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Background Eyes sustaining open globe trauma are at high risk of severe visual impairment. Proliferative vitreoretinopathy is the most common cause of retinal detachment and visual loss in eyes with open globe trauma. There is evidence from experimental studies and pilot clinical trials that the use of adjunctive steroid medication triamcinolone acetonide can reduce the incidence of proliferative vitreoretinopathy and improve outcomes of surgery for open globe trauma. Objective The Adjunctive Steroid Combination in Ocular Trauma or ASCOT study aimed to investigate the clinical effectiveness of adjunctive triamcinolone acetonide given at the time of vitreoretinal surgery for open globe trauma. Design A phase 3 multicentre double-masked randomised controlled trial randomising patients undergoing vitrectomy following open globe trauma to either adjunctive triamcinolone acetonide or standard care. Setting Hospital vitreoretinal surgical services dealing with open globe trauma. Participants Patients undergoing vitrectomy surgery who had sustained open globe trauma. Interventions Triamcinolone acetonide 4 mg/0.1 ml into the vitreous cavity and 40 mg/1 ml sub-Tenon’s or standard vitreoretinal surgery and postoperative care. Main outcome measures The primary outcome was the proportion of patients with at least 10 letters of improvement in corrected visual acuity at six months. Secondary outcomes included retinal detachment secondary to proliferative vitreoretinopathy, retinal reattachment, macula reattachment, tractional retinal detachment, number of operations, hypotony, elevated intraocular pressure and quality of life. Health-related quality of life was assessed using the EuroQol Five Domain and Visual Function Questionnaire 25 questionnaires. Results A total of 280 patients were randomised; 129 were analysed from the control group and 130 from the treatment group. The treatment group appeared, by chance, to have more severe pathology on presentation. The primary outcome (improvement in visual acuity) and principal secondary outcome (change in visual acuity) did not demonstrate any treatment benefit for triamcinolone acetonide. The proportion of patients with improvement in visual acuity was 47% for triamcinolone acetonide and 43% for standard care (odds ratio 1.03, 95% confidence interval 0.61 to 1.75, p = 0.908); the baseline adjusted mean difference in the six-month change in visual acuity was –2.65 (95% confidence interval –9.22 to 3.92, p = 0.430) for triamcinolone acetonide relative to control. Similarly, the secondary outcome measures failed to show any treatment benefit. For two of the secondary outcome measures, stable complete retinal reattachment and stable macular retinal reattachment, outcomes for the treatment group were significantly worse for triamcinolone acetonide at the 5% level (respectively, odds ratio 0.59, 95% confidence interval 0.36 to 0.99, p = 0.044 and odds ratio 0.59, 95% confidence interval 0.35 to 0.98, p = 0.041) compared with control in favour of control. The cost of the intervention was £132 per patient. Health economics outcome measures (Early Treatment Diabetic Retinopathy Study, Visual Function Questionnaire 25 and EuroQol Five Dimensions) did not demonstrate any significant difference in quality-adjusted life-years. Conclusions The use of combined intraocular and sub-Tenon’s capsule triamcinolone acetonide is not recommended as an adjunct to vitrectomy surgery for intraocular trauma. Secondary outcome measures are suggestive of a negative effect of the adjunct, although the treatment group appeared to have more severe pathology on presentation. Future work The use of alternative adjunctive medications in cases undergoing surgery for open globe trauma should be investigated. Refinement of clinical grading and case selection will enable better trail design for future studies. Trial registration This trial is registered as ISRCTN 30012492, EudraCT number 2014-002193-37, REC 14/LNO/1428, IRAS 156358, Local R&D registration CHAD 1031. