Early versus Delayed Timing of Primary Repair after Open-Globe Injury: A Systematic Review and Meta-analysis.

TOPIC: The timing of primary repair of open-globe injury is variable in major trauma centers worldwide, and consensus on optimal timing is lacking. CLINICAL RELEVANCE: Surgery is the mainstay of open-globe injury management, and appropriate timing of surgical repair may minimize the risk of potentially blinding complications such as endophthalmitis, thereby optimizing visual outcomes. METHODS: A systematic literature review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines (International Prospective Register of Systematic Reviews identifier, CRD42023442972). The Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and ISRCTN registries and ClinicalTrials.gov were searched from inception through October 29, 2023. Prospective and retrospective nonrandomized studies of patients with open-globe injury with a minimum of 1 month of follow-up after primary repair were included. Primary outcomes included visual acuity at last follow-up and the proportion of patients with endophthalmitis. Certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: Fifteen studies met inclusion criteria, reporting a total of 8497 eyes. The most common injury types were penetrating and intraocular foreign body (IOFB). Meta-analysis found that primary repair less than 24 hours after open-globe injury was associated with 0.30 odds of endophthalmitis compared with primary repair conducted more than 24 hours after trauma (odds ratio, 0.39; 95% confidence interval [CI], 0.19-0.79; I2 = 95%; P = 0.01). No significant difference was found in reported visual outcomes between patients whose open-globe injuries were repaired more than, compared with less than, 24 hours after trauma (odds ratio, 0.89; 95% CI, 0.61-1.29; I2 = 70%; P = 0.52). All included studies were retrospective and nonrandomized, demonstrating an overall low certainty of evidence on GRADE assessment. DISCUSSION: Only retrospective data exist around the effect of timing of open-globe repair, resulting in low certainty of the available evidence. However, this review of current evidence, predominantly including penetrating and IOFB injuries, suggests that primary repair performed less than 24 hours after open-globe injury is associated with a reduced endophthalmitis rate compared with longer delays, consistent with delay to primary repair increasing endophthalmitis risk. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Temporary keratoprosthesis and primary corneal graft for ocular trauma: a systematic review and meta-analysis.

PURPOSE: When severe retinal and corneal injury occur together, a temporary keratoprosthesis (TKP) is often a last resort to allow posterior segment visualization to enable vitreoretinal surgery, followed by a penetrating keratoplasty (PKP) which can restore corneal clarity in a single operation. We aimed to assess visual outcomes following combined PKP and vitreoretinal surgery with the use of a TKP for cases of ocular trauma. DESIGN: A systematic literature review was performed following PRISMA guidelines (PROSPERO registration number: CRD42023423518). METHODS: CENTRAL, MEDLINE, Embase, ISRCTN registry and ClinicalTrials.gov were searched from inception to 27 April 2023. Randomized and non-randomized studies assessing visual outcomes after combined vitreoretinal surgery and PKP with the use of a TKP after ocular trauma were eligible for inclusion. Outcomes included change in best corrected visual acuity, corneal graft survival and retinal reattachment at final follow up. Proportional meta-analysis was used to estimate the overall rate of the primary outcomes. Risk of bias for non-randomized studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist for case series. RESULTS: A total of 19 studies met inclusion criteria reporting a total of 352 eyes. All studies were retrospective and non-randomized with follow up times ranging from 6 to 91 months, with at least 79% of outcomes reported after 6 months. After combined surgery the rate of corneal graft survival was 52% (95% CI 0.41-0.62; I2 60%) successful retinal attachment was 79% (95% CI 0.73-0.84; I2 0%). and improved visual acuity, when compared to no change or decrease in visual acuity, was 45% (95% CI 0.32-0.59; I2 66%). CONCLUSION: Patients with severe injury affecting the anterior and posterior segments have very limited treatment options. This systematic review found that when combined vitreoretinal surgery and PKP with a TKP are performed, approximately half of corneal grafts survive, anatomically successful retinal reattachment is likely, and a similar proportion of patients benefit in terms of improved visual acuity, compared to their preoperative function. This systematic review of the available literature may help inform surgeons of the benefits of using a TKP for cases of ocular trauma.

The Image Warping Test: A Novel Method to Quantify and Qualify Metamorphopsia.

