Capturing the Occult Central Retinal Artery Occlusion Using Optical Coherence Tomography

AIMS: To report spectral-domain optical coherence tomography (OCT) findings in cases of impending or occult central retinal artery occlusion (CRAO) in which a diagnosis other than CRAO was made on initial presentation. METHODS: Retrospective, observational case series of patients diagnosed with CRAO for whom on initial presentation fundal examination and OCT findings were deemed unremarkable and/or a diagnosis other than CRAO was made. OCT images from the initial presentation were then reviewed for evidence of inner retinal ischaemia. RESULTS: In total, 214 cases of CRAO were identified. Eleven patients (5.14%) had been given an alternative initial diagnosis at their first presentation in casualty and were included. The age range was 20–84 years and 81% (9/11) were male. On review of initial OCT imaging performed in casualty, all cases had evidence of inner retinal ischaemia. Conclusions: CRAO is an ophthalmic emergency which leads to vision loss which is often irreversible. Examination of the fundus may be normal early in the course of the disease and therefore a timely diagnosis may be missed. This case series reports the OCT findings of inner retinal ischaemia in patients with occult or impending CRAO which may aid in the early diagnosis and referral to stroke services

Positioning In Macular hole Surgery (PIMS): statistical analysis plan for a randomised controlled trial

UK National Institute for Health Research (NIHR) through its Research for Patient Benefit scheme (grant number PB-PG-0213-30085)

Facedown Positioning Following Surgery for Large Full-Thickness Macular Hole: A Multicenter Randomized Clinical Trial.

Importance: The value of facedown positioning following surgery for large full-thickness macular holes is unknown. Objective: To determine whether advice to position facedown postoperatively improves the outcome for large macular holes. Design, Setting, and Participants: This randomized, parallel group superiority trial with 1:1 randomization stratified by site with 3 months' follow-up was conducted at 9 sites across the United Kingdom and included participants with an idiopathic full-thickness macular hole of at least 400 μm minimum linear diameter and a duration of fewer than 12 months. All participants had vitrectomy surgery with peeling of the internal limiting membrane and injection of perfluoropropane (14%) gas, with or without simultaneous surgery for cataract. Interventions: Following surgery, participants were randomly advised to position either facedown or face forward for 8 hours daily for 5 days. Main Outcomes and Measures: The primary outcome was closure of the macular hole determined 3 months following surgery by masked optical coherence tomography evaluation. Secondary outcome measures at 3 months were visual acuity, participant-reported experience of positioning, and quality of life measured by the National Eye Institute Visual Function Questionnaire 25. Results: A total of 185 participants (45 men [24.3%]; 156 white [84.3%]; 9 black [4.9%]; 10 Asian [5.4%]; median age, 69 years [interquartile range, 64-73 years]) were randomized. Macular hole closure was observed in 90 (85.6%) who were advised to position face forward and 88 (95.5%) advised to position facedown (adjusted odds ratio, 3.15; 95% CI, 0.87-11.41; P = .08). The mean (SD) improvement in best-corrected visual acuity at 3 months was 0.34 (0.69) logMAR (equivalent to 1 Snellen line) in the face-forward group and 0.57 (0.42) logMAR (equivalent to 3 Snellen lines) in the facedown group (adjusted mean difference, 0.22 [95 % CI, 0.05-0.38]; equivalent to 2 Snellen lines); 95% CI, 0.05-0.38; P = .01). The median National Eye Institute Visual Function Questionnaire 25 score was 89 (interquartile range, 76-94) in the facedown group and 87 (interquartile range, 73-93) in the face-forward group (mean [SD] change on a logistic scale, 0.08 [0.26] face forward and 0.11 [0.25] facedown; adjusted mean [SD] difference on a logistic scale, 0.02; 95% CI, -0.03 to 0.07; P = .41). Conclusions and Relevance: The results do not prove that facedown positioning following surgery is more likely to close large macular holes compared with facing forward but do support the possibility that visual acuity outcomes may be superior. Trial Registration: Isrctn.org Identifier: 12410596