Clinical variables associated with failure of retinal detachment repair: the European vitreo-retinal society retinal detachment study report number 4.

OBJECTIVE: To identify risk factors associated with failure of anatomic reattachment in primary rhegmatogenous retinal detachment repair. DESIGN: Nonrandomized, multicenter, collaborative study. PARTICIPANTS: Primary procedures for 7678 rhegmatogenous retinal detachments reported by 176 surgeons from 48 countries. METHODS: We recorded specific preoperative clinical findings, repair method, and outcome after intervention. We performed univariate, bivariate, and multivariate analyses to identify variables associated with surgical failure. MAIN OUTCOME MEASURES: Final failure of retinal detachment repair (level 1), remaining silicone oil at study conclusion (level 2), and need for additional procedures to repair the detachment (level 3). RESULTS: We analyzed 7678 cases of rhegmatogenous retinal detachment repair. Presence of choroidal detachment or significant hypotony was associated with significantly higher level 1 failure rates when grade 0 or B proliferative vitreoretinopathy (PVR) was present and higher level 2 failure rates, regardless of PVR status (P<0.05). Excluding cases with choroidal detachment or hypotony, increasing PVR was associated with increasing level 1 failure rates. The difference between grade B and C-1 PVR was significant (P = 2 × 10(-6)). No difference was observed in level 1 failure rates when operated eyes were phakic versus pseudophakic. Level 1 failure was significantly higher when all 4 quadrants of retina (4.4%) were detached than when only 1 quadrant (0.8%) had subretinal fluid. With grade B or C-1 PVR, cases with large or giant tears had significantly higher level 1 failure rates. No association was observed between number of retinal breaks and failure rates. Multivariate analysis showed grade C-1 PVR, 4 detached quadrants, and presence of choroidal detachment or significant hypotony were independently linked with a greater level 1 failure rate; the presence of a smaller retinal break was associated with a lesser level 1 failure rate. CONCLUSIONS: Choroidal detachment, significant hypotony, grade C-1 PVR, 4 detached quadrants, and large or giant retinal breaks were independent explanatory variables of retinal detachment repair failure. In contrast to earlier studies, the significance of phakic versus pseudophakic status was not confirmed.

Strategy for the management of uncomplicated retinal detachments: the European vitreo-retinal society retinal detachment study report 1.

OBJECTIVE: To study success and failure in the treatment of uncomplicated rhegmatogenous retinal detachments (RRDs). DESIGN: Nonrandomized, multicenter retrospective study. PARTICIPANTS: One hundred seventy-six surgeons from 48 countries spanning 5 continents provided information on the primary procedures for 7678 cases of RRDs including 4179 patients with uncomplicated RRDs. METHODS: Reported data included specific clinical findings, the method of repair, and the outcome after intervention. MAIN OUTCOME MEASURES: Final failure of retinal detachment repair (level 1 failure rate), remaining silicone oil at the study's conclusion (level 2 failure rate), and need for additional procedures to repair the detachment (level 3 failure rate). RESULTS: Four thousand one hundred seventy-nine uncomplicated cases of RRD were included. Combining phakic, pseudophakic, and aphakic groups, those treated with scleral buckle alone (n = 1341) had a significantly lower final failure rate than those treated with vitrectomy, with or without a supplemental buckle (n = 2723; P = 0.04). In phakic patients, final failure rate was lower in the scleral buckle group compared with those who had vitrectomy, with or without a supplemental buckle (P = 0.028). In pseudophakic patients, the failure rate of the initial procedure was lower in the vitrectomy group compared with the scleral buckle group (P = 3×10(-8)). There was no statistically significant difference in failure rate between segmental (n = 721) and encircling (n = 351) buckles (P = 0.5). Those who underwent vitrectomy with a supplemental scleral buckle (n = 488) had an increased failure rate compared with those who underwent vitrectomy alone (n = 2235; P = 0.048). Pneumatic retinopexy was found to be comparable with scleral buckle when a retinal hole was present (P = 0.65), but not in cases with a flap tear (P = 0.034). CONCLUSIONS: In the treatment of uncomplicated phakic retinal detachments, repair using scleral buckle may be a good option. There was no significant difference between segmental versus 360-degree buckle. For pseudophakic uncomplicated retinal detachments, the surgeon should balance the risks and benefits of vitrectomy versus scleral buckle and keep in mind that the single-surgery reattachment rate may be higher with vitrectomy. However, if a vitrectomy is to be performed, these data suggest that a supplemental buckle is not helpful. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Strategy for the management of complex retinal detachments: the European vitreo-retinal society retinal detachment study report 2.