PURPOSE: To determine the validity, accuracy and acceptability of the Image Warping Test (IWT), a novel test for the measurement of visual distortion in the central visual field. METHODS: 25 volunteers with metamorphopsia secondary to vitreoretinal pathology were recruited at a tertiary referral center. All subjects underwent ophthalmological examination and measurement of metamorphopsia via Amsler grid, Morphision, M-CHARTS and the IWT. Construct validity was determined through assessment of the association between symptoms, pathology, visual acuity, established metamorphopsia test results and IWT results. RESULTS: There was close association between subjective estimation of metamorphopsia severity and IWT score (p=0.005), between Morphision result and IWT score (p=0.015), and between the nature of vitreoretinal pathology and IWT score (p=0.007). There was no statistically significant correlation between best corrected distance visual acuity and IWT score, and between M-CHARTS score and IWT score. CONCLUSION: The IWT allows the creation of a digital map of subjective metamorphopsia which effectively measures its severity and nature, and opens the possibility to its non-invasive correction in future through inverse mapping of the distortion map onto live images.

A Scoping Review of the Epidemiology, Management, and Outcomes of Golf-Related Fractures.

ABSTRACT: Golf is a popular sport; however, there is a paucity of data in relation to golf-associated fractures, and the rate and timing of returning to golf. The aim of this review is to describe golf-associated fractures, including epidemiology, management, and timing of returning to golf following treatment. A literature search was performed using MEDLINE/PubMed, Embase, and Web of Science. Data were extracted and summarized in a narrative synthesis. A total of 436 articles were identified with an initial search of which 58 met the inclusion criteria. Twelve anatomical sites of golf swing-related fractures were identified, of which 10 sites were specific for stress fractures. The most common sites of golf swing-related stress fractures were the ribs followed by the hook of hamate. There was a common theme of delay to diagnosis, being initially assigned to a soft tissue injury. Most golfers with swing-related stress fractures were able to return to golf with the exception of osteoporotic associated vertebral stress fractures. Timing of returning to golf was between 4 and 12 months for most of the golfers with stress fractures following conservative management. Operative intervention was an option of hook of hamate nonunion, following a stress fracture, and tibial shaft stress fractures. Golf equipment-related fractures were not rare and were associated with major trauma and in some cases associated with significant persistent morbidity. Golf-related stress fractures commonly involve the ribs and hook of hamate; knowledge of this may aid in early diagnosis and appropriate treatment when symptomatic golfers are encountered. Although golf is a noncontact sport, fractures associated with golf equipment can be life changing, and safety training guidelines should be established.

Finite element analysis of patient-specific additive-manufactured implants.

Introduction: Bone tumors, characterized by diverse locations and shapes, often necessitate surgical excision followed by custom implant placement to facilitate targeted bone reconstruction. Leveraging additive manufacturing, patient-specific implants can be precisely tailored with complex geometries and desired stiffness, enhancing their suitability for bone ingrowth. Methods: In this work, a finite element model is employed to assess patient-specific lattice implants in femur bones. Our model is validated using experimental data obtained from an animal study (n = 9). Results: The results demonstrate the accuracy of the proposed finite element model in predicting the implant mechanical behavior. The model was used to investigate the influence of reducing the elastic modulus of a solid Ti6Al4V implant by tenfold, revealing that such a reduction had no significant impact on bone behavior under maximum compression and torsion loading. This finding suggests a potential avenue for reducing the endoprosthesis modulus without compromising bone integrity. Discussion: Our research suggests that employing fully lattice implants not only facilitates bone ingrowth but also has the potential to reduce overall implant stiffness. This reduction is crucial in preventing significant bone remodeling associated with stress shielding, a challenge often associated with the high stiffness of fully solid implants. The study highlights the mechanical benefits of utilizing lattice structures in implant design for enhanced patient outcomes.

Face-down positioning or posturing after pars plana vitrectomy for macula-involving rhegmatogenous retinal detachments.

