 Next up is our first year fellow, Dr. Charles Calvo, otherwise known as CJ. He's gonna be talking about whether or not we need to come in at three in the morning to fix the retinal detachment. His, the title of his talk is, what is the optimal timing of retinal detachment repair? Thank you. Good morning everyone, I'm CJ. Thanks for being here. So I wanted to look into, or really see what the evidence had to say about when are we best to fix a retinal detachment? So we know in ophthalmology there are a couple of clear, cut and dry emergencies. End ophthalmitis, angle closure, glaucoma, ruptured globe, giant salariditis. These are things that require treatment immediately. And we know that a retinal detachment is, you know, more emergent than say, getting a, you know, fake emulsification done on a cataract, but like where does it stand? So we wanted to look carefully and see really what does the evidence say about this problem? So first off, retinal detachment is a very common problem. They say in literature that like one in 10,000 lifetime or annual risk, but I think a better way of saying it is that one in 170 eyes will develop a retinal detachment in their life. So that's a very frequent problem. And this was once an operable problem. Once it happened, you know, it was incurable until in the 1920s, a Swiss ophthalmologist, Jules Gonen, kind of created the first technique using a coterie. We would actually cotterize the retina through the sclera. Sounds very painful and awful, but that was the first technique that was around to give these people a chance. And then they're really the next big breakthrough. And already repair was in the 1950s with Charles Scape and who invented indirect ophthalmoscopy. And that really allowed us to go into some other techniques like scleral buckling. And then now where we are today in 2018, anatomics, excess rates are very high, over 85% for mild or moderate complex primary retinal detachment. So it's really come a long way in the last century. We know that the visual outcomes are, and this is true in a lot of problems in ophthalmology, they're really related to what the preoperative visual acuity was. And the way that we commonly classify this retinal detachment is macula on, meaning that the fovea is still attached, versus macula off. And if your macula is on, you have a really good chance of having great vision. 80% of Macon RDs obtain 20, 40 vision or better, as opposed to 30% for those that were macula off. So of course it would make sense to want to fix these while the macula is still on. But there's lots of non-modifiable risk factors that influence the visual outcomes. How old the patient is, what's their lens status? How large is the RD? Do they have proliferative vitro retinopathy? So there's a lot of things that we can't change. But the one thing that we can change is, when are we gonna do the surgery? So this is the most obvious modifiable risk factor. And they talk about this duration of macular detachment, DMD, as one way of looking at this in the literature. It's basically, from when did that retinal detachment start, till when did they get it fixed? And that is what a lot of the studies look at. And so obviously the logical assumption is, sooner is better, we need to get it done. So should we do it immediately today? Should I cancel all of the clinic and get that RD fixed now? Should I do it in a week? Should I have done it yesterday? I think there's a lot of questions that come from that. So in terms of basic science research, they've done a lot of work in animals, non-primates, rabbits, where they're inducing a retinal detachment. And we've seen that there's cellular and there's molecular changes that happen almost immediately within minutes of the detachment. We see that the Mueller microglial cells in the retina, they have inflammatory changes that start within hours, they evolve and they can actually even induce changes in parts of the retina that are not detached. And then we know that when the retina is detached, the outer retina obtains its nourishment from the coriocapillaries and the inner retina receives its nourishment from the retinal arteries. But actually, there's evidence that shows that even the inner retina becomes hypoxic because there's reduced retinal blood flow due to the abnormal anatomical changes. However, if we go to clinical data, the clinical evidence really suggests that the visual outcomes depend less on time to surgery than you would expect. And so there's been lots and lots and lots of research on this and multiple retrospective or hundreds of patients demonstrate that there's really no difference in vision of those patients who are operated within one week. So we're gonna dive into and kind of see what those have to say. So this series has 104 patients with Mac-Off RDS. And as we see, it's a driver pointer. So we see over here, the pre-op vision in all of these patients is pretty poor, somewhere around 2400 to 20 over 600. And their duration of macular attachment is anywhere from one day to seven days. And the outcome in this study was the vision at 11 months. And we can see across this whole group, regardless if they got their surgery the first day or the seventh day, they're all their visions kind of ended up in the 2050 to 2060 range. And you see that from day one to two, day three to four, day five to seven, that everyone kind of ended up in that 2050 range. In another study with 94 patients with Mac-Off RDS and all of these patients had very poor vision going in. They all were 2200 or worse. And how they grouped the patients, they grouped them in the three groups. Those that