Search

Background/aims: To investigate the clinical effectiveness of adjunctive triamcinolone acetonide (TA) given at the time of vitreoretinal surgery following open globe trauma (OGT)., Methods: A phase 3, multicentre, double-masked randomised controlled trial of patients undergoing vitrectomy following OGT comparing adjunctive TA (intravitreal and subtenons) against standard care (2014-2020). The primary outcome was the proportion of patients with at least 10 Early Treatment Diabetic Retinopathy Study (ETDRS) letter improvement in corrected visual acuity (VA) at 6 months. Secondary outcomes included: change in ETDRS, retinal detachment (RD) secondary to PVR, retinal reattachment, macular reattachment, tractional RD, number of operations, hypotony, elevated intraocular pressure and quality of life., Results: 280 patients were randomised over 75 months, of which 259 completed the study. 46.9% (n=61/130) of patients in the treatment group had a 10-letter improvement in VA compared with 43.4% (n=56/129) of the control group (difference 3.5% (95% CI -8.6% to 15.6%), OR=1.03 (95% CI 0.61 to 1.75), p=0.908)). Secondary outcome measures also failed to show any treatment benefit. For two of the secondary outcome measures, stable complete retinal and macular reattachment, outcomes were worse in the treatment group compared with controls, respectively, 51.6% (n=65/126) vs 64.2% (n=79/123), OR=0.59 (95% CI 0.36 to 0.99), and 54.0% (n=68/126) vs 66.7% (n=82/123), OR=0.59 (95% CI 0.35 to 0.98), for TA vs control., Conclusion: The use of combined intraocular and sub-Tenons capsule TA is not recommended as an adjunct to vitrectomy surgery following OGT., Trial Registration Number: NCT02873026., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

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.

Importance: A lack of consensus exists with regard to the optimal positioning regimen for patients after macula-involving retinal detachment (RD) repair., Objective: To evaluate the effect of face-down positioning vs support-the-break positioning on retinal displacement and distortion after macula-involving RD repair., Design, Setting, and Participants: A prospective 6-month single-masked randomized clinical trial was conducted at a multicenter tertiary referral setting from May 16, 2016, to May 1, 2018. Inclusion criteria were fovea-involving rhegmatogenous RD; central visual loss within 14 days; patients undergoing primary vitrectomy and gas surgery, under local anesthetic; patients able to give written informed consent; and 18 years old and older. Analysis was conducted following a modified intention-to-treat principle, with patients experiencing a redetachment or failure to attach the macula being excluded from analysis., Interventions: Participants were randomized 1:1 to receive face-down positioning or support-the-break positioning for a 24-hour period postoperatively. Positioning compliance was not monitored., Main Outcomes and Measures: The proportion of patients with retinal displacement on autofluorescence imaging at 6 months postoperatively. Secondary outcomes included proportion of patients with displacement at 2 months; amplitude of displacement at 2 and 6 months; corrected Early Treatment Diabetic Retinopathy Study visual acuity; objective Distortion Scores; and quality of life questionnaire scores at 6 months., Results: Of the 262 randomized patients, 239 were analyzed (171 male [71.5%]; mean [SD] age, 60.8 [9.8] years). At 6 months, retinal displacement was detected in 42 of 100 (42%) in the face-down positioning group vs 58 of 103 (56%) in the support-the-break positioning group (odds ratio, 1.77; 95%CI, 1.01-3.11; P = .04). The degree of displacement was lower in the face-down group. Groups were similar in corrected visual acuity (face-down, 74 letters vs support-the-break, 75 letters), objective D Chart Distortion Scores (range: 0, no distortion to 41.6, severe distortion; with face-down at 4.5 vs support-the-break at 4.2), and quality of life scores (face-down 89.3 vs support-the-break 89.0) at 2 and 6 months. Retinal redetachment rate was similar in both groups (face-down group, 12.2% and support-the-break group, 13.7%). Retinal folds were less common in the face-down positioning group vs the support-the-break positioning group (5.3% vs 13.5%, respectively; odds ratio, 2.8; 95% CI, 1.2-7.4; P = .03). Binocular diplopia was more common in the support-the-break group compared with the face-down positioning group (7.6% vs 1.5%, respectively; odds ratio, 5.3; 95% CI, 1.3-24.6; P = .03). Amplitude of displacement was associated with worse visual acuity (r = -0.5; P < .001) and distortion (r = 0.28; P = .008)., Conclusions and Relevance: In this study, findings suggest that face-down positioning was associated with a reduction in the rate and amplitude of postoperative retinal displacement after macula-involving RD repair and with a reduction in binocular diplopia. No association was found with visual acuity or postoperative distortion., Trial Registration: ClinicalTrials.gov Identifier: NCT02748538.