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (12/35/64) and will be published in full in Health Technology Assessment; Vol. 27, No. 12. See the NIHR Journals Library website for further project information. Plain language summary Despite advances in surgical techniques, eye trauma remains a leading cause of blindness and visual impairment. The main cause of trauma is a scarring process within the eye – proliferative vitreoretinopathy. There is good evidence from laboratory work and small-scale clinical studies that the addition of a steroid medication, triamcinolone acetonide, given in and around the eye at the time of surgery for eye trauma, can reduce the incidence of proliferative vitreoretinopathy scarring and improve the outcomes of surgery. The Adjunctive Steroid Combination in Ocular Trauma or ASCOT study was a multicentre clinical trial designed to test the use of triamcinolone acetonide as an addition to surgery to improve outcomes in eyes with ‘open globe’ penetrating injuries. A total of 280 patients were recruited and randomised to receive standard surgery or surgery with the additional steroid (triamcinolone acetonide). No benefit was found from the addition of the steroid medication. The addition of steroid medication was not good value for money. Secondary outcome measures suggested that triamcinolone acetonide may have had a negative effect on outcomes, although this may have been due to the presence of more severe cases amongst the patients allocated to receive the additional steroid (triamcinolone acetonide). The use of adjunctive triamcinolone acetonide in eye trauma cases undergoing surgery is therefore not recommended. Future studies with different additional medications and/or more targeted case selection are indicated to improve outcomes for eyes experiencing penetrating trauma. Scientific summary Background Eyes sustaining penetrating or open globe trauma (OGT) are a group at high risk of severe visual impairment. Retinal detachment (RD) is common in these eyes and multiple surgical interventions are often necessary. Proliferative vitreoretinopathy (PVR) is the most common cause of recurrent RD and visual loss in eyes, with OGT occurring in 10–45% of cases. There is good evidence from experimental, preclinical studies and pilot clinical trials that the use of adjunctive steroid medication, in particular triamcinolone acetonide (TA), can reduce the incidence of PVR and improve outcomes of surgery for OGT. Objective The Adjunctive Steroid Combination in Ocular Trauma (ASCOT) study aimed to investigate the clinical effectiveness of adjunctive TA given at the time of vitreoretinal surgery for OGT. This included analysis of the economic and quality of life benefits of the adjunctive treatment. From an NHS perspective, to explore the incremental cost-effectiveness of TA and to explore the cost per quality-adjusted life-year (QALY) of adjunctive TA in vitreoretinal surgery for OGT to determine whether this falls below the National Institute of Health and Care Excellence threshold of £20,000–30,000 per QALY. Methods A phase 3 multicentre double-masked randomised controlled clinical trial randomising patients undergoing vitrectomy following OGT to either adjunctive TA (4 mg/0.1 ml into the vitreous cavity and 40 mg/1 ml sub-Tenon’s) or standard care. Inclusion criteria were as follows: 1.adult subjects (aged 18 years or over at the time of enrolment) 2.full thickness, open globe ocular trauma undergoing vitrectomy 3.ability to give written informed consent 4.willingness to accept randomisation and attend follow-up for six months. Patients were recruited prior to vitrectomy surgery and randomised at the completion of surgery. The primary outcome was to determine whether adjunctive intraocular and periocular steroid (TA) improves visual acuity (VA) at six months compared with standard treatment in eyes undergoing vitreoretinal surgery for OGT. This was defined as the proportion of patients with at least 10 letters of improvement in corrected VA on the Early Treatment Diabetic Retinopathy Study (ETDRS) chart at six months. Secondary outcomes were to determine whether adjunctive intraocular and periocular steroid (TA) influences the development of scarring (PVR), RD (stable complete retinal and macular reattachment), intraocular pressure abnormalities and other complications in eyes undergoing surgery for OGT. In addition, to assess the effects of treatment on quality of life measured using the EuroQol Five Dimensions (EQ-5D) questionnaire and the Visual Function Questionnaire-25 (VFQ-25) tools. The study sample size was calculated from previously published work and two non-randomised trials carried out by the investigators. Based on previous studies, to detect a 19% increase in the proportion of patients with clinically meaningful improvement in VA [from 55% to 74%, corresponding to an odds ratio (OR) of 2.33], with an allowance for an estimated 7% dropout rate, the target sample size was 300 patients (150 per study arm). The main analysis followed the intention-to-treat principle and was conducted subgroup blind (i.e. as group A vs. group B) in accordance with the prespecified ASCOT statistical analysis plan. The primary analysis model consisted of a mixed logistic model with change in VA (

