had prominent subretinal hyporeflectivity and foveal thinning with indeterminate macular hole (MH) formation (3/9 eyes), and Stage 3 demonstrated definitive full-thickness MH (3/9 eyes). No eyes were noted to have a MH preoperatively or in the immediate postoperative period. One Stage 3 eye developed a full-thickness MH 7 months postoperatively. Stage 3 configuration was associated with poorer final postoperative visual acuity (P = 0.009). CONCLUSION: Microarchitectural changes occur during intraoperative repair of retinal detachments, including significant alterations in foveal configuration and persistent subretinal fluid. These features may help to prognosticate outcomes. These findings also suggest a possible novel mechanism for postrhegmatogenous retinal detachment MH formation.

Sub-tenon anesthesia for segmental scleral buckling and assessment of postoperative pain.

BACKGROUND: To evaluate the safety and efficacy of sub-Tenon anesthesia for segmental scleral buckling. METHODS: Thirty-two patients diagnosed with rhegmatogenous retinal detachment were treated with segmental scleral buckling under sub-Tenon anesthesia. After topical anesthesia, a buttonhole was made through the conjuntiva and Tenon's capsule 4 mm posterior to the limbus. Four milliliters of anesthetic solution was then delivered into the posterior sub-Tenon space using a blunt cannula. The buckling procedure was done immediately after the completion of anesthesia. We evaluated akinesia and recorded the pain with a visual analogue scale after surgery. RESULTS: There were no anesthesia related complications. Twenty-two patients (69%) reported no pain during surgery. Nine patients (28%) felt pain during surgery. However, the pain was tolerable and the surgeries were finished smoothly with or without a supplemental anesthetic solution. One patient (3%) experienced uncomfortable pain and needed an additional retrobulbar block. Five patients (16%) retained complete eye movement 5 min after anesthesia, and only 4 patients (13%) experienced total akinesia. At the end of the surgery, 16 patients (50%) had total akinesia and 2 patients (6%) retained complete eye movement. CONCLUSIONS: Sub-Tenon anesthesia is efficient and safe in segmental scleral buckling. It can prevent the complications of peribulbar or retrobulbar anesthesia and is a good alternative to both methods of anesthesia, especially in highly myopic eyes.