Visual Acuity Inadequately Reflects Vision-Related Quality of Life in Patients After Macula-Off Retinal Detachment Surgery

BEYOND THE SURFACE: Investigating Silicone Oil's Impact on Macular Perfusion in Macula-Off Rhegmatogenous Retinal Detachment by Optical Coherence Tomography Angiography

PURPOSE

The aim of this study was to compare macular vessel density (VD) in eyes with macula-off rhegmatogenous retinal detachment after vitrectomy with gas or silicone oil (SO) tamponade.

METHODS

Patients with macula-off rhegmatogenous retinal detachment who underwent vitrectomy with either gas or SO tamponade were included. Best-corrected visual acuity (BCVA) and VD in superficial and deep retinal capillary plexuses (superficial capillary plexus and deep capillary plexus), choriocapillaris (choriocapillaris plexus), and foveal avascular zone were assessed using optical coherence tomography angiography. Comparisons were made with the unaffected fellow eye.

RESULTS

Fifty patients (average age: 57.9 ± 9.1 years) participated, with 26 eyes undergoing SO tamponade and 24 gas tamponade. No significant differences were found in baseline characteristics. Postoperative BCVA significantly improved in both groups. In the SO group, BCVA improved from 2.00 ± 0.77 logarithm of the minimum angle of resolution (20/2000 Snellen) to 0.95 ± 0.52 logarithm of the minimum angle of resolution (20/178 Snellen). In the gas tamponade group, BCVA improved from 2.12 ± 0.70 logarithm of the minimum angle of resolution (20/2636 Snellen) to 0.70 ± 0.55 logarithm of the minimum angle of resolution (20/100 Snellen) ( P < 0.001 for both groups). Moreover, the gas tamponade group achieved significantly better postoperative BCVA compared with the SO group ( P < 0.05). The silicone oil tamponade group exhibited significantly lower VD in superficial capillary plexus, deep capillary plexus, and choriocapillaris plexus quadrants ( P < 0.05), while gas tamponade showed no significant differences.

CONCLUSION

This study reveals a decrease in VD in superficial capillary plexus, deep capillary plexus, and choriocapillaris plexus induced by SO tamponade, suggesting potential toxic effects on macular perfusion. Gas tamponade resulted in superior BCVA outcomes and preserved VD. Further investigation into SO's underlying mechanisms and careful patient selection is warranted. Gas tamponade may offer better outcomes for macula-off rhegmatogenous retinal detachment.

Association Between Contrast Sensitivity and Ganglion Cell-Inner Plexiform Layer Thickness After Resolution of Macular Edema Due to Branch Retinal Vein Occlusion

Background/Objectives: We sought to assess the relationship between contrast sensitivity (CS) and optical coherence tomography (OCT) findings, including ganglion cell-inner plexiform layer (GCIPL) thickness, in eyes with cystoid macular edema, secondary to branch retinal vein occlusion (BRVO-CME), treated with intravitreal ranibizumab (IVR). Methods: This prospective study included 44 patients with BRVO-CME who underwent treatment with IVR (three monthly injections and pro re nata) and were followed up for 12 months. We collected data on CS, best-corrected visual acuity (BCVA), and OCT findings (ellipsoid zone [EZ] and external limiting membrane status [ELM], central foveal thickness [CFT], and average GCIPL thickness) at the time of the final visit when macular edema was resolved. Multiple regression analysis was used to evaluate the relationship between visual functions and OCT findings, age, and lens status. Results: Multiple regression analysis revealed that lower GCIPL thickness was significantly associated with worse CS (β = 0.008; 95% CI, 0.002-0.014; p = 0.011), whereas this was not the case with BCVA. Lower CFT and mild cataracts were also associated with worse CS (CFT: β = 0.003; 95% CI, 0.001-0.004; p = 0.001; mild cataract: β = -0.182; 95% CI, -0.286--0.078; p = 0.001) and worse BCVA (CFT: β = -0.002; 95% CI, -0.003--0.001; p < 0.001; mild cataract: β = 0.079; 95% CI, 0.008-0.150; p = 0.029). Conclusions: GCIPL thickness may serve as a valuable biomarker for CS in eyes with BRVO-CME following IVR treatment.

