Quick Referral and Urgent Surgery to Preempt Foveal Detachment in Retinal Detachment Repair

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1 ORIGINAL CLINICAL STUDY Quick Referral and Urgent Surgery to Preempt Foveal Detachment in Retinal Detachment Repair Wataru Kikushima, MD,* Akira Imai, MD,* Takao Hirano, MD,* Yasuhiro Iesato, MD, PhD,* Yuichi Toriyama, MD,* Masako Murata, MD,*Þ and Toshinori Murata, MD, PhD* Purpose: This study aimed to evaluate the consultation and referral pathway and benefit of urgent surgery within 24 hours of outpatient clinic presentation on increasing the ratio of eyes with fovea-on at surgery and visual outcomes in retinal detachment cases. Design: This is a retrospective, interventional case series. Methods: A total of 106 eyes underwent an operation for rhegmatogenous retinal detachment. Standard vitrectomy or explant scleral buckling was performed. The ratio of eyes with fovea-on at the time of operation, anatomical success rate, and postoperative best corrected visual acuity were measured. Results: Of the106 eyes, 46 (43.4%) already were fovea-off at initial eye clinic visit, and 9 eyes became fovea-off during referral. Consequently, 55 patients (51.9%) were fovea-off when presenting to our outpatient clinic. Retinal detachment was within 1 disc diameter of the fovea in 9 of 51 eyes with fovea-on at outpatient clinic presentation, but surgery within 24 hours spared 6 eyes from foveal involvement. The anatomical success rate of primary surgery was 98.8% (81/82 eyes) by vitrectomy and 83.3% (20/24 eyes) by scleral buckling. Postoperative best corrected visual acuity of the fovea-on group was significantly higher (mean [SD], j0.019 [0.22] logarithm of the minimal angle of resolution) than that of the fovea-off group (mean [SD], 0.32 [0.45] logarithm of the minimal angle of resolution; P = 0.002). Conclusions: More than half (51.9%) of our cohort had already been fovea-off by outpatient presentation. Therefore, efforts to urge patients to visit operating facilities promptly seem to be as important as the urgent surgeries themselves. Key Words: retinal detachment, foveal detachment, vitrectomy, optical coherence tomography (Asia Pac J Ophthalmol 2014;3: 141Y145) Diminished visual recovery after surgery for rhegmatogenous retinal detachment (RD) has been reported to be dependent on several preoperative factors that include poor preoperative visual acuity (VA), older age, longer duration of symptoms, longer duration of detachment, refractive error, upper or temporal location of retinal breaks, and foveal involvement. 1Y5 Among these, the most consistent predictor of a poor postoperative visual outcome is foveal detachment. 1,2,4 In fovea-off RD, the postoperative quality of vision is rarely restored to that before RD because recovery of central From the *Department of Ophthalmology, Shinshu University School of Medicine; and Department of Ophthalmology, National Hospital Organization, Matsumoto Medical Center, Matsumoto, Nagano, Japan. Received for publication April 23, 2013; accepted August 5, The authors have no funding or conflicts of interest to declare. Reprints: Toshinori Murata, MD, PhD, Department of Ophthalmology, Shinshu University School of Medicine, Asahi, Matsumoto, Nagano , Japan. murata@shinshu-u.ac.jp. Copyright * 2014 by Asia Pacific Academy of Ophthalmology ISSN: DOI: /APO.0b013e3182a81240 vision remains compromised to some extent because of mild but permanent functional damage to photoreceptors, even when reattachment surgery is successful. 6 Distorted vision is one of the major complications of otherwise satisfactory surgery in patients treated for RD. Postoperative visual distortion affects even eyes that regained excellent vision and eyes without detectable photoreceptor disruption in spectral domainyoptical coherence tomography (SD-OCT). 7,8 Consequently, many ophthalmologists consider fovea-on rhegmatogenous RD of recent onset to be a surgical emergency to avoid foveal involvement and minimize photoreceptor damage caused by a foveal detachment. 9Y11 Ho et al 2 reported that urgent surgery should be considered based on the close proximity of the RD border to the fovea, especially if it is within 1 disc diameter, to prevent foveal involvement. The Ophthalmic Procedure Assessment of the American Academy of Ophthalmology recommended that fovea-on RD should be operated on as soon as possible, preferably within 24 hours. 