Pars plana vitrectomy compared with pars plana vitrectomy combined with scleral buckle in the primary management of noncomplex rhegmatogenous retinal detachment.

PURPOSE: To compare pars plana vitrectomy (PPV) with PPV combined with scleral buckle (PPV/SB) in the treatment of primary, noncomplex rhegmatogenous retinal detachment in an academic setting. METHODS: Retrospective review of 74 consecutive cases that underwent either PPV or PPV/SB for primary rhegmatogenous retinal detachment at New York Presbyterian Hospital, Weill Cornell Medical College. Fifty-two eyes underwent PPV alone while 22 eyes had PPV combined with SB. All eyes had a minimum of 2 months of follow-up. The main outcome measure was single surgery anatomical success. RESULTS: Patients in the PPV/SB group were less likely to be phakic (P = 0.05) and more likely to have an inferior retinal break (P = 0.001) when compared with the PPV group. Between groups, there was no difference in eyes with peripheral retinal lattice degeneration (P = 0.929), multiple breaks (P = 0.801), breaks seen preoperatively (P = 0.095), or those presenting with the macula off retinal detachment (P = 0.548). The majority of patients in both groups underwent small-gauge surgery (23 G or 25 G) (P = 0.65). Attachment of the retina was obtained in 100% of the patients in both groups at most recent follow-up. Single surgery anatomical success was similar between groups (83% PPV vs. 86% PPV/SB; P = 0.695). Mean best-corrected Snellen visual acuity improved in both groups (P = 0.75), with a final best-corrected Snellen visual acuity of 0.418 logMAR in the PPV group and 0.479 logMAR in the PPV/SB group (P = 0.61). When comparing PPV with PPV/SB, no difference in single surgery anatomical success existed after evaluating eyes with inferior breaks (P = 0.68), pseudophakia (P = 0.75), or when small-gauge surgery was performed (P = 0.76). CONCLUSION: We did not find significant differences in single surgery anatomical success, final anatomical success, or change in visual acuity when comparing PPV with PPV/SB in the repair of primary noncomplex rhegmatogenous retinal detachment in an academic setting where vitreoretinal fellows participate in key aspects of all cases.

A murine model for retinopathy of prematurity identifies endothelial cell proliferation as a potential mechanism for plus disease.

PURPOSE: To characterize the features and possible mechanism of plus disease in the mouse oxygen-induced retinopathy (OIR) model for retinopathy of prematurity. METHODS: Wild-type and Adam (A Disintegrin And Metalloproteinase) knockout mice were exposed to 75% oxygen from postnatal day 7 to 12 (P7 to P12) (hyperoxia), then returned to normal air (relative hypoxia). Live fundus imaging and fluorescein angiography at P17 were compared to immunofluorescence analysis of flat-mounted retinas. Two hallmarks of plus disease, arterial tortuosity and venous dilation, were analyzed on fixed retinas (P12-P17). The length of tortuous vessels was compared to a straight line between two points; the diameter of retinal vessels was determined using ImageJ software, and bromo-deoxyuridine (BrdU) labeling was used to visualize proliferation of retinal vascular cells. RESULTS: Mice developed retinal arterial tortuosity and venous dilation after exposure to OIR, which was visible in live fundus images and fixed whole-mounted retinas. Vein dilation, arterial tortuosity, and BrdU incorporation gradually increased over time. Moreover, Adam8(-/-) and Adam9(-/-) mice and mice lacking Adam10 in endothelial cells were partially protected from plus disease compared to controls. CONCLUSIONS: The mouse OIR model can be used to study the pathogenesis of plus disease and identify potential therapeutic targets. The severity of plus disease increases over time following OIR and correlates with increased proliferation of endothelial cells, suggesting that proliferation of vascular cells may be a mechanism underlying the development of plus disease. Moreover, our findings suggest that ADAMs 8, 9, and 10 could be targets for treatment of plus disease.

Plus disease in retinopathy of prematurity: qualitative analysis of diagnostic process by experts.

IMPORTANCE: Plus disease is the most important parameter that characterizes severe treatment-requiring retinopathy of prematurity, yet diagnostic agreement among experts is imperfect and the precise factors involved in clinical diagnosis are unclear. This study is designed to address these gaps in knowledge by analyzing cognitive aspects of the plus disease diagnostic process by experts. OBJECTIVE: To examine the diagnostic reasoning process of experts for plus disease in retinopathy of prematurity using qualitative research techniques. DESIGN: Cognitive walk-through, with qualitative analysis of videotaped expert responses and quantitative analysis of expert diagnoses. SETTING: Experimental setting in which experts were videotaped while reviewing study data. PARTICIPANTS: A panel of international retinopathy of prematurity experts who had the experience of using qualitative retinal features as their primary basis for clinical diagnosis. INTERVENTION: Six experts were video recorded while independently reviewing 7 wide-angle retinal images from infants with retinopathy of prematurity. Experts were asked to explain their diagnostic process in detail (think-aloud protocol), mark findings relevant to their reasoning, and diagnose each image (plus vs pre-plus vs neither). Subsequently, each expert viewed the images again while being asked to examine arteries and veins in isolation and answer specific questions. Video recordings were transcribed and reviewed. Diagnostic process of experts was analyzed using a published cognitive model. MAIN OUTCOME AND MEASURES: Interexpert and intraexpert agreement. RESULTS: Based on the think-aloud protocol, 5 of 6 experts agreed on the same diagnosis in 3 study images and 3 of 6 experts agreed in 3 images. When experts were asked to rank images in order of severity, the mean correlation coefficient between pairs of experts was 0.33 (range, -0.04 to 0.75). All experts considered arterial tortuosity and venous dilation while reviewing each image. Some considered venous tortuosity, arterial dilation, peripheral retinal features, and other factors. When experts were asked to rereview images to diagnose plus disease based strictly on definitions of sufficient arterial tortuosity and venous dilation, all but 1 expert changed their diagnosis compared with the think-aloud protocol. CONCLUSIONS AND RELEVANCE: Diagnostic consistency in plus disease is imperfect. Experts differ in their reasoning process, retinal features that they focus on, and interpretations of the same features. Understanding these factors may improve diagnosis and education. Future research defining more precise diagnostic criteria may be warranted.