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

Twenty-five volunteers with metamorphopsia secondary to vitreoretinal pathologic condition were recruited at a tertiary referral center. All subjects underwent ophthalmologic examination and measurement of metamorphopsia using Amsler grid, Morphision, M-CHARTS, and the IWT. Construct validity was determined through assessment of the association between symptoms, pathologic condition, 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 pathologic condition 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 that effectively measures its severity and nature, and opens the possibility to its noninvasive correction in the future through inverse mapping of the distortion map onto live images.

IMAGING PREDICTORS OF FUNCTIONAL OUTCOMES AFTER RHEGMATOGENOUS RETINAL DETACHMENT REPAIR

PURPOSE

To evaluate the microstructural optical coherence tomography and fundus autofluorescence imaging predictors of visual acuity, metamorphopsia, and aniseikonia following rhegmatogenous retinal detachment repair.

METHODS

This is a multicenter retrospective study of patients with primary rhegmatogenous retinal detachment who underwent repair. Best-corrected visual acuity, metamorphopsia, and aniseikonia were formally tested at 3 months postoperatively. Metamorphopsia and aniseikonia were quantitatively assessed with M-CHARTS and the New Aniseikonia Test, respectively. High-resolution spectral-domain optical coherence tomography and fundus autofluorescence images were obtained at 3 months postoperatively. Images were assessed for discontinuity of the outer retinal bands on optical coherence tomography and retinal displacement detected by retinal vessel printings on fundus autofluorescence by two masked graders with disagreements adjudicated by a third senior masked grader. Multiple linear regression models were used to determine the predictors of postoperative visual acuity, metamorphopsia, and aniseikonia.

RESULTS

Six hundred fourteen eyes of 614 patients were included in this study. Regression analysis indicated that significant early postoperative (at 3 months) imaging predictors of visual acuity were discontinuity of the external limiting membrane (P = 0.001) and the presence of retinal vessel printings on fundus autofluorescence (P = 0.033). Discontinuity of interdigitation zone was a significant predictor of metamorphopsia [horizontal metamorphopsia (P =0.004); vertical metamorphopsia (P = 0.056); average of horizontal metamorphopsia + vertical metamorphopsia (P = 0.008)], and presence of retinal vessel printings was a significant predictor of aniseikonia (P = 0.04).

CONCLUSION

Discontinuity of the external limiting membrane and retinal displacement were significant predictors of postoperative visual acuity following rhegmatogenous retinal detachment repair. Discontinuity of the interdigitation zone and retinal displacement were significant predictors of metamorphopsia and aniseikonia, respectively.

Morphological and Clinical Characterization of Foveal Bulge Sign Three Years After Retinal Detachment Repair: A Longitudinal Prospective Evaluation

Purpose

To evaluate optical-coherence-tomography (OCT)-morphological and clinical parameters three years after primary rhegmatogenous retinal detachment (RRD) repair surgery and the role of postoperative foveal bulge sign.

Methods

Of the 32 initially enrolled patients with primary RRD 20 (14 fovea-on, 6 fovea-off) completed this prospective study. Preoperatively and 3 years after surgery best corrected visual acuity (BCVA) and OCT including macula status, central retinal thickness (CRT), central choroidal thickness (CCT), thickness of each single retinal layer, integrity of cone-interdigitation-zone (CIZ) and ellipsoid zone (EZ), and presence of foveal bulge were evaluated.

Results

Preoperatively fovea-off RRD patients show significantly thinner CCT, inner nuclear layer (INL) and inner plexiform layer (IPL) compared to fovea-on RRD patients, whereas only IPL and INL were significantly thicker compared to the fellow eye. Three years after surgery this thickening recovered. Final BCVA did not differ statistically significantly between fovea-off and fovea-on patients, no difference in CIZ-integrity or presence of foveal bulge was observed. Presence of foveal bulge at 3 years showed significantly better final BCVA and was associated with intact preoperative CIZ-integrity and postoperative EZ- and CIZ-integrity. The preoperative fovea status showed no correlation to the postoperative presence of foveal bulge.

