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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.

Background Cataract remains the world's leading cause of blindness. In the developing world, many eye clinics provide cataract surgery for only a small proportion of those in need. This is partly because of low demand—caused by barriers related to awareness, bad services, cost, and distance—and partly because of deficiencies in the supply of services. This article reviews innovations in cataract surgery in poor countries that are intended to reverse this trend. Conclusions Increasing the number of operations, through close involvement with the community, and improved surgical outcomes, enables the cost of surgery to be reduced, leading to further growth in volume. Recent innovations, such as low-cost intraocular lenses, and small-incision extracapsular cataract extraction, have contributed to improving the results of surgery without increasing the costs. Effective management enables the delivery of increasing the numbers of operations, while at the same time improving outcomes and controlling costs.

ObjectivesTo report the early surgical outcome, risk of failure and predictive value of rhegmatogenous retinal detachment (RRD) classification based on all participants in the Scottish Retinal Detachment study.MethodsOver 2 years, all incident cases of RRD in Scotland were approached for recruitment. Early postoperative success was defined as an attached retina following one procedure with a minimum follow-up of 6–8 weeks. Using a regression model, the influence of clinical factors on the failure risk was estimated and the sensitivity and specificity of the Royal College of Ophthalmologists (RCOphth) grading for RRD and the vitrectomy in retinal detachment stratification risk formula (VR-SRF) in predicting operative failure were assessed.ResultsPrimary outcome data were available for 86.2% (975/1130) of patients. The overall primary success rate was 80.8% (95% CI 78.1 to 83.3%). The presence of preoperative proliferative vitreoretinopathy of any degree and each additional clock hour of detachment increased the risk of failure by an OR of 2.4 and 1.13 respectively (p<0.05). A specificity of >95% in predicting early surgical failure was noted for highly complex RRDs according to the VR-SRF formula and the RCOphth classification.ConclusionsConsistent with previous series, the overall early success rate of RRD repair was 80% after one operation. The type of surgical repair did not influence overall success rates. Significant predictors of failure are the presence of preoperative proliferative vitreoretinopathy of any grade and the extent of detachment. The analytical value of current classification systems in predicting failure is most useful in complex RRDs.

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 LogMAR units, and 15 (9.0%) worsened by at least 0.3 LogMAR 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 tamponade 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.

Purpose To assess the efficacy of small-gauge vitrectomy with subretinal recombinant tissue plasminogen activator (rtPA) and ranibizumab for submacular haemorrhages secondary to neovascular age-related macular degeneration (nAMD), and to identify the factors associated with visual outcome. Methods A retrospective case series was performed, including all patients who had small-gauge vitrectomy with subretinal rtPA and ranibizumab for submacular haemorrhages secondary to nAMD. All patients received three consecutive monthly injections of ranibizumab after the surgery, and were reviewed monthly and treated on a pro re nata regime. Results A total of 45 eyes of 45 patients were included in the study. Mean age was 77.07±9.67 years, and 32 of 45 patients (71.1%) were women. Surgery was performed on average 6.98±5.70 days after the onset of symptoms, and patients were observed for a follow-up period of 12.9±10.8 months. On average, visual acuity improved −0.59±0.61 LogMAR between presentation and last follow-up. Visual acuity improved in 33 patients (73.3%), remained unchanged in 10 patients (22.2%), and worsened in 2 patients (4.4%). Multiple linear regression showed that patients with smaller haemorrhages ( P =0.012) and prompt surgery ( P =0.008) had better final visual acuities. A haemorrhage area of ≤30 mm 2 had 91.3% sensitivity and 73.3% specificity for predicting a final visual acuity ≥6/60. Conclusion Small-gauge vitrectomy with subretinal rtPA and ranibizumab is effective for improving visual acuity in patients with submacular haemorrhages secondary to nAMD. Small haemorrhage area and prompt surgery are associated with better final visual acuity.

Purpose To describe a survey of the use of ocriplasmin by members of the British and Eire Association of VitreoRetinal Surgeons (BEAVRS) for VitreoMacular Traction (VMT) and Full Thickness Macular Hole (FTMH) and compare it to published MIVI TRUST trial data. Methods All 173 BEAVRS members were contacted by email in October 2014 requesting data on all cases treated with ocriplasmin up to that date. The total number of cases, FTMH closure rate, VMT release rate and the frequency of adverse events were recorded. Results were compared with trial data. Results 48 members responded reporting results from 241 eyes. The respective BEAVRS and MIVI TRUST trial closure rates for small FTMHs were 42.1 and 58.3% ( P =0.09) and for medium FTMH 12.7 and 36.7% ( P =0.01). The respective VMT release rates were 34.1 and 37.4% ( P =NS). Retinal detachment was observed in 3.3% of the BEAVRS cohort compared with 0.4% in MIVI TRUST. Reduction in visual acuity to <6/60 was observed in 5.8% of the BEAVRS cohort and 0.6% in MIVI TRUST. Other complications not reported in the MIVI TRUST trial included an increase in FTMH basal diameter following unsuccessful ocriplasmin use in 46.9% of BEAVRS cases and zonular instability at the time of subsequent phacoemulsification in 2.4%. Conclusion Macular hole closure rates were lower in the BEAVRS survey than published in the MIVI TRUST trial data. The incidence of adverse events was greater than previously reported. The reasons for these disparities are unknown but could include positive reporting bias inherent to retrospective surveys, treatment and population differences.