BACKGROUND: A macula-involving rhegmatogenous retinal detachment (RRD) is one of the most common ophthalmic surgical emergencies and causes significant visual morbidity. Pars plana vitrectomy (PPV) with gas tamponade is often performed to repair primary macula-involving RRDs with a high rate of anatomical retinal reattachment. It has been advocated by some ophthalmologists that face-down positioning after PPV and gas tamponade helps reduce postoperative retinal displacement. Retinal displacement can cause metamorphopsia and binocular diplopia. OBJECTIVES: The primary objective of this review is to determine whether face-down positioning reduces the risk of retinal displacement following PPV and gas tamponade for primary macula-involving RRDs. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (which contains the Cochrane Eyes and Vision Trials Register) (2022, Issue 11), MEDLINE (January 1946 to 28 November 2022), Embase.com (January 1947 to 28 November 2022), PubMed (1948 to 28 November 2022), Latin American and Caribbean Health Sciences Literature database (1982 to 28 November 2022), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. We did not use any date or language restrictions in the electronic search. We last searched the electronic databases on 28 November 2022. SELECTION CRITERIA: We included randomized controlled trials (RCTs) in which face-down positioning was compared with no positioning or another form of positioning following PPV and gas tamponade for primary macula-involving RRDs. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodology and assessed the certainty of the body of evidence for the prespecified outcomes using the GRADE approach. MAIN RESULTS: We identified three RCTs (369 eyes of 368 participants) that met the eligibility criteria. Two RCTs provided data on postoperative retinal displacement, one reported on postoperative distortion and quality of life outcomes, two on postoperative best-corrected visual acuity (BCVA) in logMAR, and two on postoperative ocular adverse events such as outer retinal folds. Study characteristics and risk of bias All the trials involved predominantly male participants (range: 68% to 72%). Only one trial provided race and ethnicity information, was registered on a trial registry, and reported funding sources. Using the RoB 2 tool, we assessed the risk of bias for proportion of eyes with retinal displacement, mean change in visual acuity, objective distortion scores, quality of life assessments, and ocular adverse events, with most domains judged to be at low risk of bias. Findings Immediate face-down positioning may result in a lower proportion of participants with postoperative retinal displacement compared with support-the-break positioning at six months (risk ratio [RR] 0.73, 95% confidence interval [CI] 0.54 to 0.99; 1 RCT; 239 eyes of 239 participants; very low certainty evidence). One study found no evidence of a difference in BCVA at three months when comparing postoperative face-up with face-down positioning with or without perfluorocarbon liquid (mean difference [MD] -0.03, 95% CI -0.09 to 0.02; I2 = 0; 56 eyes of 56 participants; very low certainty evidence). Immediate face-down positioning appears to have little to no effect on postoperative distortion scores at week 26 (MD 1.80, 95% CI -1.92 to 5.52; 1 RCT; 219 eyes of 219 participants; very low certainty evidence) and postoperative quality of life assessment scores at week 26 (MD -1.80, 95% CI -5.52 to 1.92; 1 RCT; 217 eyes of 217 participants; very low certainty evidence). Adverse events One study that enrolled 262 participants with macula-involving RRDs suggested that immediate face-down positioning after PPV and gas tamponade may reduce the ocular adverse event of postoperative outer retinal folds at six months (RR 0.39, 95% CI 0.17 to 0.90; 1 RCT; 262 eyes of 262 participants; very low certainty evidence) and binocular diplopia (RR 0.20, 95% CI 0.04 to 0.90; 1 RCT; 262 eyes of 262 participants; very low certainty evidence) compared with support-the-break positioning. Immediate face-down positioning may increase the ocular adverse event of elevated intraocular pressure compared with support-the-break positioning (RR 1.74, 95% CI 1.11 to 2.73; 1 RCT; 262 eyes of 262 participants; very low certainty evidence). Another study found no evidence of a difference in postoperative outer retinal folds when comparing face-down versus face-up positioning at one and three months (RR 1.00, 95% CI 0.50 to 2.02; RR 1.00, 95% CI 0.28 to 3.61; 1 RCT; 56 eyes of 56 participants; very low certainty evidence). No studies reported non-ocular adverse events. AUTHORS' CONCLUSIONS: Very low certainty evidence suggests that immediate face-down positioning after PPV and gas tamponade may result in a reduction in postoperative retinal displacement, outer retinal folds, and binocular diplopia, but may increase the chance of postoperative raised intraocular pressure compared with support-the-break positioning at six months. We identified two ongoing trials that compare face-down positioning with face-up positioning following PPV and gas tamponade in participants with primary macula-involving RRDs, whose results may provide relevant evidence for our stated objectives. Future trials should be rigorously designed, and investigators should analyze outcome data appropriately and report adequate information to provide evidence of high certainty. Quality of life and patient preferences should be examined in addition to clinical and adverse event outcomes.