Conclusion

Three years after RRD repair retinal layers show similar thickness. The presence of foveal bulge is associated with better final BCVA. Sufficient pre- and postoperative CIZ-integrity as well as postoperative CIZ-integrity seem to be strongly associated with the restoration of foveal bulge. No correlation was found with the preoperative macular status or BCVA.

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.

Retinal damage extends beyond the border of the detached retina in fovea-on retinal detachment

PURPOSE

The aim of this study was to investigate the preoperative and postoperative change in retinal sensitivity in relation to the distance to the retinal detachment (RD) in patients with fovea-on RD.

METHODS

We prospectively evaluated 13 patients with fovea-on RD and a healthy control eye. Preoperatively, OCT scans of the RD border and the macula were obtained. The RD border was highlighted on the SLO image. Microperimetry was used to assess the retinal sensitivity at the macula, the RD border and the retina around the RD border. At 6 weeks, 3 and 6 months postoperatively, follow-up examinations of OCT and microperimetry were performed in the study eye. Microperimetry was performed once in control eyes. Microperimetry data were overlaid on the SLO image. The shortest distance to the RD border was calculated for each sensitivity measurement. The change in retinal sensitivity was calculated as control-study. The relation between the change in retinal sensitivity and the distance to the RD border was assessed using a locally weighted scatterplot smoothing curve.

RESULTS

Preoperatively, the greatest loss in retinal sensitivity was 21 dB at 3° inside the RD which decreased linearly, through the RD border, and reached a plateau of 2 dB at 4°. For 6 weeks and 3 months postoperatively, the greatest retinal sensitivity loss remained at 3° inside the RD but was 4 dB and sensitivity loss decreased linearly to a plateau of 0 dB at 5° outside the RD. At 6 months postoperatively, the greatest sensitivity loss was 2 dB at 3° inside the RD, and decreased linearly to a plateau of 0 dB at 2° outside the RD.

CONCLUSIONS

Retinal damage extends beyond the detached retina. Retinal sensitivity loss of the attached retina decreased drastically as the distance to the RD increased. Postoperative recovery occurred for both attached and detached retina.

Retinal detachment

Retinal detachment (RD) occurs when the neurosensory retina, the neurovascular tissue responsible for phototransduction, is separated from the underlying retinal pigment epithelium (RPE). Given the importance of the RPE for optimal retinal function, RD invariably leads to decreased vision. There are three main types of RD: rhegmatogenous, tractional and exudative (also termed serous) RD. In rhegmatogenous RD, one or more retinal breaks enable vitreous fluid to enter the subretinal space and separate the neurosensory retina from the RPE. In tractional RD, preretinal, intraretinal or subretinal membranes contract and exert tangential forces and elevate the retina from the underlying RPE. Finally, in exudative RD, an underlying inflammatory condition, vascular abnormality or the presence of a tumour causes exudative fluid to accumulate in the subretinal space, exceeding the osmotic pump function of the RPE. The surgical management of RD usually involves pars plana vitrectomy, scleral buckling or pneumatic retinopexy. The approach taken often depends on patient characteristics as well as on practitioner experience and clinical judgement. Advances in surgical technology and continued innovation have improved outcomes for many patients. However, even if retinal re-attachment is achieved, some patients still experience decreased vision or other visual symptoms, such as metamorphopsia, that diminish their quality of life. Continued research in the areas of neuroprotection and retinal biology as well as continued surgical innovation are necessary to enhance therapeutic options and outcomes for these patients.

PURPOSEFUL GAS-INDUCED RESORPTION OF SUBMACULAR FLUID IN MACULA-OFF RETINAL DETACHMENTS (PERSIMMON STUDY)

PURPOSE

To examine the visual outcomes in patients with macula-off rhegmatogenous retinal detachments with intentional submacular fluid retention after pars plana vitrectomy (PPV) or PPV/scleral buckle surgery (PPV/SB).

METHODS

Patients with macula-off retinal detachments were included if they had a PPV or PPV/SB without drainage retinotomy or perfluorocarbon liquid to flatten the retina.

