Purpose: During bank holidays and weekends (BHWE), many primary macula-on retinal detachments (RD) across the United Kingdom are performed unsupervised out-of-hours by experienced vitreoretinal (VR) fellows. We aimed to determine whether first-year (F1) and second-year (F2) fellows could safely operate out-of-hours independently with remote supervision on primary macula-on RDs. Methods: This is a retrospective consecutive series of 435 patients attending the Birmingham and Midlands Eye Centre from January 2017 to July 2020. We evaluated (i) 6-month re-detachment rate and (ii) visual outcomes of F1, F2, and consultants during office hours and BHWE as well as the effects of supervision versus non-supervision. Results: For the re-detachment rate, no difference was found between surgeon grade (p = 0.821), whether supervised (p = 1.000), whether BHWE (p = 1.000), unsupervised BHWE and supervised mid-week (p = 0.757), and unsupervised F1 and F2 (p = 1.000), with non-significance maintained on multivariate regression. No difference was detected in the level of supervision (15.7%) between fellow grades during BHWE (p = 0.761) or mid-week (p = 0.295) or between surgeon grade and logMAR letters gained pre-postoperatively (p = 0.834). Conclusion: Safe VR services can be provided by experienced VR fellows during office hours, BHWE, supervised, or unsupervised, with similar primary success and visual outcomes to consultants in this patient subgroup. Initial intensive supervision and feedback and a gradual increase in independence is fundamental for VR fellows to gain confidence and become safe independent surgeons.

Summary

  • We demonstrate that a safe vitreoretinal (VR) service can be provided by first- and second-year VR fellows during office hours, bank holidays, and weekends, whether supervised or unsupervised, with similar primary success and visual outcomes to consultants. In our unit, initial intensive supervision and feedback, followed by a gradually increasing degree of independence, is fundamental for VR fellows to gain confidence and become safe independent surgeons.

What Was Known before

  • Primary macula-on retinal detachments constitute the majority of out-of-hours (OOH) surgical intervention for a vitreoretinal (VR) service.

  • VR fellows on-call across the United Kingdom are typically expected to cover OOH emergency work for VR, mostly with remote supervision.

What This Study Adds

  • Initial intensive supervision, feedback, and training are fundamental for VR fellows to gain confidence and become safe independent surgeons.

  • A safe VR service can be provided by experienced fellows during office hours, bank holiday, and weekends, supervised or unsupervised, with similar primary success and visual outcomes to consultants.

Vitreoretinal (VR) fellowships are integral to a surgeon’s career pathway to being a consultant through acquiring adequate clinical and surgical experience. In the United Kingdom, the British & Eire Association of VR Surgeons (BEAVRS) states that a consultant VR surgeon must have at least a year of supervised surgical training in a recognized VR fellowship [1]. This is to ensure that the surgeon becomes competent in performing pars plana vitrectomy (PPV) in a vast range of VR conditions as well as external procedures such as scleral buckling.

An important part of VR fellowships is to undertake VR on-calls and to provide surgical cover for VR emergencies out of hours (OOH), that is, on a weekend (WE) or bank holiday (BH). An overwhelming majority of OOH VR procedures consist in repairing macula-on rhegmatogenous retinal detachments (RRD) as the macula status is a significant visual prognostic factor in determining final visual acuity (VA) [2]. In many units across the United Kingdom, VR fellows will operate such cases unsupervised after reaching a satisfactory level of experience.

Independent operating is an essential factor in becoming surgically competent in preparation for consultancy. In the UK, ophthalmology residents have to complete 7 years of ophthalmology training, followed by 1–2 years of fellowship in their respective subspeciality. Before the end of the 7-year training, the Royal College of Ophthalmology (RCOphth), UK, mandates that trainees should have performed at least 350 cataract operations (independently or supervised) and several other procedures and operations within the other subspecialities, including assisting in 20 VR procedures [3]. In reality, residents that are interested in VR will gain an experience well beyond the mandated requirements, and they will often be able to perform basic RRDs via PPV under supervision by the end of their residency programme.