The Risk of Sympathetic Ophthalmia Associated with Open-Globe Injury Management Strategies: A Meta-analysis.

TOPIC: Sympathetic ophthalmia (SO) is a sight-threatening granulomatous panuveitis caused by a sensitizing event. Primary enucleation or primary evisceration, versus primary repair, as a risk management strategy after open-globe injury (OGI) remains controversial. CLINICAL RELEVANCE: This systematic review was conducted to report the incidence of SO after primary repair compared with that of after primary enucleation or primary evisceration. This enabled the reporting of an estimated number needed to treat. METHODS: Five journal databases were searched. This review was registered with International Prospective Register of Systematic Reviews (identifier, CRD42021262616). Searches were carried out on June 29, 2021, and were updated on December 10, 2022. Prospective or retrospective studies that reported outcomes (including SO or lack of SO) in a patient population who underwent either primary repair and primary enucleation or primary evisceration were included. A systematic review and meta-analysis were carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Random effects modelling was used to estimate pooled SO rates and absolute risk reduction (ARR). RESULTS: Eight studies reporting SO as an outcome were included in total. The included studies contained 7500 patients and 7635 OGIs. In total, 7620 OGIs met the criteria for inclusion in this analysis; SO developed in 21 patients with OGI. When all included studies were pooled, the estimated SO rate was 0.12% (95% confidence interval [CI], 0.00%-0.25%) after OGI. Of 779 patients who underwent primary enucleation or primary evisceration, no SO cases were reported, resulting in a pooled SO estimate of 0.05% (95% CI, 0.00%-0.21%). For primary repair, the pooled estimate of SO rate was 0.15% (95% CI, 0.00%-0.33%). The ARR using a random effects model was -0.0010 (in favour of eye removal; 95% CI, -0.0031 [in favor of eye removal] to 0.0011 [in favor of primary repair]). Grading of Recommendations, Assessment, Development, and Evaluations analysis highlighted a low certainty of evidence because the included studies were observational, and a risk of bias resulted from missing data. DISCUSSION: Based on the available data, no evidence exists that primary enucleation or primary evisceration reduce the risk of secondary SO. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Improved Outcomes with Heavy Silicone Oil in Complex Primary Retinal Detachment: A Large Multicenter Matched Cohort Study.

PURPOSE: To establish whether Densiron 68, a heavier-than-water endotamponade agent, is an effective alternative to conventional light silicone oil in primary rhegmatogenous retinal detachment (RD) surgery for eyes with inferior breaks in the detached retina and severe proliferative vitreoretinopathy (PVR). DESIGN: Cohort study of routinely collected data from the European Society of Retina Specialists and British and Eire Association of Vitreoretinal Surgeons vitreoretinal database between 2015 and 2022. PARTICIPANTS: All consecutive eyes that underwent primary rhegmatogenous RD surgery using Densiron 68 or light silicone oil as an internal tamponade agent. METHODS: To minimize confounding bias, we undertook 2:1 nearest-neighbor matching on inferior breaks, large inferior rhegmatogenous RDs, PVR, and, for visual analyses, baseline visual acuity (VA) between treatment groups. We fit regression models including prognostically relevant covariates, treatment-covariate interactions, and matching weights. We used g-computation with cluster-robust methods to estimate marginal effects. For nonlinear models, we calculated confidence intervals (CIs) using bias-corrected cluster bootstrapping with 9999 replications. MAIN OUTCOME MEASURES: Presence of a fully attached retina and VA at least 2 months after oil removal. RESULTS: Of 1061 eyes enrolled, 426 and 239 were included in our matched samples for anatomic and visual outcome analyses, respectively. The primary success rate was higher in the Densiron 68 group (113 of 142; 80%) compared with the light silicone oil group (180 of 284; 63%), with an adjusted odds ratio of 1.90 (95% CI, 1.63-2.23, P < 0.001). We also observed a significant improvement favoring Densiron 68 of -0.26 logarithm of the minimum angle of resolution (logMAR) in postoperative VA between the 2 groups (95% CI, -0.43 to -0.10, P = 0.002). The anatomic benefit of using Densiron 68 in eyes with inferior retinal breaks and large detachments was more pronounced among eyes with PVR grade C. We found no evidence of visual effect moderation by anatomic outcome or foveal attachment. CONCLUSIONS: Densiron achieved higher anatomic success rates and improved visual outcomes compared with conventional light silicone oil in eyes with inferior retinal pathology and severe PVR. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Reducing the prosthesis modulus by inclusion of an open space lattice improves osteogenic response in a sheep model of extraarticular defect.