RESULTS

The mean age of the patients was 65.0 years. The mean presenting vision was 20.0 Early Treatment Diabetic Retinopathy Study (ETDRS) letters. Six months after repair, the vision improved to 62.9; 75.4% of patients had 20/40 or better at best achieved visual acuity. Pseudophakic eyes had better vision compared with phakic eyes ( P = 0.049). Patients younger than 80 years had better best achieved vision ( P = 0.0118) compared with patients 80 years or older. Patients with initial vision better than or equal to 20/100 had better best achieved vision ( P = 0.016) compared with those with initial vision worse than 20/100.

CONCLUSION

Leaving submacular fluid after macula-off retinal detachments surgery was not detrimental for visual outcomes or anatomic success for retinal detachments repair and may lead to better visual outcomes for patients, specifically for those patients younger than 80 years, who are pseudophakic, and have presenting vision 20/100 or better.

Impact of COVID-19-related lifestyle changes on diabetic macular edema

AIM

To assess diabetic macular edema (DME) progression during the early phases of the COVID-19 pandemic, when severe societal restrictions raised the concern of possible deterioration of health in patients with systemic conditions, particularly those requiring frequent office visits.

METHODS

This is a multicenter retrospective chart review of 370 patients (724 eyes) with an established diagnosis of DME seen on 3 separate visits between January 2019 and July 2021. Period 1 was January 2019 to February 2020 (considered pre-COVID-19), period 2 was March 2020 to December 2020 (considered the height of the pandemic; highest level of pandemic-related clinical and societal regulations) and period 3 was January 2021 to July 2021 (re-adjustment to the new "pandemic norms"). Main outcome measures included visual acuity, body mass index (BMI), blood pressure (BP), hemoglobin A1c (HbA1c), macular thickness, patient adherence to scheduled ophthalmology visits, and DME treatment(s) received at each visit. To facilitate measurement of macular thickness, each macula was divided into 9 Early Treatment Diabetic Retinopathy Study (ETDRS)-defined macular sectors as measured by OCT imaging.

RESULTS

There was no change of BMI, systolic BP, and diastolic BP between any of the time periods. HbA1c showed a very small increase from period 1 (7.6%) to period 2 (7.8%, P=0.015) and decreased back to 7.6% at period 3 (P=0.12). Macular thickness decreased for 100% of macular regions. The central macular thickness decreased across all 3 periods from 329.5 to 316.6 µm (P=0.0045). After analysis of multiple variables including HbA1c, BMI, adherence to scheduled appointments, different clinic centers, and treatment interventions, there was no easily identifiable subgroup of patients that experienced the increase in DME.

CONCLUSION

DME doesn't worsen during the COVID-19 pandemic, instead sustaining a very small but statistically significant improvement. While identifying a mechanism behind our findings is beyond the scope of this study, potential explanations may include a delay in retinal changes beyond our study period, an unexpected increase in treatment frequency despite pandemic restrictions, and an unanticipated pandemic-related improvement in some lifestyle factors that may have had a positive impact on DME.

An Evaluation of the Repeatability of Visual Function Following Surgical Repair of Macula-Off Rhegmatogenous Retinal Detachment

Purpose

To evaluate the reliability and reproducibility of visual function assessments for patients with macula-off rhegmatogenous retinal detachment (RRD).

Methods

This prospective study included patients with unilateral macula-off RRD of <10-day duration successfully treated with a single, uncomplicated surgery at least 1 year following repair. Visual function assessments were performed at time of enrollment and 1 month later. Testing included Early Treatment Diabetic Retinopathy Study (ETDRS) best-corrected visual acuity (BCVA), low-luminance visual acuity (LLVA), low-contrast visual acuity (VA) 2.5% and 5%, contrast sensitivity assessment with Mars and Gabor patches, reading speed (acuity, speed, and critical print size), color vision testing (protan, deutan, and tritan), and microperimetry. Spectral-domain ocular coherence tomography (SD-OCT) was performed. Paired t-statistics were used to compare values between visits and between the study and fellow eyes.

