Jose-Carlos Pastor

Surgical outcomes for primary rhegmatogenous retinal detachments in phakic and pseudophakic patients: the Retina 1 Project—report 2

Aims: To compare anatomical and functional outcomes for 546 phakic and pseudophakic primary rhegmatogenous retinal detachments (RDs) treated by pars plana vitrectomy or scleral buckling. Methods: Prospective, non-randomised, interventional study in 15 centres in Spain and Portugal, with data from RDs consecutively treated from January 2005 to May 2007. Cases with preoperative proliferative vitreoretinopathy grade C-1 or higher and perforating trauma were excluded. Minimum follow-up was 3 months. Twenty-seven pre-, intra- and post-surgical variables for each patient were analysed. Multivariate analysis was carried out by logistic regression analysis with stepwise selection of variables. Results: Data from 546 patients were analysed. Global anatomical success was 94.7%. Logistic regression analysis showed that only the development of postoperative proliferative vitreoretinopathy was associated with a poor anatomical outcome. The poorest functional results were associated with macular involvement, extension of RD, previous RD surgery, time of evolution of RD, and age of patient. Hierarchical log-linear analysis showed no effect of the lens status (phakic versus pseudophakic) on the functional results. However, pars plana vitrectomy was most often performed in pseudophakic eyes and resulted in a worse final visual acuity (p<0.001). Conclusions: No differences in anatomical success between phakic and pseudophakic eyes were found in this series. Pars plana vitrectomy was most often performed in pseudophakic eyes and had a greater probability of a worse final visual acuity than scleral buckling.

Non-complicated retinal detachment management: variations in 4 years. Retina 1 project; report 1

Aims: To assess variations in the characteristics and management of two series of non-complicated rhegmatogenous retinal detachments (RD) carried out 4 years apart in Spain. Methods: Prospective, multicentric, non-randomised comparative study. 339 consecutive cases of RD treated in five hospitals were included. Group 1 (G1) (n = 186) included cases operated on from 1999 to 2001; group 2 (G2) (n = 153) included cases from 2004 to 2006. 83 variables related to preoperative characteristics of RD, surgical management and postoperative evolution were recorded. Surgeons were allowed to treat patients following their personal criteria. Differences in preoperative characteristics, rate of vitrectomy and anatomical outcome were studied. Quantitative variables were compared by Mann–Whitney U test and qualitative variables by standard contingency tables. Multivariate analysis was carried out by logistic regression analysis. Results: G1 showed a significantly longer delay in performing surgery, since the first symptoms appeared (G1: 29 (SD 50) days; G2: 22 (55); p<0.001) and more RD without visible retinal break than G2 (G1: 17.4%; G2: 9.2%; p = 0.028). In G2, cases with multiple retinal breaks (G1: 31.6%; G2: 44.6%) were more frequent (p = 0.022). No significant differences in other preoperative variables were observed. Vitrectomy was performed in 30.1% in G1 and in 78.4% in G2 as a primary surgical approach (p<0.001). Regardless of the characteristics of the RD, the rate of vitrectomy was higher in G2. The reattachment rate was over 94% in both groups (p = 0.833). Pseudophakic RD showed better anatomical outcomes in G2 (G1: 83.9%; G2: 96.4%; p = 0.028). Conclusion: There is an increasing tendency to treat RD with primary vitrectomy, which is related to neither a higher complexity of cases nor better anatomical results.

Interaction between surgical procedure for repairing retinal detachment and clinical risk factors for proliferative vitreoretinopathy.