Primary retinectomy in eyes not previously vitrectomized has been previously rarely performed in a minority of cases, unlike non-primary retinectomies in vitrectomized eyes. This paper aims to determine anatomical and functional outcomes of primary retinectomy, and to assess structural macular changes among successful cases. In this retrospective multicentre cohort-study, 35 primary retinectomies in eyes undergoing initial vitrectomy for rhegmatogenous retinal detachment complicated by proliferative vitreoretinopathy C or D between 2014 and 2021 were included. The mean follow-up duration was 48 ± 59.24 months among successes and 46.54 ± 20.99 months among unsuccesses (p = 0.483). The anatomical success rate was 48.5% after one retinectomy and 60% after two retinectomies. Mean postoperative best corrected visual acuity (BCVA) was 1.85 ± 0.62 logMAR (6/425 Snellen equivalent). The difference from mean preoperative BCVA was not significant (p = 0.312). Final BCVA ≥ 6/60 was achieved in 17% of cases, and no cases gained ≥6/24. Final mean postoperative BCVA of successes was 1.69 ± 0.60 logMAR (6/294 Snellen equivalent) compared with 2.10 ± 0.57 logMAR (6/756 Snellen equivalent) of unsuccessful cases (p = 0.101). Post-operative macular optical coherence tomography was obtained from 95% of successes. Normal macular profile was found in 10% of cases, and the other cases demonstrated exudative maculopathy (60%), tractional maculopathy (20%) and macular atrophy (10%). Final BCVA was significantly higher in eyes with normal macular status compared to eyes with exudative maculopathy (p = 0.045) and macular atrophy (p = 0.025). Primary retinectomy may be used for rhegmatogenous retinal detachment complicated with advanced proliferative vitreoretinopathy. Anatomical and functional outcome were inferior than non-primary retinectomies for grade C proliferative vitreoretinopathy. Functional outcome was influenced by macular status. Positive prognostic factors include final anatomical success and normal final macular anatomy. [ABSTRACT FROM AUTHOR]

Background/aims To investigate the clinical effectiveness of adjunctive triamcinolone acetonide (TA) given at the time of vitreoretinal surgery following open globe trauma (OGT). Methods A phase 3, multicentre, double-masked randomised controlled trial of patients undergoing vitrectomy following OGT comparing adjunctive TA (intravitreal and subtenons) against standard care (2014-2020). The primary outcome was the proportion of patients with at least 10 Early Treatment Diabetic Retinopathy Study (ETDRS) letter improvement in corrected visual acuity (VA) at 6 months. Secondary outcomes included: change in ETDRS, retinal detachment (RD) secondary to PVR, retinal reattachment, macular reattachment, tractional RD, number of operations, hypotony, elevated intraocular pressure and quality of life. Results 280 patients were randomised over 75 months, of which 259 completed the study. 46.9% (n=61/130) of patients in the treatment group had a 10-letter improvement in VA compared with 43.4% (n=56/129) of the control group (difference 3.5% (95% CI -8.6% to 15.6%), OR=1.03 (95% CI 0.61 to 1.75), p=0.908)). Secondary outcome measures also failed to show any treatment benefit. For two of the secondary outcome measures, stable complete retinal and macular reattachment, outcomes were worse in the treatment group compared with controls, respectively, 51.6% (n=65/126) vs 64.2% (n=79/123), OR=0.59 (95% CI 0.36 to 0.99), and 54.0% (n=68/126) vs 66.7% (n=82/123), OR=0.59 (95% CI 0.35 to 0.98), for TA vs control. Conclusion The use of combined intraocular and sub-Tenons capsule TA is not recommended as an adjunct to vitrectomy surgery following OGT. [ABSTRACT FROM AUTHOR]

Vision loss after detachment of the neurosensory retina is a complex process which is not fully understood. Clinical factors have been identified which contribute to loss of macular function after retinal detachment and laboratory studies have played an important role in understanding the cellular and subcellular pathological processes which underlie the loss of visual function. As clinical imaging has advanced, multiple studies have focused on identifying and correlating clinicopathological features with visual outcomes in patients with rhegmatogenous retinal detachment. Optical coherence tomography, fundus autofluorescence, optical coherence tomography angiography and adaptive optics studies have contributed to the understanding of the anatomical changes in relation to clinical outcomes. A clear understanding of the macular pathology of retinal detachment is fundamental to develop strategies to improve outcomes in patients with rhegmatogenous retinal detachment and analogous retinal diseases where macular neurosensory retinal detachment is part of the pathology. This review assesses the evidence from experimental and pathological studies together with clinical imaging analyses (optical coherence tomography, fundus autofluorescence, optical coherence tomography angiography and adaptive optics) and the contribution of these studies to our understanding of visual outcomes. [ABSTRACT FROM AUTHOR]

