Macular changes after primary retinectomy for retinal detachment complicated by proliferative vitreoretinopathy.

CLINICAL RELEVANCE: Primary retinectomy in eyes not previously vitrectomized has been previously rarely performed in a minority of cases, unlike non-primary retinectomies in vitrectomized eyes. BACKGROUND: This paper aims to determine anatomical and functional outcomes of primary retinectomy, and to assess structural macular changes among successful cases. METHODS: In this retrospective multicentre cohort-study, 35 primary retinectomies in eyes undergoing initial vitrectomy for rhegmatogenous retinal detachment complicated by proliferative vitreoretinopathy C or D between 2014 and 2021 were included. The mean follow-up duration was 48 ± 59.24 months among successes and 46.54 ± 20.99 months among unsuccesses (p = 0.483). RESULTS: The anatomical success rate was 48.5% after one retinectomy and 60% after two retinectomies. Mean postoperative best corrected visual acuity (BCVA) was 1.85 ± 0.62 logMAR (6/425 Snellen equivalent). The difference from mean preoperative BCVA was not significant (p = 0.312). Final BCVA ≥ 6/60 was achieved in 17% of cases, and no cases gained ≥6/24. Final mean postoperative BCVA of successes was 1.69 ± 0.60 logMAR (6/294 Snellen equivalent) compared with 2.10 ± 0.57 logMAR (6/756 Snellen equivalent) of unsuccessful cases (p = 0.101). Post-operative macular optical coherence tomography was obtained from 95% of successes. Normal macular profile was found in 10% of cases, and the other cases demonstrated exudative maculopathy (60%), tractional maculopathy (20%) and macular atrophy (10%). Final BCVA was significantly higher in eyes with normal macular status compared to eyes with exudative maculopathy (p = 0.045) and macular atrophy (p = 0.025). CONCLUSION: Primary retinectomy may be used for rhegmatogenous retinal detachment complicated with advanced proliferative vitreoretinopathy. Anatomical and functional outcome were inferior than non-primary retinectomies for grade C proliferative vitreoretinopathy. Functional outcome was influenced by macular status. Positive prognostic factors include final anatomical success and normal final macular anatomy.

Diabetic Retinopathy: Soluble and Imaging Ocular Biomarkers.

Diabetic retinopathy (DR), the most common microvascular complication of diabetes mellitus, represents the leading cause of acquired blindness in the working-age population. Due to the potential absence of symptoms in the early stages of the disease, the identification of clinical biomarkers can have a crucial role in the early diagnosis of DR as well as for the detection of prognostic factors. In particular, imaging techniques are fundamental tools for screening, diagnosis, classification, monitoring, treatment planning and prognostic assessment in DR. In this context, the identification of ocular and systemic biomarkers is crucial to facilitate the risk stratification of diabetic patients; moreover, reliable biomarkers could provide prognostic information on disease progression as well as assist in predicting a patient's response to therapy. In this context, this review aimed to provide an updated and comprehensive overview of the soluble and anatomical biomarkers associated with DR.

Early vitrectomy in eyes with non-diabetic vitreous hemorrhage.

Background: Optimal management of non-diabetic vitreous hemorrhage (NDVH) is controversial, and reliability of B-scan ultrasonography in detecting retinal tears (RTs) has been reported to be highly variable by previous literature. Objectives: To report outcomes of conservative versus surgical management of NDVH and reliability of B-scan ultrasonography in detecting RTs and rhegmatogenous retinal detachment (RRD). Design: Retrospective observational single-center cohort study. Methods: Ninety-six consecutive NDVH from 96 eyes (96 patients) with minimum follow-up duration of 12 months were included. Results: Seventy-two eyes (75%) underwent early pars plana vitrectomy (PPV), 19 (20%) were managed conservatively and 5 (5%) underwent late PPV. Initial mean best corrected visual acuities (BCVAs) were 1.95 ± 1.19, 1.19 ± 1.38, and 1.14 ± 1.04 logMAR respectively, the difference was statistically significant (p = 0.039). Mean final BCVAs were 0.92 ± 1.19, 0.59 ± 0.87, and 1.25 ± 1.89 logMAR, respectively, the difference was not significant (p = 0.447). When comparing initial and final BCVAs, the difference was significant only in the early PPV group (p = 0.00001) and was not significant in the conservative group (p = 0.066) and in the late PPV group (p = 0.46). Complications included RRD (n = 2) and re-bleed in vitrectomized cavity (n = 1) in the early surgical group, need for additional laser or cryoretinopexy to RTs (n = 2), retinal detachment (n = 1), neovascular glaucoma (n = 1), persistent vitreous hemorrhage (n = 2) in the conservative group. B-scan ultrasound showed preoperative 11.53% sensitivity and a 60.0% positive predictive value for diagnosing retinal tears (RTs) in NDVH. Conclusion: The benefit of early PPV in NDVH seems to outweigh the risks of surgery, especially in the context of low sensitivity of B-scan in identifying RTs, and significant improvement in final BCVA following surgery may occur. NDVH should be promptly referred to vitreoretinal services, as surgery may be a safer and more advisable option.

