Morphologic Features of Regulated vs. Dysregulated Rhegmatogenous Retinal Detachment Using Swept-Source Optical Coherence Tomography.

OBJECTIVE: To describe varying morphological features of patients with RRD based on the extent of regulation of the subretinal space by the retinal pigment epithelium (RPE) pump using swept-source optical coherence tomography (SS-OCT). DESIGN: Prospective clinical cohort study. Methods SETTING: St. Michael's Hospital, Toronto, Canada, from August 2020-August 2023. PARTICIPANTS: 120 consecutive eyes with primary RRD. COHORTS: Subclinical, non-progressive, localized RRD defined as regulated vs. acute, progressive, and extensive defined as dysregulated assessed with swept-source SS-OCT. MAIN OUTCOME: Morphological features of regulated vs dysregulated RRDs with SS-OCT. RESULTS: 19.2 % (23/120) of RRDs were classified as regulated and 80.8% (97/120) were dysregulated. The mean age of patients with regulated RRDs was 37.1 years (±13.7 SD) versus 62.6 years (±11.6SD) for patients with dysregulated RRDs (P<0.001). The presence of outer retinal corrugations (ORCs) on OCT was observed in 4.3%(1/23) of regulated vs 81.4% (79/97) of dysregulated RRDs (P<0.001). CME was found in 41.6%(5/12) of regulated RRDs compared to 87.3%(83/95) of dysregulated RRDs(P<0.001). ORC presence was an independent predictor of having a dysregulated RRD (P= 0.02,ß = 6.6,95 %CI [1.3 -33.2]) when controlling for age, sex, baseline VA, lens status, and RD extent. Among patients with regulated RRDs, 25.0% (3/12) were in Stage 2, 0% (0/16) in Stage 3A, 8.3% (1/12) in Stage 3B, 0% (0/16) in Stage 4, and 66.7% (8/12) in Stage 5. In patients with dysregulated RRDs, 14.7% (14/95) were in Stage 2, 15.7% (15/95) were in Stage 3A, 37.9% (36/95) in Stage 3B, 22.1% (21/95) in Stage 4, and 9.5% (9/95) in Stage 5 (P<0.001). CONCLUSIONS: There are significant morphologic differences between regulated and dysregulated RRDs using SS-OCT. ORCs are present in almost all dysregulated cases but in a minority of regulated cases and they are an independent predictor of RPE-photoreceptor regulation status. Demographic and clinical features differentiate regulated and dysregulated RRD and understanding these differences has significant implications for optimal management and postoperative outcomes.

Pneumatic retinopexy for primary rhegmatogenous retinal detachment: from a clinical trial to the real-life experience.

BACKGROUND: To report real-world outcomes of patients with primary Reghmatogenous Retinal Detachment (RRD) treated with Pneumatic Retinopexy (PnR) according to the indications of the Pneumatic Retinopexy versus Vitrectomy for management of Primary Rhegmatogenous Retinal Detachment Outcomes Randomized Trial (PIVOT) trial. METHODS: Multicenter, retrospective study. Patients treated with PnR for RRD between 2021 and 2023 and a follow-up of at least 6 months were included. Single-procedure anatomical success, final anatomical success, complications, causes of failures, best corrected visual acuity (BCVA) after surgery, and the vision-related quality of life using the 25-Item National Eye Institute Visual Function Questionnaire (NEI VFQ-25) were reported. RESULTS: A total of 76 eyes of 76 patients were included. Mean age was 60 ± 8.1 years. Primary anatomic reattachment was achieved by 84.3% of patients and final anatomical reattachment after pars plana vitrectomy was obtained in 100% of patients. BCVA improved from 0.32 (20/40) to 0.04 (20/20) logMar (p < 0.001) at 6 months. The main cause of failure was related to the presence of additional (likely missed) retinal breaks (66.6% of cases). Also, primary PnR failure was more frequent in eyes of patients with older age, macular involvement, worse baseline BCVA, greater extent of the RRD, and increased duration from diagnosis to treatment. Overall, the mean NEI-VFQ 25 composite score was 93.9% ± 6.4 at 6 months. CONCLUSIONS: The criteria of the PIVOT trial can be applied to real-world scenarios in the decision-making process for the treatment of primary RRD, with excellent anatomical and functional outcomes.

Optical Coherence Tomography Features in Fovea-Off Exudative vs Rhegmatogenous Retinal Detachment.

