POSTOPERATIVE PHOTORECEPTOR INTEGRITY AND ANATOMICAL OUTCOMES BASED ON PRESENTING MORPHOLOGIC STAGE OF RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To evaluate outer retinal recovery on postoperative optical coherence tomography (OCT) based on presenting morphologic stage of rhegmatogenous retinal detachment (RRD). METHODS: Retrospective cohort of consecutive primary fovea-involving RRDs, referred from January 2012 to September 2022. Baseline OCTs were assessed for morphologic stage of RRD. Postoperative OCT scans were graded at 3, 6, and 12 months for external limiting membrane, ellipsoid zone and interdigitation zone discontinuity, epiretinal membrane formation and severity, and residual subfoveal fluid. RESULTS: Three hundred and fifty-one patients were included. Increasing baseline morphologic stage of RRD was significantly associated with external limiting membrane, ellipsoid zone, and interdigitation zone discontinuity at all time points postoperatively ( P < 0.001) and was shown to be an independent predictor of foveal photoreceptor integrity after adjusting for height of detachment, time to surgery, and duration of fovea involvement ( P < 0.001). Earlier stages were associated with residual subfoveal fluid ( P < 0.001). There was no association between the stages of RRD and epiretinal membrane severity. However, late stages presented with earlier development of epiretinal membrane ( P = 0.012). CONCLUSION: Increasing morphologic stage of RRD is associated with delayed recovery of outer retinal bands in the first year and faster development of epiretinal membrane after RRD repair. The results of this study suggest that the stages may serve as a prognostic biomarker for postoperative photoreceptor recovery.

Impact of Baseline Morphologic Stage of Rhegmatogenous Retinal Detachment on Postoperative Visual Acuity.

PURPOSE: To evaluate the association of baseline morphologic stage of rhegmatogenous retinal detachment (RRD) using OCT with postoperative anatomic and visual acuity (VA) outcomes. DESIGN: Retrospective cohort study. SUBJECTS: Consecutive primary fovea-involving RRDs referred from January 2012 to September 2022. METHODS: Patients with primary RRD and no prior macular pathology with gradable baseline OCT were assessed. Best-corrected VA (BCVA) was assessed at presentation and at 3, 6, and 12 months postoperatively. OCT scans were graded for parafoveal morphologic stage of RRD and foveal photoreceptor integrity. MAIN OUTCOME MEASURES: Association of morphologic stage of RRD with 12-month BCVA. RESULTS: Three hundred fifty-one patients were included. Sixty-eight percent (238/351) were male, the mean (standard deviation) age was 61.2 (± 12.8) years, and 59% (206/351) were phakic. Thirteen percent (47/351) presented in stages 1 and 2, 15% (54/351) in stage 3a, 36% (126/351) in stage 3b, 24% (83/351) in stage 4, and 12% (41/351) in stage 5. Increasing stage was associated with worse foveal photoreceptor integrity, reduced baseline BCVA and longer duration of central vision loss (P < 0.001). Mean (standard deviation) 12-month BCVA by stage was 0.77 (± 0.64) for stages 1 and 2, 1.00 (± 0.53) for stage 3a, 1.36 (± 0.55) for stage 3b, 1.33 (± 0.66) for stage 4 and 1.55 (± 0.47) for stage 5. Increasing stage was associated with reduced postoperative BCVA (P < 0.001) at all time points after adjusting for covariates. A subgroup analysis of acute detachments with retinal pigment epithelium-photoreceptor dysregulation demonstrated no difference in postoperative BCVA between stages 1, 2, and 3a. However, 12-month BCVA was significantly better in stages 1, 2, and 3a vs. stage 3b (P = 0.002) and stage 3a vs. 3b (P = 0.008). CONCLUSIONS: This study validates the clinical relevance of a recently proposed OCT-based staging system for outer retinal morphologic changes over time in RRD. Postoperative BCVA was significantly reduced in patients with worse presenting stage at all time points. In acute RRDs, 12-month BCVA was significantly better in stages 1, 2, and 3a vs. stage 3b, which suggests early stages may have better retinal recovery compared with stage 3b or worse. Stage 3b may represent a critical point where substantial structural changes occur, leading to worse outcomes in acute RRDs. Patients presenting with fovea-involving RRDs in stages 1, 2, or 3a may benefit from more urgent intervention. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Pathophysiology of Secondary Macular Hole in Rhegmatogenous Retinal Detachment.

Purpose: To describe the pathophysiology of secondary macular hole (MH) in rhegmatogenous retinal detachment (RRD). Methods: A retrospective cohort of 360 consecutive primary fovea-off RRDs presenting to St. Michael's Hospital, Toronto, from January 2012 to September 2022 were included. Preoperative OCT was assessed for bacillary layer detachment (BALAD) abnormalities. Histological sections of normal eyes were assessed to inform OCT interpretations. Primary outcome measure was the progression of BALAD to full-thickness MH (FTMH). Results: Of the 360 patients, 22.5% (n = 81) had BALAD abnormalities at presentation. Eight percent (29/360) had associated MH, of which 79.3% (23/29) were a BALAD-lamellar hole and 20.7% (6/29) were FTMH. After reattachment, 62% of MHs persisted (18/29), of which 83% (15/18) had BALAD-lamellar holes that subsequently progressed to FTMH in a mean of 8.1 ± 3.2 days. BALAD-lamellar holes had significantly worse postoperative visual acuity (P < 0.001) when compared with other BALAD abnormalities (58/81) or with the rest of the cohort (279/360). OCT spectrum from BALAD to FTMH includes (1) cleavage planes extending from Henle fiber layer into the BALAD; (2) central outer nuclear layer thinning; (3) Müller cell cone loss with tissue remnants at the foveal walls; (4) retinal tissue operculum close to BALAD-MH; and (5) progressive thinning or degradation of the posterior band of BALAD-lamellar hole leading to FTMH. Histological specimens identified foveal regions of low mechanical stability. Conclusions: BALAD plays a crucial role in the pathophysiology of MH in RRDs, which forms owing to sequential changes in four critical areas: RPE-photoreceptor interface, myoid zone, Henle fiber layer, and Müller cell cone with surrounding tissue. Timely management of fovea-off RRD with BALAD may be prudent to avoid the progression to BALAD-lamellar hole, subsequent FTMH, and worse functional outcomes.