Introduction: Stress shielding is a common complication following endoprosthetic reconstruction surgery. The resulting periprosthetic osteopenia often manifests as catastrophic fractures and can significantly limit future treatment options. It has been long known that bone plates with lower elastic moduli are key to reducing the risk of stress shielding in orthopedics. Inclusion of open space lattices in metal endoprostheses is believed to reduce the prosthesis modulus potentially improving stress shielding. However, no in vivo data is currently available to support this assumption in long bone reconstruction. This manuscript aims to address this hypothesis using a sheep model of extraarticular bone defect. Methods: Initially, CT was used to create a virtual resection plan of the distal femoral metaphyses and to custom design endoprostheses specific to each femur. The endoprostheses comprised additively manufactured Ti6Al4V-ELI modules that either had a solid core with a modulus of ∼120 GPa (solid implant group) or an open space lattice core with unit cells that had a modulus of 3-6 GPa (lattice implant group). Osteotomies were performed using computer-assisted navigation followed by implantations. The periprosthetic, interfacial and interstitial regions of interest were evaluated by a combination of micro-CT, back-scattered scanning electron microscopy (BSEM), as well as epifluorescence and brightfield microscopy. Results: In the periprosthetic region, mean pixel intensity (a proxy for tissue mineral density in BSEM) in the caudal cortex was found to be higher in the lattice implant group. This was complemented by BSEM derived porosity being lower in the lattice implant group in both caudal and cranial cortices. In the interfacial and interstitial regions, most pronounced differences were observed in the axial interfacial perimeter where the solid implant group had greater bone coverage. In contrast, the lattice group had a greater coverage in the cranial interfacial region. Conclusion: Our findings suggest that reducing the prosthesis modulus by inclusion of an open-space lattice in its design has a positive effect on bone material and morphological parameters particularly within the periprosthetic regions. Improved mechanics appears to also have a measurable effect on the interfacial osteogenic response and osteointegration.

The Use of Preoperative Prophylactic Systemic Antibiotics for the Prevention of Endopthalmitis in Open Globe Injuries: A Meta-Analysis.

TOPIC: This study reports the effect of systemic prophylactic antibiotics (and their route) on the risk of endophthalmitis after open globe injury (OGI). CLINICAL RELEVANCE: Endophthalmitis is a major complication of OGI; it can lead to rapid sight loss in the affected eye. The administration of systemic antibiotic prophylaxis is common practice in some health care systems, although there is no consensus on their use. METHODS: PubMed, CENTRAL, Web of Science, CINAHL, and Embase were searched. This was completed July 6, 2021 and updated December 10, 2022. We included randomized and nonrandomized prospective studies which reported the rate of post-OGI endophthalmitis when systemic preoperative antibiotic prophylaxis (via the oral or IV route) was given. The Cochrane Risk of Bias tool and ROBINS-I tool were used for assessing the risk of bias. Where meta-analysis was performed, results were reported as an odds ratio. PROSPERO registration: CRD42021271271. RESULTS: Three studies were included. One prospective observational study compared outcomes of patients who had received systemic or no systemic preoperative antibiotics. The endophthalmitis rates reported were 3.75% and 4.91% in the systemic and no systemic preoperative antibiotics groups, a nonsignificant difference (P = 0.68). Two randomized controlled trials were included (1555 patients). The rates of endophthalmitis were 17 events in 751 patients (2.26%) and 17 events in 804 patients (2.11%) in the oral antibiotics and IV (± oral) antibiotics groups, respectively. Meta-analysis demonstrated no significant differences between groups (odds ratio, 1.07; 95% confidence interval, 0.54-2.12). CONCLUSIONS: The incidences of endophthalmitis after OGI were low with and without systemic antibiotic prophylaxis, although high-risk cases were excluded in the included studies. When antibiotic prophylaxis is considered, there is moderate evidence that oral antibiotic administration is noninferior to IV. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Expansile gas kinetics for pneumatic retinopexy.