OBJECTIVE: To study the outcome of the treatment of complex rhegmatogenous retinal detachments (RRDs). DESIGN: Nonrandomized, multicenter, retrospective study. PARTICIPANTS: One hundred seventy-six surgeons from 48 countries spanning 5 continents reported primary procedures for 7678 RRDs. METHODS: Reported data included clinical manifestations, the method of repair, and the outcome. MAIN OUTCOME MEASURES: Failure of retinal detachment repair (level 1 failure rate), remaining silicone oil at the study's conclusion (level 2 failure rate), and need for additional procedures to repair the detachments (level 3 failure rate). RESULTS: The main categories of complex retinal detachments evaluated in this investigation were: (1) grade B proliferative vitreoretinopathy (PVR; n = 917), (2) grade C-1 PVR (n = 637), (3) choroidal detachment or significant hypotony (n = 578), (4) large or giant retinal tears (n = 1167), and (5) macular holes (n = 153). In grade B PVR, the level 1 failure rate was higher when treated with a scleral buckle alone versus vitrectomy (P = 0.0017). In grade C-1 PVR, there was no statistically significant difference in the level 1 failure rate between those treated with vitrectomy, with or without scleral buckle, and those treated with scleral buckle alone (P = 0.7). Vitrectomy with a supplemental buckle had an increased failure rate compared with those who did not receive a buckle (P = 0.007). There was no statistically significant difference in level 1 failure rate between tamponade with gas versus silicone oil in patients with grade B or C-1 PVR. Cases with choroidal detachment or hypotony treated with vitrectomy had a significantly lower failure rate versus treatment with scleral buckle alone (P = 0.0015). Large or giant retinal tears treated with vitrectomy also had a significantly lower failure rate versus treatment with scleral buckle (P = 7×10(-8)). CONCLUSIONS: In patients with retinal detachment, when choroidal detachment, hypotony, a large tear, or a giant tear is present, vitrectomy is the procedure of choice. In retinal detachments with PVR, tamponade with either gas or silicone oil can be considered. If a vitrectomy is to be performed, these data suggest that a supplemental buckle may not be helpful. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Using health information technology to improve drug monitoring: a systematic review.

PURPOSE: To conduct a systematic review of current evidence regarding the use of health information technology (HIT) interventions to improve drug monitoring in ambulatory care. METHODS: We searched PubMed, CINAHL, the Cochrane Library, and other computerized databases from 1 January 1998 to 30 June 2008 using the key words "drug monitoring," "medical records systems, computerized," "ambulatory care," and "outpatients." We manually reviewed reference lists of articles identified through computer searches and asked experts in the field to review our search strategy and results for completeness. RESULTS: Seven relevant studies were identified. Four of these studies assessed real-time interventions that used alerts to physicians at the time of medication ordering to ensure adequate monitoring, only one of which showed an improvement in monitoring. Of three studies using HIT outside the physician encounter, two suggested some improvement in monitoring rates. Methodological limitations were apparent in all studies identified. CONCLUSIONS: Few studies have assessed the effectiveness of HIT interventions to improve drug monitoring, and among them, there is no clear consensus regarding the most consistently effective approaches to reducing drug monitoring errors. There is a clear need for well designed randomized trials to evaluate possible interventions to reduce drug monitoring errors. Such studies should incorporate health outcomes and detailed cost analyses to further characterize the feasibility of successful interventions.

A case of intracranial hypertension and papilledema associated with nephropathic cystinosis and ocular involvement.

An 11 year old boy with nephropathic cystinosis developed moderate to severe bilateral optic disc edema two months after he received a deceased donor renal allograft. The bilateral optic disc edema was found to be a result of intracranial hypertension diagnosed by lumbar puncture. No etiology was found. He was treated with acetazolamide and his optic dis edema resolved over a period of eight months and did not recur after acetazolamide was discontinued. The mechanism of intracranial hypertension in patients with nephropathic cystinosis is not well understood, but may involve obstruction of cerebrospinal fluid outflow due to deposition of cystine crystals in arachnoid villi.

Strategy for the management of macular edema in retinal vein occlusion: the European VitreoRetinal Society macular edema study.

OBJECTIVE: To compare the efficacy of different therapies in the treatment of macular edema associated with retinal vein occlusion (RVO). DESIGN: This is a nonrandomized, multicenter collaborative study. PARTICIPANTS: 86 retina specialists from 29 countries provided clinical information, including choice of treatment and outcome, on 2,603 patients with macular edema including 738 cases of RVO. METHODS: Reported data included the type and number of treatments performed, visual acuities, and other clinical and diagnostic findings. MAIN OUTCOME MEASURES: The mean increase in visual acuity and mean number of treatments performed. RESULTS: 358 cases of central retinal vein occlusion (CRVO) and 380 cases of branch retinal vein occlusion (BRVO) were included in this investigation. Taking all RVO cases together, pars plana vitrectomy with internal limiting membrane (ILM) peeling alone resulted in an improvement in vision greater than other therapies. Those treated with intravitreal antivascular endothelial growth factor (anti-VEGF) injection alone showed the second greatest improvement in vision. Dexamethasone intravitreal implant alone and intravitreal triamcinolone alone both resulted in modest visual gains. CONCLUSIONS: In the treatment of macular edema in RVO, vitrectomy with ILM peeling may achieve visual improvement and may be a good option for certain cases. Anti-VEGF injection is the most effective of the nonsurgical treatments.

Strategy for the management of diabetic macular edema: the European vitreo-retinal society macular edema study.

OBJECTIVE: To compare the efficacy of different therapies in the treatment of diabetic macular edema (DME). DESIGN: Nonrandomized, multicenter clinical study. PARTICIPANTS: 86 retina specialists from 29 countries provided clinical information on 2,603 patients with macular edema including 870 patients with DME. METHODS: Reported data included the type and number of treatment(s) performed, the pre- and posttreatment visual acuities, and other clinical findings. The results were analyzed by the French INSEE (National Institute of Statistics and Economic Studies). MAIN OUTCOME MEASURES: Mean change of visual acuity and mean number of treatments performed. RESULTS: The change in visual acuity over time in response to each treatment was plotted in second order polynomial regression trend lines. Intravitreal triamcinolone monotherapy resulted in some improvement in vision. Treatment with threshold or subthreshold grid laser also resulted in minimal vision gain. Anti-VEGF therapy resulted in more significant visual improvement. Treatment with pars plana vitrectomy and internal limiting membrane (ILM) peeling alone resulted in an improvement in vision greater than that observed with anti-VEGF injection alone. In our DME study, treatment with vitrectomy and ILM peeling alone resulted in the better visual improvement compared to other therapies.