12 Another problem is that more than two thirds of new patients (68%, 4 75%, 13 and 86.8% 14 ) according to the previous reports already have macula-off RD when they visited the outpatient clinic of the operating facilities. Quinn et al 15 reported that avoidable delays in presentation of patients with RD to a tertiary referral center caused by inadequate referral pathway and inadequate public awareness of ophthalmic emergencies should be eliminated. In this study, we operated on 120 patients with RD (122 eyes) within 24 hours of outpatient clinic presentation. We determined if urgent surgery was effective in reducing the ratio of fovea-off cases at the time of operation and in improving postoperative visual outcome. Based on medical interviews with patients, we also evaluated the consultation and referral pathways before treatment. MATERIALS AND METHODS Patients A total of 104 patients (106 eyes) with uncomplicated rhegmatogenous RD were immediately hospitalized and surgically treated within 24 hours after outpatient clinic presentation at Shinshu University Hospital from April 2009 to March Young patients presenting with solid vitreous and small holes that suggested RD of a chronic nature were excluded from this study because careful examination of the fundus was necessary before performing scleral buckling. These patients were usually treated on the following scheduled operation day and not by urgent surgery within 24 hours of presentation. The medical records of all 120 patients (122 eyes) who underwent urgent RD surgery were reviewed. Inclusion criteria were uncomplicated rhegmatogenous RD without prior ocular disease or surgery, except for cataracts. Macular hole RD in highly myopic eyes (10 eyes) and proliferative vitreoretinopathy grade C or worse (6 eyes) were also operated on within 24 hours of outpatient presentation, but they were excluded from the present study Asia-Pacific Journal of Ophthalmology & Volume 3, Number 3, May/June

2 Kikushima et al Asia-Pacific Journal of Ophthalmology & Volume 3, Number 3, May/June 2014 because postoperative best corrected VA (BCVA) does not necessarily depend on foveal-on/off status in these diseases. The Ethics Committee of Shinshu University approved this study prospectively. The study was conducted in accordance with the tenets of the Declaration of Helsinki. Informed consent was obtained from each patient. Surgery Most patients were treated by pars plana vitrectomy with a SF6 gas tamponade because we considered fluid-air exchange followed by a gas tamponade that is effective in preempting foveal involvement in the eyes whose RD had expanded adjacently to the fovea. Vitrectomy evades persistent subfoveal fluid, which is unavoidable to some extent in eyes treated by scleral buckling. 16 The eyes without cataract and the eyes with restricted RD peripheral to the equator were treated by scleral buckling regardless of patient age. If a preoperative fundus examination to locate the causative retinal tear was hindered by a cataract, pars plana vitrectomy was selected as the treatment modality along with concomitant phacoemulsification cataract surgery with intraocular lens implantation. Preoperative Data Collected preoperative data included patient age, sex, duration and extent of central vision loss, date of first documentation of rhegmatogenous RD at nearby eye clinics, refractive error, previous ocular surgery, other ocular diseases, and location and extent of RD, BCVA, and OCT images to accurately evaluate foveal status, that is, fovea-on or fovea-off. Intraoperative Data For eyes with fovea-on RD at presentation to the outpatient clinic, whether urgent surgery succeeded in preempting foveal involvement was confirmed and recorded by operating microscopic observation. Postoperative Data Collected postoperative data included RD status at each postoperative visit, re-operation, postoperative corrected VA, and patient comments regarding quality of vision. Subjects continued periodic monitoring at nearby eye clinics after 2 months of follow-up at our hospital because it is well-known that the risk of RD recurrence due to proliferative vitreoretinopathy formation is very low 2 months after the primary operation. 11,17 All eyes have a minimum 12-month follow-up period. Statistical Analysis The evaluation of VA in this study was conducted by decimal VA. Visual acuity was treated as a continuous variable after applying a logarithm of the minimal angle of resolution (logmar) transformation. Mean (SD) VA was calculated using logmar values and then transformed back to Snellen or decimal equivalents. Categorical variables were analyzed using the Fisher exact test or the W 2 test. Comparisons between preoperative and postoperative VAs were made using the Wilcoxon signed rank test. A P value of G0.05 was considered to be statistically significant. Statistical analysis was performed using Prism version 5 software (GraphPad Software, La Jolla, Calif ). RESULTS In total, 106 eyes from 104 patients with uncomplicated rhegmatogenous RD were treated within 24 hours of outpatient clinic presentation. The