have had a retinal attachment for one to 10 days, from 10 days to six weeks, and then greater than six weeks. And obviously, as we see here, again, there's significantly better visual outcomes in the group of patients that were repaired from one to 10 days compared to the others. And so we see here their pre-operative, or their mean post-operative vision in the less than 10 day group, their vision's like 2040, their mean vision 2040. So that's pretty good. Compared to the 11 days to six weeks, which was 20 over 125 to like 20 over 180. So pretty similar, but a big difference in vision between that first group to the second and the third group. So then they did subgroup analysis. Well, let's break down that one to 10 day group. Let's see if there's really a change in there. Maybe did the people that got their surgery in one day, did they do better? And really what we're seeing here is that they, despite their visions all being pretty awful at the beginning, mean visions from 2400 to 20 over 1400. So very poor vision. At the end of the day, they all ended up having vision about that 2030 to 2050 range, regardless of whether they were the first day or the 10th day. So can I just point out a statistic for you? So one concern when you start splitting down to groups that are small as four and five or six, is all it takes is one outlier, it's a different problem. So I think the true statement here is that I don't think there's enough power here to ascertain whether there's truly differences in those different groups. I think it's important that we understand that, that you can look at trends, but I think it would be very hard to make a statistical statement as at least the word of the sum of the three. Yeah, and then that kind of goes back to, that is a big concern with any surgical evidence because usually the number of patients are smaller, every patient's different surgeon. So there definitely are a lot of accepted- There's no obvious trend. When you look at it, there's no obvious trend, but it's hard to make a definitive statement. Yeah, but there's battle. True. And you know as the associate header of AJO, we get these where they're somewhat underpowered and you get another underpowered study and it's just, it's hard to definitively answer. And this is a question that was argued vehemently clear back when I was a resident. That was almost a hundred years ago. Yeah, yeah, I agree. Within breaking down the one to 10 days, the evidence is there and even though it is, may not be the strongest evidence or have the biggest power, but this is the best research that we have in 2018, I agree. And it is what we have. So we have to work with what we have. You know, I do think there's some utility in it though. I mean, even if you, I mean, for me, like a one to four day is like a pretty quick window to get something fixed, you know, maybe one to three, but if you then, you know, take that, you've got 34 in that first group and then 24 in that second and then it still looks like there wouldn't really be a difference. Yeah, the biggest takeaway of this is really, you know, I think they did the subgroup analysis to kind of give any, or to answer the questions of the naysayers of this data. But the biggest question, or the biggest thing this really said was there's a huge difference between the first group and everything after. And that's really the takeaway is people within the first 10 days did fairly well. They got good vision. Everyone else got poor vision at the end of the day. That's really the takeaway of studying, not the one to 10 groups. And these are all Mac-off artist too. I haven't got to Mac-on yet. Okay, so what about Mac-ons? Let's talk about those. So in this series of 199 fovea-sparing RDS that were present for less than seven days, this study was done in Miami. They, 85% of those patients were repaired within three days of presentation. They only did surgery on weekends or holidays for six of the 199 cases. And this is the interesting thing about the paper. Only one of these renal attachments progressed from fovea-on to fovea-off before surgery, which is a half of a percent. And that's a pretty interesting thing. And 75% of these patients had post-op vision better than 2040, which kind of supports the outcomes of Mac-on attachments. And they noted that there was no difference in visual outcomes between patients operating on the first, second, or third day. And they didn't find any correlation between the location of the renal attachment and proximity to the matthew. So what this ends up kind of it raises questions of are renal attachments that were Mac-off or they destined to always be Mac-off? Did they immediately go Mac-off? And Mac-on attachments, do they kind of stay on? Are they slow? Have they kind of halted? Have they progressed to a point and then they are arrested in that progression? So there was one other study that looked at how quickly does a macula-on attachment become macula-off? So they had 82 patients with fovea-sparing RDS and they repaired them within one six days. And then the mean time was 2.3 days. So only 11% of the patients from when they first presented to time of surgery had progression of the renal attachment. And only in 3%, three of the 82 patients developed a macula-off renal attachment for surgery. So they determined that in the cases that did have progression, the RD progressed 1.8 disc diameters per day, which kind of seems like a lot. But given the previous study and this study, it didn't seem that retinal progression from Mac-on to Mac-off happened that frequently. But this was the only one that really has any, the only