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ObjectivesTo reassess the definition of a large macular hole, factors predicting hole closure and post-surgery visual recovery.DesignDatabase study of 1483 primary macular hole operations. Eligible operations were primary MH operations treated with a vitrectomy and a gas or air tamponade. Excluded were eyes with a history of retinal detachment, high myopia, previous vitrectomy or trauma.ResultsA higher proportion of operations were performed in eyes from females (71.1%) who were ‘on average’ younger (p < 0.001), with slightly larger holes (p < 0.001) than male patients. Sulfur hexafluoride gas was generally used for smaller holes (p < 0.001). From 1253 operations with a known surgical outcome, successful hole closure was achieved in 1199 (96%) and influenced by smaller holes and complete ILM peeling (p < 0.001), but not post-surgery positioning (p = 0.072). A minimum linear diameter of ~500 μm marked the threshold where the success rate started to decline. From the 1056 successfully closed operations eligible for visual outcome analysis, visual success (defined as visual acuity of 0.30 or better logMAR) was achieved in 488 (46.2%) eyes. At the multivariate level, the factors predicting visual success were better pre-operative VA, smaller hole size, shorter duration of symptoms and the absence of AMD.ConclusionsFemales undergoing primary macular hole surgery tend to be younger and have larger holes than male patients. The definition of a large hole should be changed to around 500 μm, and patients should be operated on early to help achieve a good post-operative VA.

Learning ObjectivesUpon completion of this activity, participants will:Assess variables associated with primary anatomical outcome (anatomical failure within 6 months of surgery) after vitrectomy and internal tamponade for rhegmatogenous retinal detachment, based on a retrospective analysis of prospectively collected dataEvaluate risk stratification using a multivariate logistic regression model incorporating variables associated with anatomical failure within 6 months of rhegmatogenous retinal detachment surgery, based on a retrospective analysis of prospectively collected dataDetermine the clinical implications of variables associated with primary anatomical outcome (anatomical failure within 6 months of surgery) after vitrectomy and internal tamponade for rhegmatogenous retinal detachment, based on a retrospective analysis of prospectively collected data.Accreditation StatementsIn support of improving patient care, this activity has been planned and implemented by Medscape, LLC and Springer Nature. Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.Medscape, LLC designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.To participate in this journal CME activity: (1) review the learning objectives and author disclosures; (2) study the education content; (3) take the post-test with a 75% minimum passing score and complete the evaluation at www.medscape.org/journal/eye; (4) view/print certificate.Credit Hours1.0Release date:Expiration date:Post-test link:https://medscape.org/eye/posttest983835EDITORSobha Sivaprasad, MD, Editor, EyeAuthors/Editors disclosure informationDavid Yorston, FRCOphth, Gartnavel Hospital, Glasgow, Scotland. Paul H.J. Donachie, MSc, Gloucestershire Hospitals NHS Foundation Trust, Cheltenham, United Kingdom, The Royal College of Ophthalmologists, National Ophthalmology Database Audit, London, United Kingdom. D.A. Laidlaw, MD, FRCOphth, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom. David H. Steel, MD, FRCOphth, Sunderland Eye Infirmary, Sunderland, United Kingdom, Bioscience Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom. G.W. Aylward, MD, FRCOphth, Moorfields Eye Hospital City Road, London, United Kingdom. Tom H. Williamson, MD, FRCOphth, Guy’s and St. Thomas’ NHS Foundation Trust, London, United KingdomJournal CME author disclosure informationLaurie Barclay has disclosed the following relevant financial relationships: formerly owned stocks in AbbVie Inc.IntroductionTo identify variables associated with primary anatomical outcome following vitrectomy and internal tamponade for rhegmatogenous retinal detachment (RD).MethodsA 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.ResultsThere 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.ConclusionsPrevious 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.

Aim:Data on the outcome of surgery facilitate informed preoperative patient counselling. Most studies on the outcome of surgery for idiopathic full thickness macular hole surgery have concentrated on rates of anatomical closure. The aim of this study was to identify factors predicting visual success (better than 20/40; 6/12 Snellen) following macular hole surgery.Methods:A retrospective study of 133 patients undergoing standardised macular hole surgery with at least 3 months of postoperative follow-up. All patients underwent preoperative measurement of the maximum macular hole diameter using optical coherence tomography.Results:Multivariable regression analysis identified that age, preoperative visual acuity and macular hole size were significant predictors of visual success. The resulting model correctly classified the visual outcome of 80% of cases. Predicted rates of visual success varied from 93% in patients <60 years old with visual acuity better than 6/24 and a hole diameter of <350 μm, to 2% in patients those >79 years old with visual acuity of 6/60 or worse and hole diameter of >500 μm.Conclusion:The results provide a simple and clinically useful model to employ when counselling patients on macular hole surgery.