mean (SD) patient age was 57 (17) years (range, 12Y88 years). A total of 41 patients (39%) were female and 65 patients (61%) were male. Symptoms at presentation included floaters, visual field defects, photopsias, distorted vision, and loss of vision. Anatomical Results Reattachment Rate in Rhegmatogenous Retinal Detachment The primary reattachment rate for rhegmatogenous RD was 99% (81/82 eyes) for patients who underwent vitrectomy and 83% (20/24 eyes) for patients who underwent scleral buckling. Anatomical success was achieved after a single re-operation in all 5 eyes whose retina had remained detached after the primary surgery. Thus, reattachment of the retina was obtained in all 106 eyes. Anatomical success rates were not significantly correlated with the preoperative or intraoperative factors of age, sex, duration of symptoms, refractive error, location or extent of rhegmatogenous RD, location or number of retinal breaks, or method of surgery (Fisher exact test, P Q 0.05). Chronological Changes in Fovea-On/Off Status After the onset of RD, eyes with fovea-on gradually progressed to fovea-off because RD enlarges with time to involve the fovea. Only the patients who were able to recount their precise ocular history from which we could estimate the onset of significant central vision loss to a specific 24-hour period were included in the following analysis. A central vision loss indicated foveal detachment. The chronological changes in fovea-on/off status based on patient interview are summarized in Figure 1. The numbers of eyes with fovea-off were 46 eyes at nearby eye clinics, 55 eyes at the hospital outpatient clinic, and 57 eyes in the operating room. Accordingly, the number of eyes with fovea-on decreased until surgical intervention. The average time required for each step in the treatment process was measured, for example, from onset of central vision loss to visiting a nearby eye clinic, the FIGURE 1. Chronological changes in fovea-on/off status in eyes with uncomplicated rhegmatogenous RD. The numbers of eyes with fovea-off are demonstrated on the right of each time point and demonstrate 46 eyes at nearby eye clinics, 55 eyes at the outpatient clinic of Shinshu University Hospital, and 57 eyes at the time of operation. The numbers of eyes with fovea-on on the left of each time point decrease accordingly and are 60 eyes at nearby eye clinics, 51 eyes at the outpatient clinic, and 49 eyes at the time of operation * 2014 Asia Pacific Academy of Ophthalmology

3 Asia-Pacific Journal of Ophthalmology & Volume 3, Number 3, May/June 2014 Preempting Foveal Detachment in Retinal Detachment referral period leading up to operating facility presentation, and the time from the outpatient clinic to the operation theater (G24 hours in the present study; Fig. 1). Duration From Onset of Symptoms to Clinic Visit Surprisingly and most disappointingly, 46 (43.4%) of 106 patients with rhegmatogenous RD were already fovea-off when they first visited a nearby eye clinic. Fovea-off status was judged by fundus examination after mydriasis and ultrasonography. The patients with fovea-off RD had waited a mean (SD) of 5.4 (4.2) days, expecting spontaneous cure after the onset of the central vision loss often preceded by a sudden increase in the number of floaters. The remaining 60 eyes (56.6%) were foveaon at first examination. These patients sought medical attention with a mean (SD) of 3.4 (4.9) days after a central vision loss appeared. Foveal Detachment During the Referral Period Of the 60 patients who had been fovea-on at their nearby eye clinics, 9 progressed to fovea-off RD by the time they reached the outpatient clinic of our operating facility. These 9 patients took a mean (SD) of 3.1 (1.6) days to visit our hospital compared with the remaining 51 patients with fovea-on who took only 1.0 (1.2) days. Among the 9 eyes with newly detached fovea, 8 eyes had RD in the nasal-upper or temporal-upper quadrant, and 1 eye had RD in the temporal lower quadrant. Discrimination of Fovea-On/Off Status Using Optical Coherence Tomography Funduscopic examination result showed that the RD border to be within 1 disc diameter of the fovea in 10 eyes at outpatient presentation, so we used SD-OCT to evaluate the fovea-on/off status more accurately. Figure 2 demonstrates representative images of the fundus and foveal status as demonstrated by SD- OCT. Fovea-on status was confirmed in 8 of 10 eyes having both sides of the retina still attached (Fig. 2, left). One side of the fovea was already detached in 2 eyes (Fig. 2, right), which FIGURE 2. Representative fundus pictures and OCT images of eyes with fovea-on (left) or fovea-off (right) RD. Funduscopic examination result shows RD extending to within 1 disc diameter of the fovea (top