thing in the literature that actually talks about a rate 1.8 disc diameters per day. One study looking at ADIs versus on same day surgery versus next day surgery. So there were 88 fovea-sparing, half of them were operated on the same day and half of them were operated on the next. They found that there was no difference in vision at the three-month mark with a mean visual beauty of 2030. However, there was a statistically significant increase in the amount of operative time, about three hours versus two and a half hours on the case that was same day. It took longer to do. And in this study, which was done like in 15, they stated to give it at their local OR, that their OR cost was $62 per minute, that it had like a mean increase of 1,600 bucks per case if you did it on the same day. There's other evidence that supports that as well, that the same day cases do cost more, even though the outcomes are the same. Why is that? Well, you could, if you came on a weekend when we did a retinal attachment repair in the vein, you came with us, you would see, because the OR, there's a lot more prep that has to come. It's not your normal turf. Things have to be transported in. There's ancillary staff, there's different anesthesia techniques, unusual environments. So things take a little bit longer. I mean, that was the same thing for that study. They were operating. Same day versus, same day in a different environment. Same day, as I understand it, but what happens here is that if it's the same day and you can pop it into the regular schedule, it's probably not a different time. But if you're doing the same day, so you've got to figure out how you're trying to do at the end of the day, or you're gonna go, like you said, the main OR or the rest, that there's just issues associated with loss of efficiency. There's a strong reason why the surgeons at the Marine Eye Center will almost give their left leg not have to go to the main OR. Absolutely. Why not, right? Yeah, you really, in an eye hospital that's so well oiled, like, or anywhere else oiled to it, when you have to then go and operate in a general hospital that was doing a C-section in that room before, you really realize how lucky you are to be in an eye-only OR. So we used to operate, I go back to the days when that's what it was, and I called up the deer in the headlight, and he'd ask for something and everybody's like, what in the world is he talking about? Now, when we go to the main OR, we bring our eye crew with us, but the big difference that we deal with is anesthesia. They're not our same anesthesia providers there. There's anesthesia residents, they're unfamiliar with doing, monitored anesthesia care here with the Ritual Bullmark Block. There are some differences there, so it does take a lot longer. And then you have, we try to be as well-prepared as we can and bring everything. There's always at least 10 to 12 points of friction, I'd call it. It's just interesting how you think, I mean, it's way better. If we had to do, there's a time we had to use staff there, we have no experience whatsoever. That's frankly scary, that's dangerous. And so that's why we've taken it, and with our staff there, it helps, but it is, as you look at it in review, those who've been there, there's just these points of friction that seem to go in that make that a much more difficult slope. Just asking for something. Yeah. Somebody's gotta run over and find it and come back. Exactly, yeah, exactly. That's the big thing. You try to be as well-prepared and bring everything you can think to the case, but then something happens and you need an instrument or the retracting machine starts to sputter, and then you gotta send the nurse and they gotta run all the way back over to Marin and they gotta push it back over and then you sit there and the patient's under anesthesia for 30 minutes and you're, so it does, it is not the same. So when I was going through this evidence of looking through the literature, I started seeing this thing called the weekend effect and it is not really described in the ophthalmology literature because we're usually at Monday through Friday type of group, but in the general surgery, the obstetric literature, they talk about this stuff a lot and there's many, many, many papers about it and so what this weekend effect is, is that there have been documented poor surgical outcomes, higher complications, longer and more expensive admissions for patients that have surgery on the weekends rather than Monday through Friday and this is gallbladders and appendectomies and emergency C-sections and all type of bowel instructions. They have evidence for every type of problem like that and they have all really chalked it up where their theories are, on the weekend they have lower weekend staffing, things take longer to get done. There's unfamiliar ancillary staff, they're not used to doing these things usually and then there's physician and staff fatigue who we work hard Monday through Friday and then having to do a unplanned surgery on the weekend can take a toll on you. But the best thing that I've learned from this, which I think is really promising, is that there's good evidence that supports that hospitals that did have the weekend effect, they weren't able to overcome it with institutional changes. So it's not, there's not something magic that causes your case to be cursed on Saturday and Sunday. You can fix it by identifying the problems and staffing, training people, trying to recreate your Monday through Friday scenarios on the weekend. Probably not completely. Probably not completely. True. It's gone away, but there is