Outer Retinal Hyperreflective Dots: A Potential Imaging Biomarker in Rhegmatogenous Retinal Detachment.

PURPOSE: To investigate hyperreflective dots (HRDs) on baseline OCT in rhegmatogenous retinal detachment (RRD). DESIGN: Retrospective cohort study. SUBJECTS: Consecutive primary fovea-off RRDs presenting between January 2012 and September 2022. METHODS: Visual acuity (VA) was obtained at baseline, 3, 6, and 12 months. Baseline foveal OCT scans were graded for the presence of HRDs in the outer retina, morphologic stage of RRD in the parafovea, and foveal photoreceptor integrity (intact, patchy or complete loss of the bacillary layer). Epiretinal membrane (ERM) and cystoid macular edema (CME) were graded after surgery. MAIN OUTCOME MEASURES: The primary outcome was the proportion of patients in each morphologic stage with HRDs present on OCT and their association with postoperative VA. Secondary outcomes included association with the height of foveal detachment, duration of central vision loss, RRD extent, and development of ERM/CME. RESULTS: A total of 351 patients were included. The presence of HRDs by morphologic stage of RRD was 0% in stage 1, 4.5% (2/42) in stage 2, 13% (7/54) in stage 3a, 16% (20/126) in stage 3b, 48% (40/83) in stage 4, and 85% (35/41) in stage 5. Hyperreflective dots were associated with increasing stage of RRD (P < 0.001), reduced integrity of foveal photoreceptors (P < 0.001), and reduced postoperative VA at 3, 6, and 12 months (P < 0.001), after excluding visually significant cataracts and adjusting for covariates. There was also a significant association between HRDs and height of foveal detachment, duration of central vision loss, and RRD extent (P < 0.001). Hyperreflective dots were neither associated with postoperative ERM formation nor with its severity (P = 0.27). Nevertheless, they were associated with the occurrence of CME at 3 and 6 months after surgery (P = 0.01; P = 0.006). CONCLUSIONS: Hyperreflective dots have been hypothesized to consist of intraretinal inflammatory cells. We found that HRDs were significantly associated with the morphologic stage, extent, duration, and height of the RRD before surgery and with reduced VA and CME after surgery. Our results suggest that HRDs are associated with photoreceptor degeneration, as longstanding and extensive RRDs are more likely to present with HRDs. The association of HRDs with CME provides insight into the possible importance of inflammatory processes in RRD before and after surgery. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

BACILLARY LAYER DETACHMENT AND ASSOCIATED ABNORMALITIES IN RHEGMATOGENOUS RETINAL DETACHMENT.

PURPOSE: To describe bacillary layer detachment and related abnormalities of the foveal bouquet in rhegmatogenous retinal detachment and assess their impact on photoreceptor recovery and full-thickness macular hole formation, using optical coherence tomography. METHODS: Prospective cohort of 93 consecutive patients with fovea-off rhegmatogenous retinal detachment presenting to St. Michael's Hospital from January 2020 to April 2022, with gradable preoperative foveal optical coherence tomography. RESULTS: 23.7% (22/93) of patients had evidence of bacillary layer detachment and associated abnormalities. The mean fovea-off duration was 6.4 days (±5.6 SD). 86.4% (19/22) had foveal bacillary layer detachment, 15.8% (3/19) of which had cleavage planes extending from the outer nuclear layer into the myoid zone, and 14% (3/22) had an inner lamellar hole with a residual bridge of photoreceptor remnants (all of which progressed to full-thickness macular hole). Among patients with gradable optical coherence tomography at 3 months post-operatively, 80% (12/15) had ellipsoid zone discontinuity, which persisted in 41% (5/12) at 1 year. CONCLUSION: Bacillary layer detachment was described for the first time in the setting of rhegmatogenous retinal detachment. This is hypothesized to occur from horizontal traction secondary to hydration/lateral expansion of the outer retina in the presence of the Müller cell cone scaffold. Bacillary layer detachment may render the fovea susceptible to further injury, possibly representing a pathophysiological basis for full-thickness macular hole formation in rhegmatogenous retinal detachment.

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.

Unique case of presumed ocular tuberculosis presenting as bilateral pseudoretinitis pigmentosa.

Ocular tuberculosis is often a challenging diagnosis with extremely diverse clinical manifestations and, most times, impractical bacilli isolation. Here we describe an unprecedented case of presumed ocular tuberculosis presenting with bilateral pseudoretinitis pigmentosa and retinal vasculitis.