left), whose fovea-on status is confirmed by OCT (bottom left). The retina is still attached on both sides of the fovea (arrow). The top right retina is evaluated as fovea-off because the retina is attached to only 1 side of the fovea (arrowhead) in OCT imaging (bottom right). were re-categorized as fovea-off despite appearing as fovea-on by funduscopy. Foveal Detachment Between Outpatient Clinic Presentation and Operation Although all 106 patients were assigned to bed rest at our hospital after immediate admission and were operated on within 24 hours, 2 of 8 eyes in which the front border of the RD was within 1 disc diameter of the fovea at presentation were found to have progressed to fovea-off status by the time of the operation. VISUAL RESULTS In 106 eyes with rhegmatogenous RD, the mean (SD) preoperative VA was 0.63 (0.79) logmar (range, j0.18 to 2 logmar). Mean (SD) postoperative VA was 0.18 (0.41) logmar (range, j0.18 to 2 logmar). Comparison of Postoperative Best Corrected Visual Acuity Between Eyes With Fovea-On and Fovea-Off Retinal Detachment In eyes with fovea-on, the mean (SD) preoperative BCVA was j0.032 (0.16) logmar (range, j0.18 to 0.52 logmar). Mean (SD) postoperative BCVA was j0.019 (0.22) logmar (range, j0.18 to 0.70 logmar). In eyes with fovea-off, the mean (SD) preoperative BCVA was 1.11 (0.65) logmar (range, j0.079 to 2 logmar). Mean (SD) postoperative BCVA was 0.32 (0.45) logmar (range, j0.18 to 2 logmar). The mean (SD) postoperative BCVA of the fovea-on group was significantly higher than that of the fovea-off group (P G 0.05), confirming that surgery before foveal involvement is critical to achieve good VA outcomes. Comparison of the Ratio of Eyes With a Postoperative Best Corrected Visual Acuity Sufficient for a Driver s License Renewal Between Eyes With Fovea-On and Fovea-Off Retinal Detachment The most frequently asked question by patients who underwent rhegmatogenous RD treatment was whether they would be able to continue driving a car. A corrected VA of 20/28 is required for renewing a driver s license in Japan. In this study, 49 (96%) of 51 eyes with fovea-on achieved a postoperative BCVA of 20/28 or better, whereas this number was limited to 35 (63.6%) of 55 eyes with fovea-off. Postoperative Metamorphopsia We were able to directly ask 34 (61.8%) of 55 patients with fovea-off and 23 (45.1%) of 51 patients with fovea-on if they experienced metamorphopsia postoperatively. In the former group, all 34 patients replied that they experienced mild to moderate distorted central vision, whereas only 2 (5.5%) of 36 patients in the latter group experienced this problem. There was no apparent macular pucker formation during the follow-up period in either group. Days Required for Referral Depending on the Day of the Week Patients Visited the Clinic Although the average time required for referral did not significantly differ between the fovea-on group (mean [SD], 1.0 [1.2] days) and the fovea-off group (3.1 [1.6] days), several patients had a longer referral period that was related to day of the week they visited their clinic. A total of 25 patients initially evaluated on Friday or Saturday took a significantly longer time to visit the hospital than those evaluated on Sunday through * 2014 Asia Pacific Academy of Ophthalmology 143

4 Kikushima et al Asia-Pacific Journal of Ophthalmology & Volume 3, Number 3, May/June 2014 Thursday (P = 0.02). Specifically, approximately half of the patients who visited the clinic on Friday waited until the following Monday (9/21 eyes, 43%) or Tuesday (2/21 eyes, 9%) to present to our outpatient clinic, whereas the remainder (10/21 eyes, 48%) visited us for treatment on the same day. Intraoperative Data A detailed fundus examination was possible during vitrectomy even in eyes with opaque media, such as from a cataract or vitreous hemorrhage, because opaque media could be removed during the operation. The causative retinal break was identified in all 106 eyes, including 24 eyes (23%) in which multiple breaks were found and were superior in 47 eyes (44%), temporal in 20 eyes (19%), nasal in 15 eyes (14%), and inferior in 24 eyes (23%). DISCUSSION Fovea-on RD is considered to be a surgical emergency, 1, 4,10,11,18 and the Ophthalmic Procedure Assessment of the American Academy of Ophthalmology encourages an urgent operation, preferably within 24 hours. 