PurposeOur aim was to evaluate the impact of intravitreal ranibizumab pretreatment on the outcome of vitrectomy surgery for advanced proliferative diabetic retinopathy. The objective was to determine the feasibility of a subsequent definitive trial and estimate the effect size and variability of the outcome measure.Patients and methodsWe performed a pilot randomised double-masked single-centre clinical trial in 30 participants with tractional retinal detachment associated with proliferative diabetic retinopathy. Seven days prior to vitrectomy surgery, participants were randomly allocated to receive either intravitreal ranibizumab (Lucentis, Novartis Pharmaceuticals UK Ltd, Frimley, UK) or subconjunctival saline (control). The primary outcome was best-corrected visual acuity 12 weeks following surgery.ResultsAt 12 weeks, the mean (SD) visual acuity was 46.7 (25) ETDRS letters in the control group and 52.6 (21) letters in the ranibizumab group. Mean visual acuity improved by 14 (31) letters in the control group and by 24 (27) letters in the ranibizumab group. We found no difference in the progression of tractional retinal detachment prior to surgery, the duration of surgery, or its technical difficulty. Vitreous cavity haemorrhage persisted at 12 weeks in two of the control group but none of the ranibizumab group.ConclusionRanibizumab pretreatment may improve the outcome of vitrectomy surgery for advanced proliferative diabetic retinopathy by reducing the extent of post-operative vitreous cavity haemorrhage. However, the effect size appears to be modest; we calculate that a definitive study to establish a minimally important difference of 5.9 letters at a significance level of P<0.05 would require 348 subjects in each arm.

Purpose: To test the hypothesis that adjunctive slow-release dexamethasone implant (Ozurdex; Allergan Inc, Irvine, CA) can improve the outcomes of vitreoretinal surgery for established proliferative vitreoretinopathy (PVR)., Design: A 2-year, single-center, prospective, participant- and surgeon-masked randomized controlled clinical trial (EudraCT No. 2011-004498-96)., Participants: A total of 140 patients requiring vitrectomy surgery with silicone oil for retinal detachment with established PVR (Grade C) were randomized to standard (control) or study treatment (adjunct) in a 1:1 allocation ratio., Methods: Intraoperatively, the adjunct group received an injection of 0.7 mg of slow-release dexamethasone (Ozurdex) at the time of (1) vitrectomy surgery and (2) silicone oil removal. The control group received standard care., Main Outcome Measures: Primary outcome measure was the proportion of patients with a stable retinal reattachment with removal of silicone oil without additional vitreoretinal surgical intervention at 6 months. Secondary outcomes included (1) final visual acuity (VA) (median and Early Treatment Diabetic Retinopathy Study [ETDRS] of 55 letters or better); (2) cystoid macular edema (CMO), foveal thickness, and macular volume; (3) development of overt PVR recurrence; (4) complete and posterior retinal reattachment; (5) tractional retinal detachment; (6) hypotony/increased intraocular pressure (IOP); (7) macula pucker/epiretinal membrane; (8) cataract; and (9) quality of life., Results: All 140 patients were recruited within 25 months of study commencement; 138 patients had primary outcome data. Primary outcome assessment showed similar results in anatomic success between the 2 groups (49.3% vs. 46.3%, adjunct vs. control; odds ratio, 0.89; 95% confidence interval, 0.46-1.74; P = 0.733). Mean VA at 6 months was 38.3 ETDRS letters and 40.2 letters in the adjunct and control groups, respectively. Secondary anatomic outcomes (complete/posterior reattachment rates and PVR recurrence) were comparable between the 2 groups. At 6 months, fewer adjunct patients had CMO (42.7%) or a foveal thickness of >300 μm (47.6%) compared with controls (67.2% and 67.7%, respectively, P = 0.004, P = 0.023)., Conclusions: A slow-release dexamethasone implant did not improve the primary anatomic success rate in eyes undergoing vitrectomy surgery with silicone oil for PVR. Further clinical trials are indicated to improve anatomic and visual outcomes in these eyes, but this study suggests that there is a greater reduction in CMO observed at 6 months in vitrectomized eyes treated with slow-release dexamethasone., (Copyright © 2017 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: Eyes sustaining open globe trauma are at high risk of severe visual impairment. Ocular injuries which result in visual loss invariably affect the posterior segment of the eye, and prevention of visual loss involves posterior segment (vitreoretinal) surgery. Despite improvements in vitreoretinal surgical techniques, outcomes in these patients remain unsatisfactory, and development of the intraocular scarring response proliferative vitreoretinopathy is the leading cause. Proliferative vitreoretinopathy is the most common cause of recurrent retinal detachment in these eyes; it is reported to occur in up to 45 % of cases., Methods/design: The Adjunctive Steroid Combination in Ocular Trauma (ASCOT) trial is a multi-centre, double-masked, parallel-arm randomised controlled trial with an internal pilot designed to investigate the effectiveness and cost-effectiveness of using intravitreal and sub-Tenon's triamcinolone acetonide peri-operatively in patients undergoing vitrectomy following open globe trauma. In total, 300 eyes of 300 patients will be recruited and randomly allocated to one of two treatment groups. Both groups will receive standard surgical treatment and routine pre-operative and post-operative treatment and care. The treatment group will receive an adjunctive peri-operative steroid combination (triamcinolone acetonide) consisting of 4 mg/0.1 ml into the vitreous cavity and 40 mg/1 ml into the sub-Tenon's space. The trial incorporates a two-stage internal pilot to examine projected recruitment and retention rates. Progression criteria from the internal pilot study will enable us to determine whether to undertake the main trial. Patients and primary outcome assessors will be masked to treatment allocation. The primary outcome will be an improvement from baseline to 6 months of at least 10 on the corrected visual acuity as measured by ETDRS letter score. Secondary outcomes will be development of scarring, retinal detachment, intraocular pressure abnormalities, quality of life and public sector service use., Discussion: This is the first powered, controlled clinical trial to investigate the use of adjunctive triamcinolone in patients undergoing vitrectomy following open globe trauma., Trial Registration: EudraCT2014-002193-37 . Registered on 5 September 2014. ISRCTN30012492 . Registered on 5 September 2014.