Results

Fourteen patients (9 male, 5 female) with a mean age of 69 years at time of surgery were evaluated. Correlation coefficients across the two visits were highest for ETDRS BCVA (0.97), tritan color vision testing (0.96), and low-contrast VA 5% (0.96), while the average t-statistic was largest for low-luminance deficit (4.2), ETDRS BCVA (4.1), and reading speed critical print size (3.7). ETDRS BCVA did not correlate with SD-OCT findings.

Conclusions

ETDRS BCVA can be considered a highly reliable and reproducible outcome measure. LLVA, protan color discrimination, contrast sensitivity, and reading speed may be useful secondary outcome measures.

Translational Relevance

This study provides guidance on the selection of visual function outcome measures for clinical trials of patients with macula-off RRD.

OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY MORPHOLOGY AFTER RHEGMATOGENOUS RETINAL DETACHMENT REPAIR: ALIGN Post Hoc Analysis

PURPOSE

To compare foveal avascular zone (FAZ) geometric indices using optical coherence tomography angiography (OCTA) in pneumatic retinopexy (PnR) versus pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD). FAZ morphology was assessed as a possible imaging feature of retinal displacement.

METHODS

This ALIGN post hoc analysis included primary fovea-off RRDs that underwent successful PnR or PPV, and performed OCTA, and fundus autofluorescence at (FAF) 3 months postoperatively at St. Michael's Hospital, Toronto, Canada. FAZ area (mm 2 ), axial ratio, circularity, and roundness were measured, and FAF images were assessed for retinal displacement.

RESULTS

Seventy-two patients were included, 78% (56/72) were male mean age was 60 ± 9 years, and 60% (43/72) were phakic. Sixty-five percent (47/72) and 35% (25/72) underwent PnR and PPV, respectively. The mean baseline logarithm of the minimum angle of resolution visual acuity was 1.49 ± 0.76. FAZ circularity was lower after PPV (0.629 ± 0.120) versus PnR (0.703 ± 0.122); P = 0.016. Sixty-six patients had gradable FAF images. Retinal displacement was present in 29% (19/66), 84.2% (16/19) of which had displacement in the macula. FAZ circularity was lower in eyes with displacement in the macula (0.613 ± 0.110) versus those without displacement (0.700 ± 0.124); P = 0.015. There was a moderate negative correlation between 12-month aniseikonia and FAZ circularity(r = -0.262; P = 0.041).

CONCLUSION

FAZ circularity was lower after PPV and in eyes with retinal displacement in the macula. Circularity was negatively correlated with 12-month aniseikonia scores. FAZ circularity may be another imaging feature to consider postoperatively after RRD repair.

Vision-Related Parameters Affecting Stereopsis after Retinal Detachment Surgery

Even after successful surgery, the stereopsis of retinal detachment (RD) patients is inferior to that of normal subjects. However, it is unclear which visual dysfunction in the affected eye is responsible for the postoperative stereopsis impairment. This study included 127 patients after successful surgery for unilateral RD. Stereopsis, best-corrected visual acuity (BCVA), severity of metamorphopsia, letter contrast sensitivity and amount of aniseikonia were examined at 6-month postoperatively. Stereopsis was assessed using the Titmus Stereo Test (TST) and TNO stereotest (TNO). Postoperative stereopsis (log) in patients with RD were 2.09 ± 0.46 in the TST and 2.56 ± 0.62 in the TNO. Multivariate analysis with stepwise regression revealed postoperative TST was associated with BCVA, and TNO was associated with BCVA, letter contrast sensitivity, metamorphopsia and absolute values of aniseikonia. In a subgroup analysis that selected those with more impaired stereopsis, postoperative TST was associated with BCVA (p < 0.001), and TNO was associated with letter contrast sensitivity (p < 0.005) and absolute values of aniseikonia (p < 0.05) by multivariate analysis. Deterioration of stereopsis after RD surgery was affected by a variety of visual dysfunctions. The TST was affected by visual acuity, while the TNO was affected by contrast sensitivity and aniseikonia.

How should we report the foveal status in eyes with "macula-off" retinal detachment?