PURPOSE: To study the behaviour of expansile intravitreal gases and air used in treating rhegmatogenous retinal detachment. METHODS: A validated mathematical model of gas expansion and absorption in human eyes was used to simulate the effect of varying volumes of pure air, SF6, C2F6 and C3F8 injected into the vitreous cavity. Variation in axial length was accounted for by using three different vitreous cavity volumes to represent hypermetropic, emmetropic and myopic eyes. RESULTS: The time course of varying volumes of pure air and fluorinated gases injected into the vitreous cavity were tabulated, with calculated parameters including volume of gas, percentage gas fills and corresponding retinal contact angles at different time points. CONCLUSION: We produced a comprehensive compilation of expansive gas kinetics aiming to facilitate surgeon selection of the most suitable choice of gas and volume to use, tailored to an individual patient's clinical need.

Scleral Buckle, Vitrectomy, or Combined Surgery for Inferior Break Retinal Detachment: Systematic Review and Meta-Analysis.

TOPIC: To compare outcomes of scleral buckle (SB), pars plana vitrectomy (PPV), and combined PPV-SB to treat rhegmatogenous retinal detachments (RRDs) with inferior retinal breaks (IRBs). CLINICAL RELEVANCE: Rhegmatogenous retinal detachments with IRBs are not uncommon; their management is challenging with higher risk of failure. There is no consensus about their treatment, specifically whether SB, PPV, or PPV-SB should be performed. METHODS: Systematic review and meta-analysis. Randomized controlled trials, case-control, and prospective/retrospective series (if n > 50) in English were eligible. Medline, Embase, and Cochrane databases were searched up to January 23, 2023. Standard systematic review methods were followed. The following outcomes at 3 (± 1) and 12 (± 3) months were evaluated: number of eyes with retinal reattachment after ≥ 1 surgeries, change in best-corrected visual acuity from preoperative to postoperative levels, and number of eyes with improvement of > 10 and > 15 ETDRS letters after surgery. Authors of eligible studies were asked for individual participant data (IPD) and IPD meta-analysis was undertaken. Risk of bias was assessed using National Institutes of Health study quality assessment tools. This study was registered prospectively in PROSPERO (CRD42019145626). RESULTS: A total of 542 studies were identified: 15 were eligible and included and 60% were retrospective. Individual participant data was obtained from 8 studies (1017 eyes). Given that only 26 patients had received SB alone, these data were not considered in the analysis. There was no evidence for differences between treatment groups (PPV versus PPV-SB) in the probability of having a flat retina at 3 or 12 months postoperatively after 1 (P = 0.067; odds ratio [OR], 0.47; P = 0.408; OR 2.55; respectively) or > 1 (OR, 0.54; P = 0.21; OR, 0.89; P = 0.926; respectively) surgery. Pars plana vitrectomy-SB showed less improvement in vision postoperatively at 3 months (estimate, 0.18; 95% confidence interval, 0.01-0.35; P = 0.044), but this difference was no longer observed at 12 months (estimate, -0.07; 95% confidence interval, -0.27, 0.13; P = 0.479). CONCLUSION: Available evidence suggests a lack of benefit of adding SB to PPV to treat RRDs with IRBs. Evidence, however, comes mainly from retrospective series and, thus, despite the large number of eyes included, should be interpreted with caution. Further research is needed. FINANCIAL DISCLOSURE(S): The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Stratifying the risk of re-detachment: variables associated with outcome of vitrectomy for rhegmatogenous retinal detachment in a large UK cohort study.