12 In the present study also, there was a statistically significant difference in vision recovery between the fovea-on group and the fovea-off group (P G 0.05). These data suggest the importance of increasing the ratio of patients who undergo surgery before the fovea becomes detached. However, we found that our urgent operation strategy did not increase much the ratio of patients who underwent surgery while the fovea was still attached as much as we had expected. More than half (52%) of the patients were already experiencing fovea-off RD when they visited our outpatient clinic because of delays in visiting nearby eye clinics and referral lags. Urgent surgery (within 24 hours of the presentation) was especially effective for particular 8 eyes with RD whose border was within 1 disc diameter of the fovea. Of the 8 eyes, 6 were operated on before foveal involvement, and the remaining 2 eyes that had become fovea-off also regained 20/20 VA. Although the remaining 55 (52%) of 106 eyes were already fovea-off when they arrived at our hospital, the number of eyes we may speculate to have benefitted from urgent surgery in our cohort was 6 (5.7%). Because all 6 eyes had RD in the superior or temporal quadrant, it is likely that all cases would have experienced foveal detachment by the time of an operation on the next regular operation day. The present study uncovered that the mean (SD) of foveaoff duration before patients visited our hospital totaled 6.1 (5.7) days. In light of this, our efforts for early surgery may only have had a modest effect on net fovea-off duration. The most surprising finding was that patients with fovea-off waited a mean (SD) of 5.4 (4.2) days until they visited a clinic, whereas they had central visual field defects. To shorten this unnecessary time lag, it is important to increase public awareness by educating unaffected healthy individuals that RD requires emergency surgery to preserve adequate vision for daily life. For example, in elderly patients requiring regular outpatient treatment, losing a driver s license because of poor vision would result in an inability to access their hospital. It has been reported that elderly nondrivers may become unable to meet basic needs while living independently, including seeing doctors for their health problems. Furthermore, not driving is an independent risk factor for entering long-term care institutions among the elderly persons. 19 In our cohort, 94.7% of patients with foveaon achieved a postoperative BCVA sufficient for renewal of a driver s license, whereas this rate was a considerably 64.6% lower in the fovea-off group. Thus, RD surgery while the fovea is still on is paramount, especially in functionally monocular patients. The current study also revealed the need to shorten the time from a referral at an eye clinic to operating facility presentation to reduce foveal involvement in RD. The 9 patients who progressed to fovea-off status after referral waited a mean (SD) of 3.1 (1.6) days compared with only 1.0 (1.2) days for their fovea-on counterparts. This was mainly because the patients who received an initial examination on a Friday or Saturday tended to visit the hospital the following week, which may have led to foveal detachment and resulting compromised postoperative vision. To avoid this delay, we have become explicitly clear with local clinics that we accept emergency patients even on Friday nights or weekends. In conclusion, our findings confirmed that early surgery increased the number of patients who underwent treatment before foveal involvement and therefore enjoyed a better visual prognosis. In several RD cases with imminent foveal involvement, urgent surgery was believed to preempt foveal detachment and improve visual outcome. However, we also uncovered that more than half of our patients with RD were already foveaoff at presentation to our outpatient clinic. Consequently, emergency surgery alone is not the only key in achieving fovea-sparing RD repair. Public education is necessary to prevent future patients with RD from waiting to see if symptoms subside, and clinics need to emphasize the importance of avoiding foveal involvement when making referrals. A combination of patient misinformation about the vision-threatening pathology of RD and treatment delays led to fovea-off status in more than half of the patients by the time they arrived at the hospital. To increase the ratio of patients with fovea-on at surgery, which is the most important key to improve the visual prognosis, education of the public about the necessity of urgent treatment is critical. Lastly, hospitals need to commit adequate resources to urgent RD treatment, which required considerable resources and manpower in the current study. Through these strategies, patients will be able to maintain a level of vision that is essential for a good quality of life. REFERENCES 1. Hassan TS, Sarrafizadeh R, Ruby AJ, et al. The effect of duration of macular detachment on results after the scleral buckle repair of primary, macula-off retinal detachments. Ophthalmology. 2002;109:146Y Ho SF, Fitt A, Frimpong-Ansah K, et al. 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