Tips to optimize digital education in ophthalmology: Results from ESASO survey.

PURPOSE: To identify audience and faculty preferences to optimize digital education sessions in ophthalmology. METHODS: We distributed an online survey to ophthalmology trainees and specialists worldwide. The survey investigated respondents' preferences on various findings of hypothetical digital educational sessions. Data were analyzed using descriptive statistics, Fisher's exact probability and ANOVA tests. RESULTS: The survey was completed by 655 respondents, from 53 different countries. According to most respondents, the optimal duration and timeframe for a valuable digital education session would be 30-60 min, without a break (52%), in the evening time-slot (6-8 p.m.) (45%) of a weekday (Monday-Thursday) (46%), regardless of age (p-value = 0.84, 0.39, 0.89, respectively) and job position (p-value = 0.31, 0.29, 0.08, respectively). The availability of webinars and recorded surgical videos/clinical cases, associated with live discussion, represented the most important opportunity of digital educational channels for 46% and 42% of respondents, respectively. CONCLUSION: Appropriate planning of timing and structure of digital educational ophthalmology sessions may optimize their effectiveness. Using multiple e-learning formats may be helpful to ensure the continuity of learning activities, also in view of a long-term replacement of traditional in-person education.

Lean approach to the management of patients undergoing intravitreal injections during COVID-19 pandemic.

BACKGROUND: To introduce Lean approach principles in the management of patients undergoing intravitreal injections (IVIs) for wet age-related macular degeneration. METHODS: Retrospective single-centre cohort study. Services location, IVIs scheduling, utilization of staff, data recording methods, ophthalmic examination and surgical procedures were analysed; a new Intravitreal Injection Centre (IVIC) was developed according to Lean principles. Mean number of daily IVIs performed, mean time between registration and discharge, mean turnover time in between patients, percentages of performed IVIs on the monthly scheduled IVIs and of patients rating their experience ⩾8/10 via standardized feedback questionnaires were retrospectively analysed. RESULTS: The mean IVIs number per day increased from 20 ± 4.08 to 50 ± 7.07, and the mean time between registration and discharge of a patient decreased from 240 ± 14.14 to 60 ± 8.16 min (p = 0.00057 and p < 0.00001, respectively). Mean turnover time in between patients decreased from 10 ± 1.41 to 8 ± 2 min (p = 0.055). The percentage of monthly IVIs performed on the total of scheduled IVIs increased from 60% to 100%, and the percentage of satisfied patients who rated IVIC ⩾8/10 increased from 45% to 95% (p = 0.0177 and p < 0.00105, respectively). CONCLUSION: The IVIC improved the quality, efficiency, speed of the overall procedures and clinical capacity of the IVI service through a fast one-way route for patients, limiting time wasted and total distance travelled. This model facilitates the creation of a one-stop clinic through the just-in-time management principle and may be relevant to other ophthalmology services.

STRUCTURAL AND FUNCTIONAL MACULAR CHANGES AFTER RETINECTOMY FOR RETINAL DETACHMENT COMPLICATED BY PROLIFERATIVE VITREORETINOPATHY.

PURPOSE: To report anatomical and functional outcomes of nonprimary retinectomy for rhegmatogenous retinal detachment with Grade C proliferative vitreoretinopathy, to assess the structural and functional macular changes in successful eyes. METHODS: Retrospective single-center cohort study: one hundred-one consecutive retinectomies of 101 eyes affected by rhegmatogenous retinal detachment with C proliferative vitreoretinopathy between January 2014 and February 2020 were included. RESULTS: The mean preoperative best-corrected visual acuity (BCVA) was 1.48 ± 0.71 logarithm of the minimal angle of resolution (20/604 Snellen equivalent). The anatomical success rate was 78.2% after one retinectomy and 83.1% after two retinectomies. The final BCVA ≥ 20/200 was achieved in 29% of cases, 8% gained ≥ 20/80. The final mean postoperative BCVA of successes with oil in situ was 1.68 ± 0.59 (20/957 Snellen equivalent) compared with 1.07 ± 0.63 logarithm of the minimal angle of resolution (20/235 Snellen equivalent) of successes after oil removal (P = 0.00005). Postoperative macular optical coherence tomography was obtained from 60/84 successes (71%). The normal macular profile was found in 3%, whereas majority demonstrated exudative maculopathy (51.5%), macular atrophy (22%), tractional maculopathy (21.5%), and macular disciform scar (2%). Bivariate linear relationship between final central foveal thickness and BCVA was statistically significant (P = 0.000013). CONCLUSION: Satisfactory anatomical and functional outcome is possible after retinectomy for C proliferative vitreoretinopathy. Positive prognostic factors include the removal of oil without redetachment, normal macular status, and lower central foveal thickness. The functional outcome was influenced by macular changes, as final BCVA and central foveal thickness correlated.