Rhegmatogenous retinal detachment (RRD) is the most common form of retinal detachment (RD), affecting 1 in 10,000 patients per year. The condition has significant ocular morbidity, with a sizeable proportion of patients obtaining poor visual outcomes. Despite this, the genetics underpinning Idiopathic Retinal Detachment (IRD) remain poorly understood; this is likely due to small sample sizes in relevant studies. The majority of research pertains to the well-characterised Mende lian syndromes, such as Sticklers and Wagners, associated with RRD. Nevertheless, in recent years, there has been an increasing body of literature identifying the common genetic mutations and mechanisms associated with IRD. Several recent Genomic Wide Association Studies (GWAS) studies have identified a number of genetic loci related to the development of IRD. Our review aims to provide an up-to-date summary of the significant genetic mechanisms and associations of Idiopathic RRD. [ABSTRACT FROM AUTHOR]

There is still much that is unknown of the abnormal pathology in multifocal chorioretinal inflammatory disease. The choroid is the middle of three tunics that covers most of the back of the eye; it is highly vascular and pigmented. The retina is the delicate inner tunic of the eye that is made up of nerve tissue and is continuous with the optic nerve. A case is presented of a woman who died of a heart attack, but previously suffered for nine years from multifocal posterior uveitis (inflammation of the pigmented vascular tunic of the eye beneath the sclera, the outer fibrous tunic of the eye). When first seen the patient had a one-month history of aching pain and blurred vision in both eyes. She had mild inflammation of the iris and swelling of the optic disc (the small blind spot on the surface of the retina where the central artery of the retina enters the eye). The eye inflammation was controlled by steroid therapy and good vision had been preserved for nine years; however, the cause was never determined. Following the woman's death, extensive study of the eye did not reveal the cause of the condition. There was evidence of ongoing chorioretinal inflammation causing destruction of Bruch's membrane (the transparent inner layer of the choroid that is in contact with the pigmented layer of the retina and connects the choroid and the retina), and the retinal pigment epithelium, the outer retina. Neither ischemic (oxygen deprivation of tissue as a result of reduced blood flow) nor infective causes for the disorder were identified. (Consumer Summary produced by Reliance Medical Information, Inc.)

Abstract Background Rhegmatogenous retinal detachment (RRD) is a potentially blinding condition and a common cause of ocular morbidity. Establishing an accurate estimate of disease incidence and distribution is an important first step in assessing the healthcare burden related to this condition and in subsequent planning and provision of treatment strategies. The aim of this study is to obtain a first estimate incidence of RRD in Scotland, to estimate the incidence of familial RRD and to describe the known associations of RRD within the study population. Methods/Design We have established a national prospective observational study seeking to identify and recruit all incident cases of RRD in the Scottish population over a 2 year period. After fully informed consent, all participants will have a blood sample taken and a full medical history and clinical examination performed including visual acuity, refraction, slit-lamp examination, intra-ocular pressure measurement and detailed fundal examination. We describe the study design and protocol. Conclusion This study will provide the first estimate of the annual incidence of RRD in Scotland. The findings of this study will be important in estimating the burden of disease and in the planning of future health care policy related to this condition. This study will also establish a genetic resource for a genome wide association study to investigate if certain genetic variants predispose to RRD.