Purpose: To asses risk factors of proliferative vitreoretinopathy (PVR) and a model for predicting it. Methods: Observational, case-control. 335 patients with non-complicated retinal detachment (RD) were included: 134 developed PVR (Cases); 201 patients did not (Controls). Risk factors for PVR were identified by multivariate analysis. Influence of variables was assayed according to the surgical approach. By logistic regression analysis a model to predict the risk of developing PVR and odds ratio (OR) values for each clinical factor were estimated. Results: Risk was higher in patients > 70 years and with intraocular pressure lower than 14 (OR: 3.84; CI 95%: 2.04–7.30) and in retinal breaks larger than “1 clock hour” (OR: 2.54; CI: 1.28–5.05), extended retinal detachments (OR: 4.01; CI: 1.98–8.10) and reinterventions (OR: 1.55; CI: 1.14–9.22). Scleral surgery also was a risk factor (OR: 3.89; CI: 2.12–7.14) and aphakia/pseudophakia when scleral surgery is performed (OR: 3.33; CI: 1.54–7.22). A model to predict PVR was proposed with these results. Conclusions: Surgical approach modifies risk factors of PVR, and should be taken into account to improve the models for predicting it.

Factores clínicos de riesgo para el desarrollo de la vitreorretinopatía proliferante (VRP) postquirúrgica: Estudio prospectivo

espanolObjetivo: Identificar los factores de riesgo de VRP, la incidencia y el momento de aparicion de esta complicacion en una serie prospectiva de desprendimientos de retina regmatogenos (DR). Metodos: Se ha realizado un estudio multicentrico y prospectivo de 223 casos de DR. Se han incluido 83 variables referentes a caracteristicas preoperatorias, intraoperatorias y postquirurgicas. Se ha efectuado un analisis de regresion logistica. Resultados: De los 223 casos de DR, 22 desarrollaron una VRP (incidencia 9,9%, intervalo de confianza al 95%: 5,9-13,9). Se han detectado 4 factores con una «odds-ratio» superior a 1,0 (la existencia de un DR de 4 cuadrantes, el empleo de crioterapia, la afaquia o pseudofaquia y la necesidad de utilizar cerclaje). Ninguno de estos factores ha presentado una p EnglishPurpose: To identify clinical risk factors for development of postoperative PVR, to determine the incidence of this complication and its time of onset by a prospective multicentric study. Methods: A multicentric and prospective study of 223 patients with rhegmatogenous retinal detachment (RD) was conducted. Logistic regression analysis was used to identify risk factors for PVR among 83 variables related to preoperative, intraoperative and postoperative characteristics. Results: 22 out of 223 RD developed PVR (incidence 9.9%, confidence interval 95%: 5.9-13.9). After logistic regression analysis, four variables showed an odds ratio higher than 1.0 (RD affecting 4 quadrants, cryopexy, aphakia/pseudophakia and those RD in which an encircling band was implanted). None of these factors showed a «p» value lower than 0.05. Most of postoperative PVR (77.2%) appeared in the first month after surgery. Conclusions: This study establishes the incidence of PVR, and its time of onset, but it was not effective to identify clinical risk factors with a high level of confidence.

Acortamiento retinado: la forma más grave de la vitreorretinopatía proliferante (VRP)