INTRODUCTION: To identify variables associated with primary anatomical outcome following vitrectomy and internal tamponade for rhegmatogenous retinal detachment (RD). METHODS: A retrospective analysis of prospectively collected data, using a database of RD treated with vitrectomy and internal tamponade. Collected data complied with the RCOphth Retinal Detachment Dataset. The main outcome measure was anatomical failure within six months of surgery. RESULTS: There were 6377 vitrectomies. 869 eyes were excluded, either because no outcome was recorded, or inadequate follow up, leaving 5508 operations for analysis. 63.9% of patients were male, and the median age was 62. Primary anatomical failure occurred in 13.9%. On multivariate analysis, the following were associated with increased risk of failure: age <45, or >79, inferior retinal breaks, total detachment, one quadrant or greater inferior detachment, low density silicone oil, and presence of proliferative vitreoretinopathy. C2F6 tamponade, cryotherapy, and 25 G vitrectomy, were associated with reduced risk of failure. The area under the receiver operator curve was 71.7%. According to this model, 54.3% of RD are at low risk (<10%), 35.6% are at moderate risk (10-25%), and 10.1% are at high risk (>25%) of failure. CONCLUSIONS: Previous attempts to identify high risk RD have been limited by small numbers, the inclusion of both scleral buckling and vitrectomy, or by excluding some types of RD. This study examined outcomes in unselected RD, treated by vitrectomy. Identification of the variables associated with anatomical outcome after RD surgery enables accurate risk stratification, which is valuable for patient counselling and selection, and for future clinical trials.

Robot-assisted implantation of additively manufactured patient-specific orthopaedic implants: evaluation in a sheep model.

PURPOSE: Bone tumours must be surgically excised in one piece with a margin of healthy tissue. The unique nature of each bone tumour case is well suited to the use of patient-specific implants, with additive manufacturing allowing production of highly complex geometries. This work represents the first assessment of the combination of surgical robotics and patient-specific additively manufactured implants. METHODS: The development and evaluation of a robotic system for bone tumour excision, capable of milling complex osteotomy paths, is described. The developed system was evaluated as part of an animal trial on 24 adult male sheep, in which robotic bone excision of the distal femur was followed by placement of patient-specific implants with operative time evaluated. Assessment of implant placement accuracy was completed based on post-operative CT scans. RESULTS: A mean overall implant position error of 1.05 ± 0.53 mm was achieved, in combination with a mean orientation error of 2.38 ± 0.98°. A mean procedure time (from access to implantation, excluding opening and closing) of 89.3 ± 25.25 min was observed, with recorded surgical time between 58 and 133 min, with this approximately evenly divided between robotic (43.9 ± 15.32) and implant-based (45.4 ± 18.97) tasks. CONCLUSIONS: This work demonstrates the ability for robotics to achieve repeatable and precise removal of complex bone volumes of the type that would allow en bloc removal of a bone tumour. These robotically created volumes can be precisely filled with additively manufactured patient-specific implants, with minimal gap between cut surface and implant interface.

The effect of sex and laterality on the phenotype of primary rhegmatogenous retinal detachment.

BACKGROUND: To assess the effect of sex and laterality on clinical features of primary rhegmatogenous retinal detachment (RRD). METHOD: This study is a retrospective analysis of data prospectively collected. We extracted data from two online datasets over a 7-year period of patients older than 16 years who had undergone surgery for primary RRD. Data on baseline characteristics were analyzed to compare males versus females, and right versus left eyes. RESULTS: Of 8133 eyes analyzed, 4342 (53.4%) were right. The overall male predominance (63.7%) was more marked in the age range 50-69 years. Men were more commonly pseudophakic and presented more frequently with baseline posterior vitreous detachment (PVD). Female sex was significantly associated with baseline myopia, retinal holes as causative retinal break, and isolated inferior RD. Men had more frequent foveal involvement, greater RRD extent, greater numbers and larger sized retinal tears including dialysis and giant retinal tears. Regarding laterality, foveal involvement, larger retinal breaks, isolated temporal RD and temporal retinal breaks were more common in right eyes, whereas left eyes were more myopic at baseline and presented more frequently with isolated nasal RD and nasal retinal breaks. CONCLUSIONS: This study confirmed the predominance of male sex and right laterality in RRD. Sex and laterality were associated with multiple presenting features of RRD including extent, break distribution, number, size and type, as well as RD distribution.

Artificial intelligence using deep learning to predict the anatomical outcome of rhegmatogenous retinal detachment surgery: a pilot study.