Background: Proliferative vitreoretinopathy (PVR) is the commonest cause of late anatomical failure in rhegmatogenous retinal detachment. Visual and anatomical outcomes remain poor despite advances in vitreoretinal surgical techniques with reported primary failure rates of up to nearly 50%. Numerous adjunctive medications have been evaluated in clinical trials with no agent gaining widespread acceptance and use.This study was designed to investigate the benefits of using a slow-release dexamethasone implant delivered intra-operatively in patients undergoing vitrectomy surgery for retinal detachment with established PVR., Methods/design: For the study, 140 patients requiring vitrectomy surgery with silicone oil for retinal detachment with established PVR will be randomised to receive either standard treatment or study treatment in a 1:1 treatment allocation ratio. Both groups will receive the standard surgical treatment appropriate for their eye condition and routine peri-operative treatment and care, differing only in the addition of the supplementary adjunctive agent in the treatment group. The investigated primary outcome measure is stable retinal reattachment with removal of silicone oil without additional vitreoretinal surgical intervention at 6 months., Discussion: This is the first randomised controlled clinical trial to investigate the use of an adjunctive slow-release dexamethasone implant in patients undergoing vitrectomy surgery for retinal detachments with proliferative vitreoretinopathy., Trial Registration: EudraCT No: 2011-004498-96.

Purpose:  To provide data on the outcome of pseudophakic retinal detachment (PRD)., Methods: In a retrospective case-control study, we identified a consecutive series of 63 298 cataract extractions (45 520 patients) performed in a single institution between 1994 and 2003. We included 249 cases with PRD and 845 controls that had cataract surgery on the same day as cases but without PRD. Outcome measures were the risk of impaired vision (6/18-6/60) or blindness (<6/60). A multinomial logistic regression model evaluated risk factors for impaired vision or blindness, while multivariable regression models measured the relative risk of poor visual outcome for posterior capsule tear (PCT) and PRD., Results: Primary pars plana vitrectomy was performed on 207 (84.5%) of the 245 cases treated with surgery, of which 175 (71.4%) needed one procedure. The final acuity was <6/60 in 62 cases (24.9%) and 34 controls (4.0%). After PRD, the relative risk for a final visual outcome <6/60 was 6.8 [95% confidence interval (CI) 4.3-10.6; p < 0.001], and we estimated that the proportion of blindness attributable to PRD was 1.1% (CI 0.7-1.9%). A PCT prior to a PRD was not associated with an increased risk of macular detachment (p = 0.165), but it did carry an increased risk of blindness [odds ratio 4.8 (CI 2.2-10.2; p < 0.001]., Conclusion:  Although a PCT has an adverse effect on visual outcome after cataract surgery, a PRD is the foremost surgery-related risk for a poor visual outcome. Patient education of symptoms and prompt treatment may limit the visual consequences., (© 2011 The Authors. Acta Ophthalmologica © 2011 Acta Ophthalmologica Scandinavica Foundation.)