espanolObjetivo: Identificar las caracteristicas clinicas de los pacientes que presentan una VRP con acortamiento retiniano no producido por membranas perirretinianas. Metodo: Estudio observacional, retrospectivo, de una cohorte de 110 pacientes intervenidos por VRP en 2000 y 2001. Durante la cirugia, tras eliminar las membranas epirretinianas y comprobar que no existian subretinianas, se inyecto un perfluorocarbono liquido. Los ojos en los que no se consiguio la reaplicacion retiniana se catalogaron como VRP intrarretiniana (grupo 1). Los casos en los que se consiguio una reaplicacion que permitio la aplicacion de endolaser sin realizar otras maniobras, constituyeron el grupo control (grupo 2). Se han comparado las caracteristicas clinicas preoperatorias de ambos grupos mediante el test de la chi- cuadrado. Resultados: 60 casos (54,5%, IC 95%: 40,5-68,5) se incluyeron en el grupo 1 y 24 casos (21,8%, IC 95%: 12,9-30,7) en el grupo 2. En los casos restantes, 26 (23,6%), la evaluacion presento dudas. En 9 (15%) de los 60 casos del grupo 1 fue necesario realizar una retinectomia. No hubo diferencias estadisticamente significativas en ninguna de las variables preoperatorias comparadas entre ambos grupos. Unicamente se observo un mayor numero de casos con larga evolucion (mas de 2 meses) entre los pacientes del grupo 1 que requirieron una retinectomia (20,7%), que en los que no fue necesaria (3,7%) (p=0,04). Conclusion: La aparicion de fenomenos de acortamiento retiniano es frecuente en la VRP. Son necesarios mas estudios para caracterizar mejor esta presentacion clinica de la VRP y para conocer los mecanismos patogenicos que la provocan. EnglishPurpose: To identify the clinical characteristics of patients developing retinal shortening due to intraretinal PVR. Methods: Observational and retrospective cohort study on 110 PVR patients operated on between 2000 and 2001. During surgery, after removing epiretinal membranes and ruling out the presence of subretinal membranes, a perfluorocarbon liquid was injected. Those cases in which retinal flattening was not accomplished, were considered intraretinal PVR (group 1). Those in which retinal flattening allowed endolaser application, were taken as the control group (group 2). Clinical features of both groups were compared by chi-square test. Results: 60 cases (54.5%, CI 95%: 40.5-68.5) showed retinal shortening (group 1). In 24 cases (21.8%, CI 95%: 12.9-30.7) complete retinal flattening was accomplished (group 2). In 26 cases (23.6%), evaluation was inconclusive. In 9 out of the 60 cases of group 1 (15%) a retinectomy was necessary to reattach the retina. Differences between both groups were not statistically significant for any of the clinical variables. However, the number of retinal detachments of more than 60 days of evolution was significantly higher in retinectomized eyes (20.7%) than in group 1 (3.7%) (p=0.04). Conclusions: Retinal shortening is a relatively frequent phenomenon in PVR. Further studies are necessary to characterize this clinical presentation of PVR and its pathogenesis.

Manejo de los desprendimientos de retina regmatógenos urgentes en el Sistema Nacional de Salud de España: Proyecto Retina 2

espanolObjetivo: Establecer los problemas en el manejo de los desprendimientos de retina (DR) durante los fines de semana en el Sistema Nacional de Salud (SNS) espanol. Metodos: Se envio una encuesta confidencial al jefe de Servicio de 217 hospitales del SNS. Los datos fueron almacenados en una base de datos Microsoft Access y analizados estadisticamente con Excel y Statgraphics. Las variables cualitativas fueron analizadas con el test de Chi-cuadrado y el test exacto de Fisher, y las cuantitativas con el test no parametrico de Kruskall-Wallis. Resultados: Se obtuvo una tasa de respuesta del 54,8% con mayor participacion de hospitales docentes (HD). Los Comarcales (HC) se incluyeron en el grupo de los No Docentes (HnD) por su patron de respuestas similares. El 18% de centros no tiene oftalmologo de guardia. De los que si disponen, el 36% tiene especialistas de vitreo retina de guardia. Mas del 80% de los centros admite tener problemas para atender los DR urgentes. El 24% no tiene acceso a quirofano de oftalmologia; el 50% refiere problemas con Anestesia y el 22% dispone de enfermeras de Oftalmologia. El 64% realiza vitrectomias y de ellos, el 77% atiende urgencias. El 90% de los centros reconoce que un paciente con DR superior y macula no afectada tardaria mas de 24 horas en intervenirse, aunque el 84% lo considera una practica inadecuada. Conclusion: A pesar de los sesgos y cuestiones metodologicas, se han identificado problemas del SNS relacionadas al manejo de los DR urgentes. Esto proporciona importante informacion para organizar una cobertura mas eficiente. EnglishObjective: To identify problems in the urgent management of retinal detachments (RD) in hospitals of the Spanish National Health System (NHS). Methods: A questionnaire was submitted confidentially to the heads of Ophthalmic Departments of 217 hospitals of the NHS to obtain information on the management of urgent RD during the last year. Data was stored in a Microsoft Access database and statistically analyzed by Excel and Statgraphics. Qualitative variables were analyzed by Chi-Square and Fisher exact tests and quantitative variables by the Kruskall-Wallis test. Results: A global response rate of 54.8% was achieved with higher participation of the Teaching Hospitals (TH). District Hospital and non-Teaching Hospital responses were similar and grouped as non-TH. Eighteen percent of centers, mostly non-TH, had no ophthalmologist on duty. Thirty-six percent had a vitreoretinal specialist on call. Eighty percent of centres admitted to have problems handling urgent RD during weekends. Twenty-four had no ophthalmic surgical theatre available. Fifty percent refered to have problems having an anaesthesiologist available and only 22% had ophthalmic trained personnel (nurses) available. Sixty-four percent of centres performed pars plana vitrectomy (PPV) and 77% of those were able to perform an urgent PPV. Ninety percent admitted that a patient with a macula-threatening RD occurring at the beginning of the week-end would not be treated until at least 24 hours had elapsed, although 84% considered this to be inadequate. Conclusion: Despite the methodological problems and bias of this questionnaire, we did identify several important problems in the management of urgent RD by NHS hospitals. The data obtained provides useful information to enable the quality of the NHS care of RD to be improved, particularly that available at the week-end.