Purpose To investigate the incidence and natural history of persistent subfoveolar fluid (PSF) following surgery for macular off rhegmatogenous retinal detachment and the effect of PSF on photoreceptor structure and final visual acuity. Methods Retrospective study of 61 cases with post-operative optical coherence tomography (OCT) performed within 12 weeks of surgery. Based on aetiology, cases were categorized into tractional retinal tears (TRT) group or atrophic round holes and dialyses (RHD) group to investigate the incidence and duration of PSF. A Kaplan–Meier graph was plotted to compare survival time of subfoveolar fluid for both groups. Following secondary reclassification of cases into those with and without PSF, the effect of PSF on final visual acuity and photoreceptor structure was investigated with Mann–Whitney U -test used for comparison. Spearman's correlation testing was used to probe associations between time to recorded resolution of PSF with final visual acuity and photoreceptor structure. Results Incidence of PSF was greater in the RHD group and persisted for longer compared with TRT group. No detectable adverse effect of PSF on final visual acuity was seen however an individual case of severe photoreceptor atrophy was observed. No significant correlation was found between the time to recorded resolution of PSF and the final visual acuity or to photoreceptor grading scores. Conclusions A difference in incidence of PSF was detected between the aetiological groups. PSF was ubiquitous and slow to resolve in the RHD group. Most cases of PSF resolve without adverse sequelae; however, progressive photoreceptor atrophy and sub-optimal visual outcome may result in a minority.

Aim To briefly review and discuss the literature on vitrectomy for diabetic macular oedema. Methods Literature review. Results There is a copious literature on the subject of vitrectomy for diabetic macular oedema (DMO). The most commonly hypothesised mechanism for the potential benefit of vitrectomy is relief of vitreomacular traction; however, both transvitreal oxygenation and improved growth factor diffusion away from the premacular retina have also been suggested to be potentially beneficial effects. Other systemic and local factors including duration of oedema, extent of ischaemia and exudation, and extent of laser may result in permanent photoreceptor and capillary damage, which precludes anatomical or visual benefit. Much of the literature on the subject of vitrectomy for DMO is retrospective and uncontrolled but strongly suggestive of a benefit in terms of improved acuity and reduced macular thickness following vitrectomy. There are five published small randomised controlled trials on this subject. Taken as a whole, these studies do not suggest a benefit from surgery. Selection of patients for surgery on the basis of OCT partial vitreomacular separation or clinical signs of traction such as an epiretinal membrane or taut thickened hyaloid has been reported to be associated with a modest improvement in prospective studies but this has not been subjected to controlled study. Conclusion The evidence at present suggests that vitrectomy for DMO should be restricted to those with clinical or OCT signs of traction.

Purpose To develop and validate a classification system for focal vitreomacular traction (VMT) with and without macular hole based on spectral domain optical coherence tomography (SD-OCT), intended to aid in decision-making and prognostication. Methods A panel of retinal specialists convened to develop this system. A literature review followed by discussion on a wide range of cases formed the basis for the proposed classification. Key features on OCT were identified and analysed for their utility in clinical practice. A final classification was devised based on two sequential, independent validation exercises to improve interobserver variability. Results This classification tool pertains to idiopathic focal VMT assessed by a horizontal line scan using SD-OCT. The system uses width (W), interface features (I), foveal shape (S), retinal pigment epithelial changes (P), elevation of vitreous attachment (E), and inner and outer retinal changes (R) to give the acronym WISPERR. Each category is scored hierarchically. Results from the second independent validation exercise indicated a high level of agreement between graders: intraclass correlation ranged from 0.84 to 0.99 for continuous variables and Fleiss’ kappa values ranged from 0.76 to 0.95 for categorical variables. Conclusions We present an OCT-based classification system for focal VMT that allows anatomical detail to be scrutinised and scored qualitatively and quantitatively using a simple, pragmatic algorithm, which may be of value in clinical practice as well as in future research studies.