PURPOSE: To describe the optical coherence tomography (OCT) features that can differentiate eyes with fovea-off exudative retinal detachment (ERD) vs. rhegmatogenous retinal detachment (RRD), with particular attention to outer retinal corrugations (ORCs). DESIGN: Multicenter, retrospective cross-sectional study. METHODS: Multicenter, retrospective cross-sectional study of patients diagnosed with unilateral or bilateral fovea-off ERD or primary, acute, fovea-off RRD between 2016 and 2021. This study was performed with the approval from the Research Ethics Board at the University of Toronto and was conducted in accordance with the Declaration of Helsinki. Patients with any ERD etiology and evidence of extensive, bullous fovea-off detachment and in the RRD group: consecutive patients with acute, primary fovea-off RRD with good quality baseline SD-OCT imaging were included. Patients with exudative choroidal neovascularization from any etiology, optic nerve pit, significant media opacity, or OCT images with poor quality or low signal strength were excluded. Primary outcome was to describe the morphological features of the macula using SD-OCT in patients diagnosed with ERD vs RRD, with specific interest in ORCs. RESULTS: 161 eyes (51 ERD and 110 RRD) of 154 patients were included. Fifty-one eyes with ERD presented with 1 of 15 etiologies. ERD were associated with a greater risk of having hyperreflective dots in the outer retina (92.2% vs 74.5%, p=0.009), hyperreflective material and dots in the subretinal fluid (72.5% vs 34.5%, p<0.001), internal limiting membrane and inner retinal undulations (70.6% vs 39.4%, p<0.001), and retinal pigment epithelium undulations (44.9% vs 6.4%, p<0.001) compared to RRD. RRD was associated with a greater risk of outer retinal corrugations (80% vs 0%, p<0.001), intraretinal fluid (90.9% vs 41.2%, p<0.001) and ellipsoid zone thickening (90% vs 66.7%, p<0.001) compared to ERD. CONCLUSION: The presence of ORCs are highly specific for RRD and absent in ERD. This is likely related to differences in the pathophysiology of the diseases process, specifically the content of the subretinal fluid. Understanding the differences in OCT morphological features of ERD vs RRD may aid with diagnosis and management.

Optical coherence tomography homography for detection of retinal displacement: a validation study.

PURPOSE: Retinal displacement following rhegmatogenous retinal detachment (RRD) has been associated with inferior functional outcomes. Recent evidence using an overlay technique suggests that fundus-autofluorescence underestimates post-RRD repair retinal displacement. This study aims to validate the overlay technique in normal eyes and to determine its sensitivity and specificity at detecting retinal displacement. METHODS: We conducted a retrospective case series involving 66 normal eyes, each with at least two separate infrared (IR) images at different time points. Overlay of the two images was based on manual marking of choroidal and optic nerve head (ONH) landmarks. For each set of two IR images, computer code for homography generated two outputs, flipping view video and an overlay picture. First, validation of choroidal/ONH alignment was performed using the flipping view video to ensure accurate manual markings. Then, two different masked graders (AB + IM) evaluated the overlays for presence of retinal displacement. 16 control eyes following RRD repair with detected retinal displacement on FAF imaging assessed sensitivity and specificity of the technique. RESULTS: 94% of overlays were found to be well aligned (62/66). 11 cases exhibited errors on flipping view analysis (choroidal/ONH misalignment). Those 11 cases had a significantly higher rate of retinal displacement (false positives) compared to cases without errors (8/11,72% Vs 54/55,98%,P = 0.001). Sensitivity and specificity of the overlay technique for detecting retinal displacement considering only adequate flipping view cases (n = 55) were calculated as 100% and 98%, respectively. CONCLUSIONS: IR overlay emerges as a reliable and valid method for detecting retinal displacement, exhibiting excellent sensitivity and specificity.

Physical and Psychosocial Challenges as Predictors of Vision Difficulty in Children: A Nationally Representative Survey Analysis.