Whilst pre- and postoperative multimodal imaging technologies including optical coherence tomography (OCT) have investigated the morphological correlates of worsened visual outcomes in rhegmatogenous retinal detachment (RRD) with foveal involvement, the nomenclature has adhered to the traditional ophthalmoscopy-based and rather vague term "macula-off". This article appraises the current literature with regard to the preoperative assessment and nomenclature of the foveal status in macula involving retinal detachment (MIRD). A literature review of recent publications assessing functional or morphological outcomes in MIRD was conducted, using the search terms "fovea-off" or "macula-off". The search date was April 28^th, 2021. Original studies in English language were included. Case reports, review articles or letters were excluded. Forty relevant articles (range of publication dates: July 29^th, 2020 - April 18^th, 2021) were reviewed to assess the diagnostic modalities used, morphological parameters assessed, and any specific nomenclature introduced to specify the extent of macular detachment. The results suggest widespread variability and inconsistencies with regard to the preoperative assessment, diagnostic modalities and nomenclature used to describe the foveal status in eyes with RRD termed "macula-off". The extent of macular detachment may be classified by a wide range of morphological parameters, including the height of foveal detachment and the ETDRS grid as overlay tool in OCT devices. There is a scientific and clinical need for an updated nomenclature for eyes with "macula-off" RRD. Preoperative OCT findings should be reported on a regular and standardized basis in order to establish a consensus how to report the foveal status in eyes with MIRD.

LONG-TERM CHANGES IN VISUAL FUNCTION AND EN FACE OPTICAL COHERENCE TOMOGRAPHY FINDINGS IN FOVEA-OFF RETINAL DETACHMENT: A 2-Year Prospective Study

PURPOSE

To investigate the long-term changes in visual function and outer retinal abnormalities on en face optical coherence tomography after fovea-off rhegmatogenous retinal detachment and to assess associations between functional outcomes and outer retinal abnormalities.

METHODS

Prospective, observational study. The following data were collected at 1, 3, 6, 12, and 24 months after retinal reattachment: Best-corrected visual acuity, metamorphopsia (M-CHARTS), aniseikonia (New Aniseikonia Test), altered ellipsoid zone reflectivity, outer retinal folds, macular detachment demarcation, and subfoveal fluid.

RESULTS

Thirty-eight patients were included. Best-corrected visual acuity improved significantly from 1 to 12 months and from 12 to 24 months (P < 0.001; P = 0.022). Vertical and horizontal metamorphopsia improved significantly from 1 to 12 months (P < 0.001; P = 0.002), and at 24 months, scores of ≥0.2° were present in 54% and 42% of patients, respectively. The degree of aniseikonia did not change. Best-corrected visual acuity and aniseikonia scores were positively associated with outer retinal fold (r 0.4, P = 0.009; r 0.4, P = 0.048). A gradual normalization of outer retinal reflectivity took place during 24 months.

CONCLUSION

Visual acuity improved significantly during the second year after reattachment surgery for fovea-off rhegmatogenous retinal detachment, in parallel with normalization of outer retinal abnormalities on en face optical coherence tomography. Metamorphopsia did not improve after 12 months, and aniseikonia remained unchanged.

Patient-reported outcome measures in vitreoretinal surgery: a systematic review

This review article systematically reviews the use of Patient Reported Outcome Measures (PROMs) in Vitreoretinal surgery, with the aim of recommending a preferred PROM-tool for use in clinical practice. Vitreoretinal surgery lags behind other ophthalmic subspecialties in the adoption of PROMs as a core outcome measure of success post-operatively. Current outcomes rely heavily on post-operative Best Corrected Visual Acuity (BCVA) and anatomical success on imaging modalities such as Ocular Coherence Tomography (OCT), despite the link between each of these measures and patient satisfaction being uncertain. We systematically reviewed the available literature in March 2021, in accordance with PRISMA guidelines, searching six databases: MEDLINE, EMBASE, Web of Science, APA PsycINFO, SCOPUS and Cochrane Library. Critical appraisal of PROM-tools was facilitated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias checklist. We identified 14 eligible original research papers that used PROMs as a primary or secondary outcome of success post-operatively in patients having undergone vitreoretinal surgery. Eight different generic and vision-related PROM-tools were identified as being used in vitreoretinal studies, none of which were vitreoretinal-disease-specific. Our review article considers whether generic-health PROMs (e.g., EQ5D) or vision-related PROMs (e.g. NEI VFQ-25) are precise or responsive enough following vitreoretinal surgery to have a meaningful impact on clinical or research practice. We also consider the importance of standardisation of clinical outcomes in vitreoretinal clinical trials.