Purpose To compare the outcomes of phacoemulsification with either a 2.5-mm clear corneal incision and a foldable intraocular lens (IOL) or a 5-mm sclerocorneal tunnel incision and a rigid polymethyl methacrylate (PMMA) IOL. Methods In a prospective, randomised clinical trial of phacoemulsification cataract surgery, 1200 patients received either a foldable hydrophilic acrylic IOL through a 2.5-mm corneal incision or an inexpensive rigid PMMA IOL via a 5-mm sclerocorneal tunnel. Intra- and post-operative data and visual acuity at discharge, 6 weeks, and 1 year follow-up were analysed. Results At 1 year after surgery, 996 (83.0%) patients were followed up with an uncorrected visual acuity of 6/18 or better in 90.3% of the foldable and 94.3% in the rigid IOL group (risk ratio (RR) 0.96, 95% confidence intervals (CI) 0.92–0.99). Poor outcome (best-corrected acuity 6/60 or worse) occurred in 1.0% and 0.4%, respectively (RR 4.28, 95% CI 0.48–38.18). The surgical cost of consumables and overall surgical time were similar in both groups; however, the cost of the foldable IOL was eight times higher than the PMMA IOL. Posterior capsule opacification was more common in the rigid IOL group at 12 months (36.1% vs 23.3%); however, this did not affect post-operative vision. Conclusion In the hands of experienced cataract surgeons, phacoemulsification with implantation of a foldable or a rigid IOL gives excellent results. Using an inexpensive rigid PMMA IOL will make phacoemulsification more affordable for poor patients in low- and middle-income countries.

Objective This was a pilot randomised controlled trial (RCT) to investigate the effect of post-operative face-down positioning on the outcome of macular hole surgery and to inform the design of a larger definitive study. Methods In all, 30 phakic eyes of 30 subjects with idiopathic full-thickness macular holes underwent vitrectomy with dye-assisted peeling of the ILM and 14% perfluoropropane gas. Subjects were randomly allocated to posture face down for 10 days (posturing group) or to avoid a face-up position only (non-posturing group). The primary outcome was anatomical hole closure. Results Macular holes closed in 14 of 15 eyes (93.3%; 95% confidence interval (CI) 68–100%) in the posturing group and in 9 of 15 (60%; 95% CI 32–84%) in the non-posturing group. In a subgroup analysis of outcome according to macular hole size, all holes smaller than 400  μ m closed regardless of posturing (100%). In contrast, holes larger than 400  μ m closed in 10 of 11 eyes (91%; 95% CI 58–99%) in the posturing group and in only 4 of 10 eyes (40%; 95% CI 12–74%) in the non-posturing group (Fisher's exact test P =0.02). Conclusion Post-operative face-down positioning may improve the likelihood of macular hole closure, particularly for holes larger than 400  μ m. These results support the case for a RCT.

Aim: To report the short and medium term outcome of a prospective series of sutureless manual extracapsular cataract extractions (ECCE) at a high volume surgical centre in Nepal. Methods: Cataract surgery was carried out, on eyes with no co-existing diseases, in 500 consecutive patients who were likely to return for follow up. The technique involved sclerocorneal tunnel, capsulotomy, hydrodissection, nucleus extraction with a bent needle tip hook, and posterior chamber intraocular lens (PC-IOL) implantation according to biometry findings. Surgical complications, visual acuity at discharge, 6 weeks, and 1 year follow up, and surgically induced astigmatism are reported. Results: The uncorrected visual acuity at discharge was 6/18 or better in 76.8% of eyes, and declined to 70.5% at 6 weeks’ follow up, and 64.9% at 1 year. The best corrected visual acuity was 6/18 or better in 96.2% of eyes at 6 weeks and in 95.9% at 1 year. Poor visual outcome (<6/60) occurred in less than 2%. Intraoperative complications included 47 (9.4%) eyes with hyphaema, and one eye (0.2%) with posterior capsule rupture and vitreous in the anterior chamber. Surgery led to an increase in against the rule astigmatism, which was the major cause of uncorrected visual acuity less than 6/18. Six weeks postoperatively, 85.5% of eyes had against the rule astigmatism, with a mean induced cylinder of 1.41 D (SD 0.8). There was a further small increase in against the rule astigmatism of 0.66 D (SD 0.41) between 6 weeks and 1 year. The mean duration of surgery was 4 minutes and the average cost of consumables, including the IOL, was less than $10. Conclusion: Rapid recovery of good vision can be achieved with sutureless manual ECCE at low cost in areas where there is a need for high volume cataract surgery. Further work is required to reduce significant postoperative astigmatism, which was the major cause of uncorrected acuity less than 6/18.