PURPOSE: To elicit associations between vision difficulties and physical or psychosocial challenges in children in the United States. METHODS: Children aged 2-17 years old from the 2021 National Health Interview Survey with data pertaining to vision difficulty were included in our retrospective, population-based analysis. Our primary aim was investigating physical and psychosocial challenges as predictors of vision difficulty. Logistic regression models were performed on Stata version 17.0 (StataCorp LLC, College Station, Texas). Analyses were accompanied by an odds ratio (OR) and 95% confidence interval (CI). RESULTS: A total of 7,373 children had data pertaining to their level of vision difficulty and were included in our sample. In our multivariable analysis, children with a good/fair (OR = 1.84, 95% CI = [1.31, 2.60], p < 0.01), or poor (OR = 5.08, 95% CI = [1.61, 16.04], p < 0.01) general health status had higher odds of vision difficulty relative to children with an excellent/very good health status. Furthermore, children with difficulties hearing (OR = 8.67, 95% CI = [5.25, 14.31], p < 0.01), communicating (OR = 1.96, 95% CI = [1.18, 3.25], p < 0.01), learning (OR = 1.93, 95% CI = [1.27, 2.93], p < 0.01), and making friends (OR = 1.94, 95% CI = [1.12, 3.36], p = 0.02) had higher odds of vision difficulty. Nonetheless, the following factors were only predictors of vision difficulty in our univariable analysis: requiring equipment for mobility (p < 0.01), experiencing anxiety (p < 0.01), and experiencing depression (p < 0.01). CONCLUSION: Several factors pertaining to physical and psychosocial challenges in children are associated with vision difficulty. Future research should further explore potential causal links between vision difficulty and physical or psychosocial factors to aid in coordinating public health efforts dedicated to vision health equity.

International Classification System for Ocular Complications of Anti-Vascular Endothelial Growth Factor Agents in Clinical Trials.

OBJECTIVE: Complications associated with intravitreal anti-vascular endothelial growth factor (VEGF) therapies are inconsistently reported in the literature, thus limiting an accurate evaluation and comparison of safety between studies. This study aimed to develop a standardized classification system for anti-VEGF ocular complications using the Delphi consensus process. DESIGN: Systematic review and Delphi consensus process. PARTICIPANTS: 25 international retinal specialists participated in the Delphi consensus survey. METHODS: A systematic literature search was conducted to identify complications of intravitreal anti-VEGF agent administration based on randomized controlled trials (RCTs) of anti-VEGF therapy. A comprehensive list of complications was derived from these studies, and this list was subjected to iterative Delphi consensus surveys involving international retinal specialists that voted on inclusion, exclusion, rephrasing, and addition of complications. As well, surveys determined specifiers for the selected complications. This iterative process helped refine the final classification system. MAIN OUTCOME MEASURES: The proportion of retinal specialists who choose to include or exclude complications associated with anti-VEGF administration. RESULTS: After screening 18,229 articles, 130 complications were initially categorized from 145 included RCTs. Participant consensus via the Delphi method resulted in the inclusion of 91 (70%) complications after three rounds. After incorporating further modifications made based on participant suggestions, such as rewording certain phrases and combining similar terms, 24 redundant complications were removed, leaving a total of 67 (52%) complications in the final list. A total of 14 (11%) complications met exclusion thresholds and were eliminated by participants across both rounds. All other remaining complications not meeting inclusion or exclusion thresholds were also excluded from the final classification system after the Delphi process terminated. In addition, 47 out of 75 (63%) proposed complication specifiers were included based on participant agreement. CONCLUSION: Using the Delphi consensus process, a comprehensive, standardized classification system consisting of 67 ocular complications and 47 unique specifiers was established for intravitreal anti-VEGF agents in clinical trials. The adoption of this system in future trials could improve consistency and quality of adverse event reporting, potentially facilitating more accurate risk-benefit analyses.

Pars Plana Vitrectomy With Silicone Oil or Gas Tamponade for Uncomplicated Retinal Detachment: A Systematic Review and Meta-Analysis.

PURPOSE: To compare the efficacy and safety of pars plana vitrectomy (PPV) with silicone oil compared to gas tamponade for uncomplicated rhegmatogenous retinal detachment (RRD). DESIGN: Systematic review and meta-analysis. METHODS: A systematic literature search was conducted on Ovid MEDLINE, Embase, and the Cochrane Library from January 2000 to September 2023 for comparative studies evaluating the efficacy and safety of PPV with either silicone oil or gas tamponade in the setting of uncomplicated RRD. Our primary outcome was best-corrected visual acuity at the last study observation. Secondary outcomes included the rates of retinal reattachment, retinal thickness, and the incidence of adverse events. We performed a meta-analysis using a random-effects model. RESULTS: Nine observational studies reporting on 491 RRD eyes were included. The mean best-corrected visual acuity at the last study observation was significantly better in the gas tamponade group than in the silicone oil group (weighted mean difference [WMD] = 0.17 logMAR, 95% confidence interval [CI] = [0.06, 0.27], P = .002). Rates of primary retinal reattachment were similar between the silicone oil and gas tamponade groups (P = .89). The ganglion cell layer was significantly thinner in the silicone oil group compared to the gas tamponade group (WMD =-3.70 µm, 95% CI = [-5.87, -1.53, P = .0008), as was the inner plexiform layer (WMD = -2.45, 95% CI = [-4.50, -0.40], P = .02) and outer nuclear layer (WMD = -11.74 µm, 95% CI = [-18.39, -5.10], P = .0005). CONCLUSIONS: PPV with gas tamponade was associated with better functional outcomes compared to PPV with silicone oil, although both tamponades yielded comparable primary reattachment rates. The absence of randomized trials and the potential for selection bias underscore the importance of further investigation in diverse patient populations.