Aim: Devise simplified formulae, using preoperative clinical data, to give risk estimates of (1) failure and (2) proliferative vitreoretinpathy (PVR) following primary retinal detachment repair by vitrectomy., Methods: 641 patients were analysed as part of an RCT investigating use of 5-fluorouracil and low-molecular-weight heparin. Treatment status had no effect on success rates and did not therefore form part of the analyses. Preoperative risk factors for surgical failure and for PVR within 6 months of retinal detachment surgery were identified, and a multiple variable logistic regression model developed. Further analyses were performed to devise a simple points system to produce risk estimates of failure., Results: Three risk factors were related to failure-previous lens extraction (p=0.046), grade C PVR (p=0.039) and extent of detachment (p<0.001). Three risk factors were also related to failure due to PVR-vitreous haemorrhage (p=0.088), grade C PVR (p=0.044) and extent of detachment (p<0.001). There was good agreement between risk estimates produced by the points system and those calculated directly using a multivariate regression model. The points-system model gave an area under the receiver operating characteristic curve of 0.658. The receiver operating characteristic curve for the PVR model gave an area under the curve of 0.8399 suggesting greater diagnostic value., Conclusions: A simple points system may be used as a clinical guide to identify patients at higher risk of failure following retinal detachment repair by vitrectomy. This may help clinicians select appropriate surgical approaches and stratify cases in research and surgical training.

Aim: To identify preoperative features associated with surgical failure following vitrectomy using data collected in a large, prospective randomised controlled trial. Outcomes of patients who redetached were then examined in more detail., Methods: 615 patients were analysed as part of an randomised controlled trial investigating the use of 5-fluorouracil and low-molecular-weight heparin. Treatment status had no effect on success rates and did not therefore form part of the analyses. Failure was defined as retinal redetachment within 6 months of primary vitrectomy. Univariate logistic regression analysis was used to assess association between failure and putative risk factors (age, pathological myopia, intraocular pressure, vitreous haemorrhage, previous lens extraction, uveitis, number of retinal quadrants detached, number and distribution of retinal breaks, and grade C proliferative vitreoretinopathy (PVR)). Additional characteristics of patients were then elucidated including number of operations required to achieve retinal reattachment, surgical techniques used and final logMAR visual acuity., Results: 96 patients (15.6%) redetached following surgery, and 37 failed due to PVR. Surgical failure was associated with number of retinal quadrants detached (OR per increase, 1.69 (1.33 to 2.15) p<0.001) and grade C PVR (OR 3.98 (1.47 to 10.73) p=0.006). Inferior breaks were not identified as a risk factor (p=0.602). Repeat retinal detachment surgery showed a trend towards reduced visual acuity at 6 months providing PVR did not develop. PVR resulted in a significant deterioration in visual acuity., Conclusions: The extent of retinal detachment and preoperative PVR are risk factors for surgical failure following vitrectomy for primary retinal detachment. PVR was again confirmed as the major factor influencing visual outcomes.

Aim: To evaluate outcome following retinectomy surgery and to identify factors that predict visual outcome., Methods: This was a retrospective uncontrolled interventional case-series of patients who underwent retinectomy surgery at Moorfields Eye Hospital (London, UK) during a 2-year period. We recorded peri-operative factors with the potential to influence functional outcome including aetiology of retinal detachment; type of ocular trauma; preoperative visual acuity and intraocular pressure; grade of PVR; extent and position of retinectomy; peri-operative complications; tamponade agent and prophylactic 360 degrees laser retinopexy., Results: The authors identified 145 patients who underwent retinectomy surgery. After a mean follow-up period of 23.2 months (6-58 months) 16% of eyes had visual acuity of 20/60 or better, 33% had visual acuity of between 20/60 and 20/400, and 51% had visual acuity less than 20/400. Visual acuity was improved or stable in 76% of eyes and the rate of complete retinal reattachment was 68%. For each stepwise increase in the grade of PVR there was an approximately 15% increased risk of final visual acuity of less than 20/40. The use of additional 360 degree prophylactic laser retinopexy prior to removal of silicone oil was associated with a higher rate of final retinal reattachment., Conclusions: This study provides important information to help surgeons inform and counsel their patients about visual prognosis following retinectomy surgery. Furthermore, the study demonstrates that the aetiology of retinal detachment, the stage of PVR and the use of 360 degrees laser retinopexy have significant predictive value for visual outcome., Summary: Retinectomy is a valuable technique in the management of complex retinal detachment but is associated with a significant risk of retinal redetachment and poor visual outcome. In this large study, we identified that the aetiology of retinal detachment, the stage of proliferative vitreoretinopathy and the use of 360 degrees prophylactic laser retinopexy are predictive of functional outcome.