PURPOSE: To develop and evaluate an automated deep learning model to predict the anatomical outcome of rhegmatogenous retinal detachment (RRD) surgery. METHODS: Six thousand six hundred and sixty-one digital images of RRD treated by vitrectomy and internal tamponade were collected from the British and Eire Association of Vitreoretinal Surgeons database. Each image was classified as a primary surgical success or a primary surgical failure. The synthetic minority over-sampling technique was used to address class imbalance. We adopted the state-of-the-art deep convolutional neural network architecture Inception v3 to train, validate, and test deep learning models to predict the anatomical outcome of RRD surgery. The area under the curve (AUC), sensitivity, and specificity for predicting the outcome of RRD surgery was calculated for the best predictive deep learning model. RESULTS: The deep learning model was able to predict the anatomical outcome of RRD surgery with an AUC of 0.94, with a corresponding sensitivity of 73.3% and a specificity of 96%. CONCLUSION: A deep learning model is capable of accurately predicting the anatomical outcome of RRD surgery. This fully automated model has potential application in surgical care of patients with RRD.

Rate and Timing of Return to Golf After Hip, Knee, or Shoulder Arthroplasty: A Systematic Review and Meta-analysis.

BACKGROUND: The physical and mental health benefits of golf are well recognized, and as a moderate-intensity activity, it is an ideal sport for patients after joint arthroplasty. PURPOSE: To assess the rate and timing of returning to golf and the factors associated with these after hip, knee, or shoulder arthroplasty. STUDY DESIGN: Meta-analysis; Level of evidence, 4. METHODS: A search of PubMed and Medline was performed in March 2021 in line with the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Search terms included sport, golf, and arthroplasty. The criterion for inclusion was any published research article studying return to golf after arthroplasty. Random-effects modeling was used to measure rates of returning to golf for each type of arthroplasty. RESULTS: A total of 23 studies were included for review. All studies were retrospective in their methodology. The mean age of patients was 66.8 years (SD, 3.37). Four studies reported on hip arthroplasty, 6 on knee arthroplasty, and 13 on shoulder arthroplasty. Among 13 studies, the mean rate of returning to golf was 80% (95% CI, 70%-89.9%). Hip, knee, and shoulder arthroplasty had mean return rates of 90% (95% CI, 82%-98%), 70% (95% CI, 39%-100%), and 80% (95% CI, 68%-92%), respectively. Among 9 studies, the mean time to return to golf was 4.4 months (95% CI, 3.2-6). Change in handicap was reported in 8 studies (35%) with a mean change of -0.1 (95% CI, -2.4 to +2.2). There were no studies presenting factors associated with return to golf. CONCLUSION: This is the first meta-analysis of returning to golf after joint arthroplasty. The study reports a high rate of returning to golf, which was greatest after hip arthroplasty. However, the study highlights the paucity of prospective data on demographic, surgical, and golf-specific outcomes after arthroplasty. Future prospective studies are required to eliminate response bias and accurately capture golf and patient-specific outcomes.

The effect of age on phenotype of primary rhegmatogenous retinal detachment.

BACKGROUND: To evaluate the influence of age on the clinical characteristics of primary rhegmatogenous retinal detachments (RRD). METHODS: We conducted a retrospective review of a prospectively collected dataset. Data regarding adult patients (aged 16-100 years) who had undergone primary RRD repair, were extracted from two online databases. Baseline demographics, preoperative clinical characteristics and surgical management details were collected. Age-based groups (16-30, 30-39, 40-49, 50-59, 60-69, 70-79, ≥80) were compared using univariate analysis, with multivariate testing for interaction of age with sex, laterality and pseudophakia. RESULTS: In total, 8,133 eyes were analysed, of which the majority (59%) were in the 50-69 age-range peaking at 60, with a male predominance (64%). Myopia was significantly more frequent in patients aged <50 years. The presence of posterior vitreous detachment increased up to 50 years, then remained >95%. Foveal involvement, grade C proliferative vitreoretinopathy, total RD and greater RD extent were more common and progressively increased after 60 years, with worsening visual acuity. Isolated superior RRDs became more prevalent with age reaching a plateau in the age-range 50-69, before reducing again; conversely, isolated inferior RRDs were commoner in those <30, with a minimum in the 70-79 age-range. The incidence of fellow-eye RRD decreased linearly with age. CONCLUSIONS: Age appeared a key variable in RRD phenotype influencing a wide range of RRD characteristics. The higher incidence of myopia, PVD absent and bilateral RRD in patients <40 years and the significant phenotypical differences in the under 40 and over 50 age-groups highlight that there are several discrete forms of RRD.