Vision-related quality of life and subscale items following intravitreal ranibizumab injections for central retinal vein occlusion

PURPOSE

To evaluate the vision-related quality of life (VR-QOL) before and after intravitreal ranibizumab injections (IVR) for central retinal vein occlusion (CRVO) and to investigate subscale items of VR-QOL in detail.

STUDY DESIGN

A multicenter, open-label, prospective and comparative study.

METHODS

Twenty-three patients with treatment naïve CRVO and 22 age-matched normal controls were included. VR-QOL was assessed by 25-Item Visual Function Questionnaire (VFQ-25) before and up to 12 months post-treatment. The VFQ-25 composite score and 12 subscales were compared between CRVO patients and normal controls.

RESULTS

The VFQ-25 composite scores of CRVO patients showed significant improvement throughout the treatment period compared with baseline. The VFQ-25 composite scores both before and after treatment for CRVO were significantly lower than in normal controls. The subscale items, including general health, general vision, near activities, social functioning, mental health, role difficulties, dependency, and peripheral vision in CRVO, were significantly lower than in the normal controls even after treatment.

CONCLUSION

Vision-related QOL was low in patients with CRVO before treatment and improved with IVR. In spite of the improvements, several subscale items remained lower than in normal controls following treatment. Attention should be paid to the patients with CRVO and their decreased visual, social and psychological QOL.

Visual Functions Affecting Vision-Related Quality of Life Following Intravitreal Ranibizumab Therapy for Central Retinal Vein Occlusion

Visual functions that affect vision-related quality of life (VR-QoL) before and after intravitreal injection of ranibizumab in patients with cystoid macular edema secondary to central retinal vein occlusion (CRVO-CME) are poorly understood. This multicenter, open-label, single-arm prospective study included 23 treatment-naïve patients with CRVO-CME. The best-corrected visual acuity (BCVA), letter contrast sensitivity (LCS), severity of metamorphopsia (M-CHARTS), amount of aniseikonia (New Aniseikonia Test), and stereopsis (Titmus Stereo Test and TNO stereotest) were examined every month from before treatment to 12 months after treatment. For VR-QoL assessment, the 25-item National Eye Institute Visual Function Questionnaire (VFQ-25) was provided to the patients before treatment and at 3, 6, and 12 months after treatment. Stepwise multiple regression analysis revealed that the BCVA of the fellow eye was related to the VFQ-25 composite score before treatment, and that the BCVA of the fellow eye and TNO values were related to the VFQ-25 composite score 12 months after treatment. Changes in LCS were significantly correlated with changes in the VFQ-25 composite score. In patients with CRVO-CME, visual acuity of the fellow eye had the strongest impact on VR-QoL. The contrast sensitivity of the affected eye and stereopsis were also associated with VR-QoL.

Scleral Buckling: A Look at the Past, Present and Future in View of Recent Findings on the Importance of Photoreceptor Re-Alignment Following Retinal Re-Attachment