Background: Stickler syndrome is a hereditary oculo-systemic disorder where patients are predisposed to retinal detachments which are often complex and challenging to manage. Significant progress has been made regarding the molecular genetics of the condition; however, there is little recent literature on surgery for retinal detachment in Stickler syndrome. Our aim is to describe a population of Stickler patients presenting to Moorfields Eye Hospital with detachment from 1986 to 2003. We looked at patient characteristics, characteristics of detachment, management and anatomical and functional outcomes. We also aim to compare this group from 1986 to 2003 with a past group of Stickler patients treated at Moorfields between 1965 and 1985, reported by (Billington et al. in Trans Ophthalmol Soc UK 104:875-879, 1985). This comparison of 20-year matched cohorts examined patient characteristics, features of detachment, management and anatomical outcome in the two groups using the same definitions as the earlier authors., Results: In the Stickler group from 1986 to 2003, complete re-attachment rate was 67% for primary scleral-buckle surgery, 84.2% for primary vitrectomy and 78.57% for all surgery in 30 eyes of 23 patients. Overall in this group there was an average increase in Logmar visual acuity of 0.33 and 0.32 in patients undergoing primary cryo-buckle and primary vitrectomy surgery respectively. When comparing the two groups using Fisher's exact test, we found that the group from 1986 to 2003 had significant improvement in re-attachment for detachments with multiple tears and for vitrectomy surgery, compared with the group from 1965 to 1985., Conclusions: This study shows that despite complicated surgery and often multiple procedures, good anatomical outcomes were achieved as well as useful functional visual results after retinal detachment surgery in Stickler patients. It would also appear that when comparing the group of Stickler patients from 1986 to 2003 with the group from 1965 to 1985 improvements were seen in outcome from vitrectomy surgery and surgery for multiple breaks probably due to advances in technique and technology in vitreoretinal surgery, over the past 4 decades.

Background: This study was undertaken to relate the anatomic and functional results of patients who underwent retinectomy for complex retinal detachment (RD) to preoperative prognostic variables., Methods: Three hundred and four eyes of 302 patients whose surgery involved retinectomy were included in the analysis. All eyes had established proliferative vitreoretinopathy (PVR grade C). The main outcome measures were (1) postoperative visual acuity of 6/24 or better, (2) status of the retina at the end of follow-up, and (3) incidence of hypotony whilst under review., Results: PVR was secondary to rhegmatogenous RD in 237 eyes (78%), posterior trauma in 51 eyes (16.8%), tractional RD in vasoproliferative vasculitides in 12 eyes (4%), acute retinal necrosis in 2 eyes and endophthalmitis in 2 eyes. Complete reattachment rate after one operation was 51%, with final complete reattachment success rate of 72%. The visual acuity improved in 138 eyes (45%), remained the same in 73 eyes (24%) and became worse in 89 cases (29%). Postoperative visual acuity of 6/24 or better was significantly associated with preoperative vision, the duration of silicone oil tamponade, silicone oil removal and retinectomy size. There was also some evidence of association between visual outcome and the number of clock hours of retinal detachment. Final retinal attachment was significantly associated with silicone oil removal and preoperative vision, and final hypotony was significantly associated with silicone oil removal. The incidence of sympathetic ophthalmia in our study was 0.09% (one case)., Conclusions: Good functional outcome is possible following retinectomy surgery despite advanced pathology and often multiple surgical procedures. Retinal redetachment as a result of reproliferation and hypotony appear to be the main reasons for anatomical and functional failure. The clinical features we have identified as good indicators for improved final visual acuity such as shorter tamponade duration, removal of silicone oil, smaller retinectomy size, fewer previous operations and better preoperative vision are surrogate markers of less advanced PVR and should prompt retinal surgeons to consider retinectomy at an earlier stage in the process of PVR development. Clinicians should be aware of the small risk of sympathetic ophthalmia from complex retinal surgery.