evidence that there's still, there's a reason why people do not want to try to come and have it done there. Just as a, there's another one that's well known. Everybody, any heard of the July effect? That's a very real one too. You know, I don't know what that is. Yeah. Well, we'll take you off the corner and let you understand the July effect. It's probably true that we've actually had a student working on this weekend and after hours in the hospital, because that is a general hospital that we operate at. And if we have to add on the cat record about the coma case, there's been multiple times where I've had a team come in that doesn't even know how to turn on or get the constellation set up. And so we've got a dedicated eye team there. So we've kind of watched this whole process unfold a little bit at the crime area. It's been interesting. Yeah. So the conclusions from the evidence is, you know, a rental attachment repair should be performed at the earliest reasonable surge of opportunity. There's lots of considerations, OR availability, staff availability. What's the preoperative health of the patient? Does this patient have aortic stenosis and should they get an echo before the surgery? You know, are they on an anticoagulant? Do they have caretakers available? If they're going to be face down or if they're going to, if this is our only eye and we're putting gas in it and they're going to be visually disabled after the surgery, should we do it right now or should we wait until their son or daughter can be available to take care of them? So there's lots of things that go into this decision on when to fix a rental attachment. And so I think that just saying that this is an emergency you need to have surgery today is probably a, would probably be a mistake to say that. It's a little bit more complicated and there are lots of concerns that need to be looked at. So what the evidence really says is that macula off rental attachments can be repaired within seven to 10 days with no impact on visual outcome. And then macula sparing rental attachments can be deferred for a short period of time. And that does not compromise the visual outcome. So really the evidence does support that RD repair is an urgent, but it's not an emergent surgery. So practically, practically. Just asking here we've got some more rental colleagues in place. Today, if we have a macula on attachment that shows up on Saturday morning, do we do it on the weekend or do we wait until Monday? I would say that it depends. It's an inferior attachment and it's not threatening it over the following weeks. Wait until Monday. It's a superior temporal attachment that's coming down on the superior okay. We do a fair number of dramatic rental effects this year which are a fairly easy procedure to do in the office. You don't have this high success rate which is a little bit, probably a good 75% of those will be fine with that. If we want to do that. So that's another option too that you can do for a surgery. I have done one case of the main alarm in the last five years. You don't do it in a different way. So my general rule of thumb is macula on attachment. I try to get it repaired within 24 hours. Mac off within a week. So middle of the night, never, essentially. I can't think of a release. Used to be that was a lot of middle of the night surgery. Part of the problem is sometimes we'll get somebody sent in from an outside, whoever, optometrist or somebody. Vision is 2,200 patients have decreased vision for three or four days. They come in and they're told I need surgery today. My doctor told me to come in now and have surgery. I'll say, you know, maybe it's Wednesday and I have surgery Friday. I said, well, I'm gonna put you on my schedule Friday. My doctor told me I had to have it today. And then it's a more of a re-education, re-educating the patient about that. But if the patient ends up maybe a less than stellar visual outcome, they're always gonna question that. Exactly. If you'd operated on an eye sight, you'd understand what I have done better. Yeah, I was gonna bring that up. I think it is totally reasonable for referring all the top optometrists to say, you have a retinal attachment. I think you need to see a retina specialist today. But there's absolutely no benefit whatsoever in telling the patient that you need surgery today. All that does is erode that doctor and patient relationship and they'll always question it in the future and say, well, I'm 2040 and it's probably your fault because I didn't get it on the same day. It's really not the referring physician's place to say that. And only bad things come from saying that. And can I just add to that is I think it's reasonable also for the referring physician to say, but why don't you stay and peel? Just in case they want to do that or they are able to do it or they deem that it's important for you. And sometimes we will. I mean, if it's not Friday and I've got women, they come in in the morning and they get back up because I'm fine. I got women the afternoon will do it today. And we work as a team. I mean, I think the redness service here, I feel I can say this because I've been in other redness practices, but the redness service here really works well to try to deliver the best care for the patient. So sometimes if we do have someone urgent and somebody's on call or somebody and they can do it and there's another person who has time, now that we have more time in the OR, I think that's really been really valuable. With somebody with a redness surgeon in the OR every day. Yeah. Delaying it to the next person, guys. Thank you. Very good. Thank you.