Encuesta nacional sobre la cirugía vítreo-retiniana y la atención de los desprendimientos de retina regmatógenos en España: Proyecto Retina 2

espanolObjetivo: Obtener informacion de ambito nacional sobre el manejo habitual de la patologia quirurgica de la retina, del numero de especialistas dedicados a esta actividad y del manejo urgente de los desprendimientos de retina. Metodos: Se realizaron 2 envios postales de un cuestionario de 30 preguntas a los jefes de servicio de 276 centros oftalmologicos de toda Espana. Resultados: Se obtuvo una tasa de respuesta global del 48,2%. Las respuestas de los centros de caracter privado fueron solo el 9,4% por lo que se eliminaron del estudio. Los centros que mas respondieron fueron los docentes (HD) (52,3%) existiendo un sesgo por sobre-representacion de este grupo. El 64% de los centros respondieron que, en el ultimo ano, realizaron vitrectomias por pars plana (VPP) y de ellos, el 70% practicaron mas de 100 programadas. El 77% de los centros que realizan VPP las hacen tambien de urgencia. El 75% dispone de especialistas en vitreo retina, con una mediana de 2 retinologos por centro, lo que representa el 23% de la plantilla. El 11,5% responden que sus oftalmologos generales realizan cirugia de retina. Y solo el 40,3% de los centros auditan sus resultados (37,5% HD). Conclusiones: A pesar de la relativa baja tasa de respuesta, la existencia de algunos sesgos y algunos problemas metodologicos, se han obtenido por primera vez datos sobre el manejo de la patologia vitreo-retiniana quirurgica a nivel nacional, que pueden facilitar estudios posteriores y que pueden ser aprovechados para mejorar la planificacion de la atencion oftalmologica en Espana. EnglishPurpose: To obtain information throughout Spain on the current management of vitreo-retinal surgical diseases, the number of ophthalmologists involved in retinal surgical diseases care, and the urgent management of retinal detachments. Methods: A 30 item questionnaire was sent by mail, on two separate occasions, to the heads of Ophthalmology Departments of 276 centers in Spain. Results: A total response rate of 48.2% was achieved, however the answers from private centers represented only 9.4% of the total so these were excluded from the analysis. The centers most likely to respond were those in Teaching Hospitals (TH) (52.3%). Of these, 64% of hospitals responded that, in the last year, they performed pars plana vitrectomies (PPV) and 70% performed more than 100 PPVs in the year. In all, 77% of the centers that performed PPVs had also performed them urgently. A total of 75% of hospitals indicated that they had ophthalmologists mainly dedicated to retinal diseases care, with a median of 2 specialists per center, with this representing 23% of their total staff. Retinal surgery was performed by general ophthalmologists in 11.5% of centres. Only 40.3% of hospitals audit their results (37.5% TH). Conclusions: Despite the existence of a relatively low response rate, as well as some biases and methodological problems, data on the management of retinal surgical disease has been obtained for the first time at a national level. This data will facilitate later studies and must be taken into consideration in improving the planning and adequate management of these diseases in Spain.