Google Gemini and Bard artificial intelligence chatbot performance in ophthalmology knowledge assessment.

PURPOSE: With the popularization of ChatGPT (Open AI, San Francisco, California, United States) in recent months, understanding the potential of artificial intelligence (AI) chatbots in a medical context is important. Our study aims to evaluate Google Gemini and Bard's (Google, Mountain View, California, United States) knowledge in ophthalmology. METHODS: In this study, we evaluated Google Gemini and Bard's performance on EyeQuiz, a platform containing ophthalmology board certification examination practice questions, when used from the United States (US). Accuracy, response length, response time, and provision of explanations were evaluated. Subspecialty-specific performance was noted. A secondary analysis was conducted using Bard from Vietnam, and Gemini from Vietnam, Brazil, and the Netherlands. RESULTS: Overall, Google Gemini and Bard both had accuracies of 71% across 150 text-based multiple-choice questions. The secondary analysis revealed an accuracy of 67% using Bard from Vietnam, with 32 questions (21%) answered differently than when using Bard from the US. Moreover, the Vietnam version of Gemini achieved an accuracy of 74%, with 23 (15%) answered differently than the US version of Gemini. While the Brazil (68%) and Netherlands (65%) versions of Gemini performed slightly worse than the US version, differences in performance across the various country-specific versions of Bard and Gemini were not statistically significant. CONCLUSION: Google Gemini and Bard had an acceptable performance in responding to ophthalmology board examination practice questions. Subtle variability was noted in the performance of the chatbots across different countries. The chatbots also tended to provide a confident explanation even when providing an incorrect answer.

ADAPTIVE OPTICS IMAGING IN DIABETIC RETINOPATHY: A Prospective Cohort Study.

PURPOSE: To investigate the correlation between diabetic retinopathy (DR) severity and microscopic retinal and vascular alterations using adaptive optics imaging. METHODS: In this single-center, prospective cohort study, adult participants with healthy eyes or DR underwent adaptive optics imaging. Participants were classified into control/mild nonproliferative DR, moderate/severe nonproliferative DR, and proliferative DR. Adaptive optics imaging using the RTX1 camera was obtained from 48 participants (87 eyes) for photoreceptor data and from 36 participants (62 eyes) for vascular data. RESULTS: Photoreceptor parameters significantly differed between DR groups at 2° and 4° of retinal eccentricity. Wall-to-lumen ratio varied significantly at 2° eccentricity, while other vascular parameters remained nonsignificant. Cone density and dispersion were the strongest predictors for DR severity ( P < 0.001) in multivariable generalized estimating equation modeling, while other vascular parameters remained nonsignificant between DR severity groups. All photoreceptor parameters showed significant correlations with visual acuity overall and across most DR severity groups. CONCLUSION: To date, this is one of the largest studies evaluating the use of adaptive optics imaging in DR. Adaptive optics imaging was demonstrated to differentiate between various levels of disease severity in DR. These results support the potential role in diagnostic and therapeutic microstructural evaluation in research and clinical practice.

Preoperative Visual Acuity Thresholds in Pars Plana Vitrectomy for Epiretinal Membrane: A Systematic Review.