Scleral buckling (SB) remains an important technique to master for those interested in treating rhegmatogenous retinal detachment (RRD). Several ways to repair RRD include pneumatic retinopexy (PR), pars plana vitrectomy (PPV), SB or a combination of these. There is a growing worldwide trend that favors PPV as the preferred method for retinal reattachment of primary uncomplicated RRD. Reimbursement issues, operating room access, and technological advances in PPV that improve retinal visualization and less exposure to SB during fellowship training may explain this trend. As the number of SB cases decreases over time, there is a risk that SB becomes a dying art and surgeons in training may not be trained in SB. SB is preferred in eyes with no posterior vitreous detachment and retinal dialysis. SB with minimal gas vitrectomy may be indicated for eyes with inferior pathology. Non-contact wide-angled visualization with chandelier assisted SB may be well suited for teaching new generations of aspiring vitreoretinal surgeons. Its functional and anatomic results compare favorably with conventional SB for primary uncomplicated primary RRD. The main advantage of this technique is the improved visualization even through small pupils. Better visualization ensures treatment of all breaks while avoiding complications during drainage of subretinal fluid and a safer placement of intrascleral sutures for scleral fixation of the buckling element. Recordings of the procedure are easily performed, allowing the surgeons involved to review the case and learn from it. The main disadvantage is the cost involved with the chandelier and the need to have a microscope or a 3D system with a wide angle viewing system. Photoreceptor re-alignment following retinal re-attachment is an important determinant of the post-operative functional outcomes. Different methods of retinal re-attachment apparently result in different degrees of photoreceptor re-alignment. SB may hold an advantage over PPV in this regard.

Quality of life study in ophthalmic practice

The article discusses various methods for studying the quality of life in all kinds of eye diseases. General and special questionnaires used in modern ophthalmological practice are presented. The presence of a sufficiently large amount of data indicating the relationship between the quality of life and objective indicators of the visual system was established. A fairly good comparability of results obtained in the assessment of various quality of life questionnaires in a patient with ophthalmic condition was revealed.

Relationship between stereopsis and vision-related quality of life following intravitreal ranibizumab injections for central retinal vein occlusion

The study aimed to evaluate changes in stereopsis and vision-related quality of life (VR-QOL) in patients with central retinal vein occlusion (CRVO) following intravitreal ranibizumab injection (IVR) and investigate the relationship between stereopsis and VR-QOL. This study included 23 treatment-naïve patients with non-ischemic CRVO and 13 age-matched normal controls. Stereopsis, best-corrected visual acuity (BCVA), VR-QOL, and retinal microstructures were examined pre-treatment and 12 months post-treatment. The Titmus Stereo Test (TST) and TNO stereotest (TNO) were used to evaluate stereopsis. VR-QOL was evaluated using the 25-item National Eye Institute Visual Function Questionnaire (VFQ-25). IVR immediately and significantly improved the TST values, TNO values, composite VFQ-25 score, BCVA, and central foveal thickness in patients with CRVO. The 12-month post-treatment TST and TNO values were significantly worse in the CRVO group compared to those in the normal group. At the baseline, the composite VFQ-25 score significantly correlated only with the TST value. Multivariate analysis revealed significant associations between the 12-month post-treatment composite VFQ-25 score and the baseline and 12-month post-treatment TNO values. In conclusion, IVR immediately improved stereopsis in CRVO, albeit below normal levels. Stereopsis (not visual acuity) was associated with pre- and post-treatment VR-QOL in patients with CRVO.

Clinical Update on Metamorphopsia: Epidemiology, Diagnosis and Imaging

Purpose: To discuss the pathophysiology of metamorphopsia, its characterisation using retinal imaging and methods of assessment of patient symptoms and visual function.Methods: A literature search of electronic databases was performedResults: Metamorphopsia has commonly been associated with vitreomacular interface disorders (such as epiretinal membrane) and has also regularly been noted in diseases of the retina and choroid, particularly age-related macular degeneration and central serous chorioretinopathy. Developments in optical coherence tomography retinal imaging have enabled improved imaging of the foveal microstructure and have led to the localisation of the pathophysiology of metamorphopsia within the retinal layers of the macula. Alteration of alignment of inner and outer retinal layers at various retinal loci has been identified using multimodal imaging in patients with metamorphopsia in a range of conditions. Although the Amsler Grid assessment of metamorphopsia is a useful clinical indicator, new emerging methods of metamorphopsia assessment with psychophysical tests such as M-CHARTS and preferential hyperacuity perimetry, have been developed.Conclusions: It appears that there is a complex relationship between visual acuity and metamorphopsia symptoms that vary between retinal conditions. Although metamorphopsia has traditionally been challenging to measure in the clinic, advances in technology promise more robust, easy-to-use tests. It is possible that home assessment of metamorphopsia, particularly in conditions such as age-related macular degeneration, may help to guide the need for further clinic evaluation and consideration of treatment.