Pain perception description after advanced surface ablation

Purpose The objective of this study was to characterize the evolution of ocular pain after advanced surface ablation (ASA) to improve strategies in postoperative pain management. Methods This was a multicenter, prospective, descriptive, cohort study. The inclusion criteria were healthy individuals ≥18 years old receiving bilateral alcohol-assisted surface ablation with epithelial removal. Pain intensity was evaluated with the visual analog scale (VAS) and the numeric pain rating scale before and after surgery. Comorbidities (photophobia, burning, tearing, and foreign body sensation) and Hospital Anxiety and Depression (HAD) questionnaire were evaluated before and at 6 hours after surgery. Postoperative treatments included cold patch, topical cold antibiotics, topical steroids, and benzodiazepines. Results Thirty-two consecutive patients having similar profiles of postoperative pain evolution were included. At 0.5 hour after ASA, the pain score by VAS was 37±20 mm, and the maximum pain, 61±31 mm, occurred at 24 hours. Afterward, it decreased progressively until 72 hours after surgery (19±20 mm). Most patients (81%) scored >60 mm, and 44% required rescue medication. Among the comorbidities, all patients had photophobia and 84% had burning sensation. At 6 hours, the HAD score was 5.4±3.9, within the range of values considered as normal. Conclusion Postoperative acute ocular pain after ASA showed a characteristic evolution over time. Recognition of the pattern could be important for improving the acceptance of ASA and for improving strategies in pain management in the postoperative period.

Formación y actividad clínica de los retinólogos en España: un primer acercamiento: Proyecto retina 2. Análisis descriptivo

espanolObjetivo: Obtener un listado de oftalmologos espanoles dedicados a la patologia retiniana y describir algunas caracteristicas de su formacion especifica y de su actividad clinica cotidiana. Metodo: Se ha enviado una encuesta por correo postal a 504 probables retinologos identificados a partir de la informacion proporcionada por las Sociedades Espanola de Oftalmologia y de Retina y Vitreo y un conjunto minimo de tres retinologos de cada Comunidad Autonoma. Resultados: Se han obtenido 267 respuestas (52,9% de la poblacion). El 83% obtuvo su especialidad despues de 1980. El 94% ha recibido formacion especifica, sobre todo durante la residencia (82,1%) y de companeros mas expertos (67,7%). La realizacion de masteres oficiales es muy minoritaria (solo un 16,7% tienen al menos un master). El 12% se dedica en exclusiva a la patologia quirurgica, el 24,7% a la medica y el 62,9% combinan ambas actividades. Un 22,5% opera patologia retiniana, un 14,6% realiza cirugia del segmento anterior y un 60,7% combina ambas. Conclusiones: A pesar de no haberse tenido en cuenta el sesgo de la no repuesta, se dispone de los primeros datos sobre el perfil y la actividad de los denominados retinologos, en Espana. EnglishPurpose: To create a database of Spanish ophthalmologists mainly dedicated to retinal pathology care, describing their training period characteristics and their daily activity (clinical and surgical). Methods: A postal questionnaire was sent to 504 possible retinologists identified through the information supplied by the Spanish Ophthalmological Society and the Spanish Vitreous-Retina Society, with a minimum of 3 retinologists per Autonomous Region. Results: 267 (52.9% of the sample population) responses were collected and processed. Most of the respondents had started their residency after 1980 (82.4%). Ninety-four percent had received specific training in retinal pathology, mostly during the residency period (82.1%) and from more experienced colleagues (62.9%). Official fellowships were held in a minority of cases (around 12%). Twelve percent of retinologists performed retinal surgery only, 14.6% performed anterior segment surgery, and 60.7% performed both types of surgery. Conclusions: Despite not having taken into consideration non-response bias, this study provides the first reported data on the professional profile of Spanish retinologists.