BACKGROUND AND OBJECTIVE: This review consolidates findings from studies that used a preoperative visual acuity (VA) threshold as an indication for epiretinal membrane (ERM) surgery. METHODS: The literature was systematically searched using Ovid MEDLINE, EMBASE, and Cochrane Library from January 2000 to October 2022 to select studies reporting on pars plana vitrectomy (PPV) for ERM that used a preoperative VA threshold as an inclusion criterion. Primary outcomes were final best-corrected visual acuity (BCVA) and change in BCVA relative to baseline. Secondary outcomes included risk of intra- and postoperative complications. RESULTS: A total of 639 eyes from seven studies were included. The most liberal preoperative VA threshold was 20/28.5 or worse, whereas the most conservative threshold was worse than 20/60. The mean preoperative BCVA was 0.55 logarithm of the minimum angle of resolution (logMAR) (∼20/70), and the mean postoperative BCVA was 0.35 logMAR (∼20/45). Generally, VA improved relative to baseline, regardless of the preoperative VA threshold. The smallest improvement in VA was observed in a study where the pre-operative VA to consider surgery was liberal (20/30 or worse), whereas the greatest VA improvement was observed in a study that used a conservative preoperative VA threshold (worse than 20/60). CONCLUSIONS: The greatest improvement in BCVA was observed in studies where a conservative pre-operative VA threshold was used. The decision to operate should involve a patient-centered approach with a thorough discussion of the risks and benefits of PPV, regardless of the preoperative VA threshold used. [Ophthalmic Surg Lasers Imaging Retina 2024;55:400-407.].

SURGICAL DRAINAGE METHODS DURING PARS PLANA VITRECTOMY FOR RHEGMATOGENOUS RETINAL DETACHMENT: A Systematic Review and Meta-Analysis.

PURPOSE: To assess efficacy and safety outcomes of subretinal fluid drainage methods during pars plana vitrectomy for rhegmatogenous retinal detachment. METHODS: A systematic search strategy was conducted for studies published between January 2000 and October 2022. Included studies reported on either the safety or efficacy of two or more drainage methods during pars plana vitrectomy for patients with rhegmatogenous retinal detachment. RESULTS: Two randomized and five observational studies consisting of 1,524 eyes were included. Best-corrected visual acuity at the last study observation and primary reattachment rates were similar across groups. A significantly lower risk of epiretinal membrane formation was associated with draining subretinal fluid through preexisting retinal breaks (risk ratio = 0.70, 95% confidence interval = [0.60, 0.83], P = <0.01, I 2 = 0%) or with perfluorocarbon liquid (risk ratios = 0.70, 95% confidence interval = [0.59, 0.83], P = <0.01, I 2 = 0%) compared with posterior retinotomy. The risk of an abnormal foveal contour was significantly greater in perfluorocarbon liquid-treated eyes relative to posterior retinotomy (risk ratios = 1.56, 95% confidence interval = [1.13, 2.17], P = <0.01, I 2 = 0%). CONCLUSION: No significant differences were observed in the final best-corrected visual acuity at the last study observation and primary reattachment rates across different drainage methods. There remains limited information on the topic, so future research is warranted.

VALIDATION OF M-CHARTS FOR QUANTITATIVE ASSESSMENT OF METAMORPHOPSIA FOLLOWING RHEGMATOGENOUS RETINAL DETACHMENT REPAIR.

PURPOSE: To validate the quantitative assessment of metamorphopsia in rhegmatogenous retinal detachment (RRD) using M-CHARTS by determining its correlation with subjective reporting of metamorphopsia with a validated metamorphopsia questionnaire (modified MeMoQ). METHODS: The Research Ethics Board approved a prospective observational study carried out at St. Michael's Hospital, Toronto, Canada. Patients with primary, unilateral RRD and healthy controls were included. Metamorphopsia at 3 months was assessed with modified MeMoQ and M-CHARTS. RESULTS: One hundred patients (50 with RRD, 50 controls) were included. Seventy percent (35/50) of the RRD group had metamorphopsia with M-CHARTS and 80% (40/50) with MeMoQ. The modified MeMoQ and total M-CHARTS scores were significantly higher in patients with RRD compared with controls ( P < 0.0001). Cronbach's alpha reliability coefficient was 0.934 in the RRD group. Horizontal, vertical, and total M-CHARTS scores were significantly correlated with MeMoQ scores (r s  = 0.465, P = 0.0007; r s  = 0.405, P = 0.004; r s  = 0.475, P = 0.0005, respectively). M-CHARTS was 72.7% sensitive and 94.6% specific for detection of metamorphopsia (positive score ≥ 0.2), with an area under the receiver operating characteristic curve = 0.801. A stronger correlation was found in patients who scored ≥0.2 on the M-CHARTS and reported metamorphopsia with the MeMoQ (r s  = 0.454, P = 0.001). CONCLUSION: The authors have validated M-CHARTS as a tool to quantitatively assess metamorphopsia in patients with RRD, which is significantly correlated with patient-reported outcomes using the MeMoQ. A total score of ≥0.2 with M-CHARTS was more strongly correlated with MeMoQ.