Purpose: To determine factors associated with anatomical and functional outcomes of macula-off retinal detachment surgery in a modern vitreoretinal unit., Methods: A retrospective casenote review of 185 patients presenting with macula-off retinal detachment was performed. Demographic and ocular characteristics were determined. Logistic regression analysis was used to determine (1) the effect of these factors on visual outcome and (2) their effect on primary and final anatomical success., Results: Primary and ultimate anatomical success were achieved in 76 and 84% of cases. Patients with oil in at final follow-up were considered to be anatomical failures. Statistically significant factors predicting primary anatomical success using a multiple variable model were preoperative logMAR visual acuity, preoperative PVR and number of breaks. Preop logMAR visual acuity and duration of macular detachment were the statistically significant factors predicting ultimate success. In all, 44% of patients regained 6/12 Snellen or better with a median improvement of 0.78 logMAR. For prediction of visual outcome (in patients with no ocular comorbidity) only preoperative logMAR visual acuity achieved statistical significance (P=0.001) at the P=0.05 level., Conclusion: In all, 76% of macula-off detachments may be repaired with one operation and 44% of patients regain at least 6/12 Snellen. The median logMAR acuity increment of 0.78 far exceeds that seen in cataract surgery. Preoperative visual acuity is the most important factor predicting primary and final anatomical success as well as visual outcome. Preoperative PVR, number of breaks and duration of detachment also affect outcomes.

Objective: To determine the efficacy of a combination of 5-fluorouracil (5FU) and low-molecular-weight heparin (LMWH) in the treatment of unselected rhegmatogenous retinal detachment (RRD) undergoing primary vitrectomy., Design: Double-masked, prospective, randomized, placebo-controlled clinical trial., Participants: Six hundred forty-one patients presenting with primary RRD were recruited from 2 specialized vitreoretinal units-Moorfields Eye Hospital, London (n = 553) and St. Pauls Eye Unit, Liverpool (n = 88)., Intervention: All patients underwent primary vitrectomy and gas endotamponade. Adjuvant therapy in the treatment group consisted of 5 IU/ml LMWH and 200 mug/ml 5FU added to the perioperative infusion fluid., Main Outcome Measures: The primary outcome measure was retinal reattachment after primary vitrectomy without any reoperations at 6 months. Secondary outcome measures recorded at 6 months were the occurrence and grade of proliferative vitreoretinopathy (PVR), best-corrected visual acuity in logarithm of the minimum angle of resolution, intraocular pressure (mmHg), corneal clarity, and complications., Results: The overall primary success rate was 84.4%; in the treatment group, the primary success rate was 82.3% compared with 86.8% in the placebo group (P = 0.12). At 6 months, the final complete anatomical reattachment rate was 97.9% in both treatment and placebo groups. The number of patients who failed due to the development of PVR was not statistically significant, 23 in the treatment group (7.0%) and 14 in the placebo group (4.9%) (P = 0.309). There was no significant difference in the mean visual acuity at 6 months in the placebo group (0.48) versus the treatment group (0.53; P = 0.072). The visual acuity at 6 months of patients presenting with a macula-sparing retinal detachment was significantly worse in the treatment group (P = 0.0091). There was no significant difference between the 2 groups in patients who presented with a macula involving retinal detachment (P = 0.896)., Conclusions: Primary vitrectomy has a high anatomic and visual success rate for RRD. Adjuvant therapy with 5FU and LMWH does not improve the anatomic or visual success rate of unselected primary retinal detachments undergoing vitrectomy. After adjuvant therapy, a worse visual outcome was observed in patients presenting with macula-sparing retinal detachments. A combination of 5FU and LMWH should not be used routinely for primary RRD surgery.