Intraocular pressure changes following topical ocular hypotensive medications washout.

BACKGROUND: To review the changes in intraocular pressure (IOP) following topical hypotensive medications washout in patients with primary open angle glaucoma (POAG), ocular hypertension (OHT) and uveitic glaucoma (UG)/OHT. METHODS: The study included 120 patients with POAG, OHT and UG recruited from prospective clinical trials between February 2013 and July 2017. We excluded 20 eyes with IOP of ≤21 mm Hg, 11 eyes with previous incisional surgery and 17 eyes with incomplete data. UG eyes with active inflammation and on steroid treatment were excluded. Participants underwent a 1-month washout period from topical ocular hypotensive medications before IOP phasing. Comparisons were made between pre/post-washout IOP, and highest-recorded (peak) and post-washout IOP. RESULTS: A total of 110 eyes with POAG, 33 eyes with OHT and 43 eyes with UG were included for analysis. The mean pre-washout IOP was 18.1±3.3 mm Hg in POAG, 18.8±3.3 mm Hg in OHT and 17.9±8.8 mm Hg in UG; the mean post-washout IOP was 26.6±4.8 mm Hg, 26.4±3.9 mm Hg, 23.1±10.1 mm Hg in POAG, OHT and UG, respectively. The mean increase in IOP after washout was significantly lower in UG compared with POAG and OHT eyes (p=0.01). The percentage of eyes with post-washout IOP <22 mm Hg was 12.7% in POAG, 6.1% in OHT and 51.2% in UG. CONCLUSION: Active inflammation and steroid treatment contributes to elevated IOP in uveitis. Therefore, IOP may revert to normal once inflammation subsides. We recommend ocular hypotensive treatment washout to be considered in UG eyes that have IOP under control in the absence of recurrence of uveitis.

Delayed spontaneous closure of traumatic macular hole in a 66-year-old patient - role of optical coherence tomography follow-up.

Objective: To report a case of delayed spontaneous closure of traumatic macular hole at 5 months in a 66-year-old man. Traumatic macular holes generally do not close spontaneously after 4 months and over 30 years of age. Methods: A 66-year-old man presented with central blurred vision and metamorphopsia in his right eye for 3 weeks after previous ocular blunt trauma occurring 2 months earlier. Best corrected visual acuity was 6/36 in his right eye, fundus examination and OCT revealed right traumatic macular hole. Results: 4 weeks later, best corrected visual acuity was 6/18, OCT showed initial reattachment of traumatic macular hole margins. 8 weeks later, best corrected visual acuity improved to 6/9, OCT showed almost complete reattachment of the margins, residual outer retinal defect being still present. At 12 weeks after initial presentation, best corrected visual acuity was 6/6, OCT showed normal neuroretinal profile. Conclusion: Clinical monitoring of traumatic macular holes might be performed up to 5 months even in patients >30 years before considering surgery.

Central Retinal Vein Prethrombosis Secondary to Retinal Vasculitis: Early Detection and Treatment.

The aim was to report a case of central retinal vein prethrombosis (CRVP), responsive to systemic steroids. An 18-year-old male presented with right sudden blurred vision and central scotoma for 2 days. Right best-corrected visual acuity (BCVA) measured 6/36, and fundoscopy revealed vascular congestion and blurred disc margins. Fluorescein angiography (FA) showed CRVP secondary to retinal vasculitis. Systemic oral prednisone was started. Six months later, right BCVA was 6/6, FA showed reduced vascular congestion, and retinal vasculitis and residual optic disc hyperfluorescence resolved. CRVP should be considered in young patients with sudden central scotoma. Early systemic steroids might be effective in the treatment of "active" retinal vasculitis.

A new paradigm for delivering personalised care: integrating genetics with surgical interventions in BEST1 mutations.

BACKGROUND: The availability and reduced cost of genotyping has improved gene susceptibility testing and our scientific understanding of disease pathophysiology. Whilst several personalised translational models exist within medical frameworks, genetic-based surgical therapy is a translational application not widely used in surgical specialties. METHOD: We present a clinical series of five patients with genetically confirmed bestrophinopathy and malignant glaucoma (MG). Patients were followed up for 12 months or more after receiving surgical intervention to manage refractory intraocular pressure (IOP) resistant to medical treatment. FINDINGS: Patients with BEST1 gene mutations are at higher risk of MG after filtration surgery. A multi-disciplinary approach after four patients experienced poor outcomes concluded that traditional first-line glaucoma surgery was not sufficient to prevent visual loss. A fifth patient presenting with the identified at-risk phenotype underwent primary pars plana vitrectomy, with pars plana Baerveldt tube insertion, successfully preventing MG and had no glaucoma progression after 5 years. INTERPRETATION: We provide proof-of-principle that genetic analysis can be used to inform the selection of surgical therapy to improve outcomes. In this case, a refinement of current surgical methods to avoid MG. Although challenges remain, personalised surgery has the potential to improve clinical outcomes beyond the scope of current surgical practice.