Background/Aim:The COMPlog clinical visual acuity measuring system is being developed for both routine and research use. This study aimed to validate its performance in amblyopic children and both normal and diseased adults against the gold standard ETDRS chart and the E-ETDRS computerised acuity measurement algorithm.Method:Timed test and retest fully interpolated five letters per line logMAR visual acuity measurements were taken for 70 adults and 59 amblyopic children using the ETDRS chart and the COMPlog visual acuity measurement system. 39 of the adults also underwent computerised acuity testing using the E-ETDRS testing algorithm. The tested adults included normals as well as subjects with a range of ocular diseases. The methods of Bland and Altman were employed with test–retest variability (TRV) expressed as 95% confidence limits for agreement.Results:No significant bias was observed between the gold standard ETDRS acuity measurements and those taken with either COMPlog or E-ETDRS. TRVs of ±0.12 logMAR and ±0.10 logMAR were respectively found for COMPlog measurements in the amblyopic children and adult groups compared with ±0.12 logMAR for the ETDRS chart in both groups. The TRV of the E-ETDRS system was slightly greater at ±0.16 logMAR. Median testing times for COMPlog and ETDRS were 95 and 85 s and 66 and 56 s respectively in the paediatric and adult groups and 120 s for the E-ETDRS measurements on adults.Discussion:COMPlog measurements agree well with and are similarly reliable to the gold standard ETDRS chart with comparable test times. E-ETDRS algorithm measurements took approximately twice as long.

BACKGROUND/AIMS The advantages of logMAR acuity data over the Snellen fraction are well known, and yet existing logMAR charts have not been adopted into routine ophthalmic clinical use. As this may be due in part to the time required for a logMAR measurement, this study was performed to determine whether an abbreviated logMAR chart design could combine the advantages of existing charts with a clinically acceptable measurement time. METHODS The test-retest variability, agreement (with the gold standard), and time taken for “single letter” (interpolated) acuity measurements taken using three prototype “reduced logMAR” (RLM) charts and the Snellen chart were compared with those of the ETDRS chart which acted as the gold standard. The Snellen chart was also scored with the more familiar “line assignment” method. The subjects undergoing these measurements were drawn from a typical clinical outpatient population exhibiting a range of acuities. RESULTS The RLM A prototype chart achieved a test-retest variability of +/−0.24 logMAR compared with +/−0.18 for the ETDRS chart. Test-retest variability for the Snellen chart was +/−0.24 logMAR using clinically prohibitive “single letter” scoring increasing to +/−0.33 with the more usual “line assignment” method. All charts produced acuity data which agreed well with those of the ETDRS chart. “Single letter” acuity measurements using the prototype RLM charts were completed in approximately half the time of those taken using the ETDRS and Snellen charts. The duration of a Snellen “line assignment” measurement was not evaluated. CONCLUSION The RLM A chart offers an acceptable level of test-retest variability when compared with the gold standard ETDRS chart, while reducing the measurement time by half. Also, by allowing a faster, less variable acuity measurement than the Snellen chart, the RLM A chart can bring the benefits of logMAR acuity to routine clinical practice.

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.

Purpose The optimal method and timing of the surgical treatment for idiopathic macular holes remains unknown. The aim of this retrospective study was to identify factors associated with anatomical and visual success in macular hole surgery. Methods Case records of 55 patients undergoing macular hole surgery at three units in the 2-year period up to July 2002 were reviewed to identify factors associated with anatomical and visual success. The following potential prognosticators were evaluated: patient age, hole stage, hole latency prior to surgery, preoperative acuity, simultaneous phacoemulsification, and intraocular lens implantation, internal limiting membrane peeling with and/or without indocyanine green, and postoperative posturing. Results The duration of preoperative symptoms, indocyanine green-assisted internal limiting membrane peeling, hole stage, and better preoperative visual acuity were associated with both anatomical success and regaining a postoperative visual acuity of 6/12 or better. Discussion The closure rate in patients undergoing surgery within 1 year of onset was 94.0%, and in those waiting 1 year or more it was 47.4%. Clinical governance and quality issues should dictate that NHS macular hole surgery is available to all within 1 year of onset. This study showed no adverse effect of ICG dye retinal staining. The results support the use of a ‘patient-friendly’ approach of simultaneous cataract surgery with no prone postoperative posturing.