Objective: To define the incidence, pattern, duration, and clinical consequences of persistent localized submacular fluid after scleral buckle surgery for retinal detachment (RD)., Design: Prospective observational cohort series., Participants: Ninety-eight patients were identified and recruited to the study., Methods: Patients aged > or =18 years undergoing scleral buckle surgery for uncomplicated primary RD over an 18-month period were recruited. All patients underwent clinical examination and optical coherence tomography (OCT) scan of the macula preoperatively and at 6 weeks postoperatively. Those patients who had an abnormality on OCT 6 weeks after surgery underwent follow-up with repeat of the study investigations at 3, 6, 9, 12, and 18 months after surgery until the abnormality resolved. If no abnormality was seen at the 6-week examination, no further investigation was undertaken., Main Outcome Measure: Presence of submacular fluid on OCT 6 weeks after surgery. Other outcome measures were duration of persistent fluid and associations with poor visual outcome, type, or duration of detachment., Results: Of the 98 patients recruited into the study, 54 (55%) had subretinal fluid (SRF) on OCT 6 weeks after surgery. We identified 3 patterns of submacular fluid: confluent fluid, a single discrete bleb of fluid, and multiple blebs of fluid. Fluid was associated with delayed visual recovery. Of those with SRF, 78% had persistent fluid at 6 months; resolution of fluid took a median of 10 months and was associated with an improvement in vision., Conclusions: Optical coherence tomography is a useful noninvasive diagnostic method that can detect SRF not seen on clinical examination. Persistent SRF 6 weeks after scleral buckle surgery occurs in approximately half of patients, may persist for many months, and can cause delayed visual recovery.

Aim: To devise a quantative method for the measurement of the extent of macular subretinal fluid using optical coherence tomography (OCT), and to assess the interobserver and intraobserver agreement for this grading system., Methods: Observational cohort series. Patients were a cohort who underwent retinal detachment surgery over an 18-month period. All patients had OCT scan at 6 weeks after surgery. The scans were graded by two independent observers experienced in OCT interpretation and each grader was masked to the others findings. Observer 1 then regraded the scans on a later day masked to his previous findings. The interobserver and intraobserver agreement was assessed using weighted Kappa (Kw) statistics., Results: In all, 116 patients were analysed. Both the intraobserver and interobserver agreement was very high, with Kw being 0.9631 and 0.9070, respectively., Conclusions: The grading system for assessment of the extent of macular subretinal fluid using OCT appears to have very good reproducibility and repeatability. We propose that this grading system would be clinically useful when applied to pathologies visible on OCT scan of the macula.

Objective: To define the incidence, duration, and clinical associations of persistent localized submacular fluid after pars plana vitrectomy (PPV) retinal detachment surgery., Design: Observational cohort series., Participants: One hundred patients were identified and recruited into the study., Methods: Patients aged 18 years and older who had undergone PPV and gas as a primary procedure for rhegmatogenous retinal detachment and postoperative follow-up were recruited from February through August 2004. All patients underwent clinical examination, optical coherence tomography (OCT) scan of the macula, and retinal thickness analysis scan of the macula. Those patients in whom an abnormality was seen on OCT at 6 weeks after surgery underwent follow-up with repeat of the study investigations at 3, 6, 9, 12, and 18 months after surgery until the abnormality resolved. If no abnormality was seen at the 6-week examination, no further investigation was undertaken. Demographic data, including detachment characteristics, were collected retrospectively from the patient case notes., Main Outcome Measures: The principle outcome measure was the presence of subretinal fluid (SRF) on OCT at 6 weeks after surgery. Other outcome measures included duration of persistent fluid and association with visual outcome and type and duration of detachment., Results: One hundred patients were recruited; 15 of these had SRF on OCT performed at 6 weeks after surgery. Subretinal fluid was associated with significantly worse visual acuity (VA) at 6 weeks (P = 0.033, Wilcoxon rank-sum); those with SRF had a median VA of 0.4, and those with no SRF had a median VA of 0.3. The fluid took a median of 5.5 months to resolve. Seven patients had combined PPV and scleral buckle surgery; none of these had fluid at 6 weeks., Conclusions: Optical coherence tomography is a useful noninvasive diagnostic method that can detect SRF not appreciated on clinical examination. Persistent SRF after PPV and gas surgery occurred in 15% of patients in this study and was still present in 53% of these at 6 months. The presence of SRF at 6 weeks after surgery was associated with a poorer visual outcome at this time point.

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.

Objectives: To identify risk factors for retinal redetachment after removal of silicone oil. To determine the effectiveness of prophylactic laser in preventing retinal redetachment after removal of silicone oil., Design: A nonrandomized retrospective comparative interventional trial., Participants: Three hundred seventy-six patients undergoing vitrectomy with silicone oil tamponade for rhegmatogenous retinal detachment at one institution over a 4-year period. Two hundred eighty-seven patients with fully attached retinas subsequently underwent removal of silicone oil. One hundred thirty-eight cases had undergone prophylactic 360 degrees laser retinopexy before removal of silicone oil, either at the time of their final retinal reattachment procedure (n = 36) or as a separate supplementary procedure (n = 102)., Methods: A retrospective case note review was performed to identify clinical and demographic factors associated with increased or reduced odds of retinal redetachment after removal of silicone oil. Both univariate and multiple variable analysis were used to identify significant risk factors., Main Outcome Measures: Incidence of retinal redetachment after removal of silicone oil., Results: Median follow-up after removal of silicone oil was 272 days. Three hundred sixty-degree prophylactic laser retinopexy was associated with a reduction from 26% to 14% in the incidence of redetachment after removal of silicone oil (adjusted odds ratio, 0.42; 95% confidence interval, 0.22-0.78; P = 0.006). Patients requiring further retinal reattachment surgery after their first oil procedure were at twice the odds of re-detachment after oil removal (adjusted odds ratio, 2.10; 95% confidence interval, 1.03-4.26; P = 0.04)., Conclusions: The need for retinal reattachment surgery subsequent to a first silicone oil procedure was associated with twice the odds of retinal redetachment after removal of silicone oil. Prophylactic laser retinopexy may halve the incidence of retinal redetachment after removal of silicone oil.

Aim: To review retrospectively 74 consecutive cases of combined phacoemulsification and transpupillary drainage of silicone oil., Methods: Candidate patients for intraocular silicone oil removal and cataract extraction underwent combined phacoemulsification and transpupillary drainage of silicone oil through a planned posterior capsulorrhexis and without the use of a pars plana infusion line., Results: The retina remained attached in 59 (79.7%) patients postoperatively. In this success group, the postoperative visual acuity improved in 42 (71.2%) patients. There was no association between age, duration of silicone oil tamponade, preoperative diagnosis, macular status or number and nature of previous surgery, and the incidence of redetachment following silicone oil removal., Conclusion: Combined phacoemulsification and transpupillary drainage of silicone oil is a safe and reliable technique that offers the main advantage of diminished surgical trauma.

PurposeInflammation is a risk factor for scarring after trabeculectomy surgery. Mast cells are important mediators of inflammation and scarring in allergic eye disease. This exploratory project investigated the presence of mast cells in the conjunctiva of glaucoma patients having trabeculectomy surgery.MethodsConjunctival biopsies from glaucoma patients belonging to specific groups: medically treated glaucoma (M, n=6), repeat glaucoma surgery (S, n=8), and uveitic glaucoma (U, n=7). The control group (C, n=8) was retinal detachment patients undergoing repair surgery for the first time. Immunohistochemistry techniques stained for the presence of the intracellular mast cell enzyme tryptase.ResultsThe median mast cell tryptase-positive counts for all glaucoma groups (M, S, and U) ranged from 0.102–0.113 cells/mm2 compared to 0.064 cells/mm2 for group C. This was statistically significant comparing group S to group C (P=0.0063), but not when comparing groups U or M to group C. The mast cell tryptase-positive counts did not significantly differ among the groups.ConclusionsMast cell numbers were significantly increased in glaucoma patients who have previously undergone surgery (group S). Mast cell activity may contribute to the scarring process and the increased risk of excessive conjunctival scarring after trabeculectomy surgery. Further investigation needs to be performed to evaluate this potential role. [ABSTRACT FROM AUTHOR]

Objective: To study the preoperative characteristics, complications and outcomes of vitrectomy for proliferative diabetic retinopathy and to identify any factors that may predict visual outcome. Methods: Prospective study of 174 consecutive vitrectomies in 148 patients, with a minimum follow-up of 4 months. Results: 41(27.7%) patients had a vision of <6/60 in their better eye at presentation. Posterior retinal breaks occurred in 47(27.0%) eyes. Postoperative complications included vitreous cavity haemorrhage in 37(22.0%) eyes, retinal detachment in five eyes (3.0%), and rubeotic glaucoma in five eyes (3.0%). 124 (74.7%) eyes improved by at least 0.3 L0gMAR units, and 15 (9.0%) worsened by at least 0.3 L0gMAR units. 119 (71.7%) eyes had a visual acuity of 6/60 or better, and 27(16.3%) were counting fingers or worse. Only 16 (11.1%) patients had a vision of <6/60 in both eyes at latest follow-up. Preoperative vision in both the operated eye and the contralateral eye, macular detachment, and long-acting intraocular tampo- nade were independent predictors of poor postoperative vision, but this model accounted for only a small proportion of the observed variation in outcomes. Conclusions: Major complications are rare after vitrectomy for proliferative diabetic retinopathy, and >70% of eyes will regain vision of 6/60 or better. Visual outcomes remain unpredictable. [ABSTRACT FROM AUTHOR]