The RCOphth specifies that trainees should operate independently when the clinical supervisor deems them able to do so [4]. In a survey of UK Ophthalmology trainees, 79.9% felt confident in performing cataract surgery independently, which increased to 100% from year 4 to 7 of training [5]. Similar to cataract surgery during the Ophthalmology residency, once VR fellows acquire the necessary skills, they are expected to operate VR cases independently. In the UK, this is considered as an integral part of the VR fellowship training to allow VR fellows to gradually improve their independent thinking and confidence. However, operating unsupervised and particularly OOH represents a stressful situation for most surgeons, and this might have an effect on the final outcomes.

To confront this issue, we analysed the surgical outcomes of macula-on RRDs performed by first- and second-year VR fellows within office hours and OOH and with or without supervision. To the best of our knowledge, no previous study has assessed this topic yet.

This is a retrospective consecutive case series of patients operated on by VR fellows and consultants attending the Birmingham and Midland Eye Centre (BMEC) from January 2017 to July 2020. The research adhered to the tenets of the Declaration of Helsinki, and all patient data extracted were anonymized for analysis.

First-year VR fellows (F1) are expected to possess the basic surgical skills for performing straightforward RRD repair via PPV in their respective postgraduate resident training. In our unit, F1 performed a minimum of 40 vitrectomies during the residency program prior to commencing their fellowship. Around 100 vitrectomies are generally performed before a fellow is deemed able to operate independently. However, this varies depending on individual surgical ability and attitude. Independent surgery by the fellows is approved following 2–3 months of supervised training, reviewing of recorded surgeries, and structured teaching by the consultants. Within our fellowship training, timetables include an average of 4 theatre sessions a week. First-year fellows are initially placed on a 5-theatre session per week rotation involving predominantly emergency cases to help them to gain surgical independence during the on-call cover. Our primary outcome measures are the primary success rate following macula-on RRD repair via PPV and the visual outcomes achieved.

Inclusion and Exclusion Criteria

As our primary aim was to assess the safety of VR fellows operating independently OOH in our cohort, we only included primary straightforward macula-on RRDs to reflect the case complexity encountered. We excluded macula-off RRDs, eyes with prior trauma, those that presented with PVR grade C, and cases which required oil tamponade or a scleral buckle as part of the surgical intervention. These complex cases were mostly operated under supervision and during working hours, not allowing a comparison with OOH surgery. Recent publications suggested that recent macula-off RRDs achieve better visual outcomes if operated within 72 h [6]. Such cases presenting on a BHWE to our unit are operated on Monday which follows the most recent evidence. In addition, recent-onset macula-off RRDs have a similar degree of complexity to macula-on RRDs.

All data for primary macula-on RRD were extracted from electronic patient records (EPR, Medisoft). Re-detachment rates were based on repeat retinal detachment surgery in the same eye within 6 months. A 6-month period was chosen to include late re-detachments in line with other publications [7, 8]. This allowed the retinal assessment over several months following the absorption of the longer-lasting gas intraocular tamponade. As a tertiary referral centre, patients whose postcode was outside our immediate catchment area were excluded to avoid selection bias as these patients may have further surgery at the referring unit. The re-detachment rate of F1 and F2 was compared against consultants’ detachment rate which was considered as the gold standard in our unit. All cases had transconjunctival 23-gauge PPV, vitreous-base trim, fluid air exchange, and gas tamponade. Retinopexy of retinal breaks was achieved with either external cryotherapy, endolaser retinopexy, or a combination of the two. The following data were collated: age of patient, gender, pre-operative and post-operative VA, tamponade used, grade of the operator, level of supervision, and whether the operation was performed OOH or not. Generally, surgery at BMEC is not performed OOH during mid-week, and macula-on retinal detachments presenting in the evening are operated on the next working day. Therefore, all OOH cases included in our series were performed either during a bank holiday or a weekend (BHWE). A case was labelled as performed under supervision if a consultant was present in the theatre either scrubbed or watching the operation at the screen. No supervision during office hours meant that the consultant was onsite but not in the theatre. No supervision during BHWE means the consultant is off site and available within 30 min.

Statistical Analysis

All statistical analyses were performed using IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY, USA). Statistical significance was defined as p < 0.05. Prior to analysis, continuous variables were assessed using the Shapiro-Wilk test and found not to be normally distributed. Hence, data are primarily reported as medians and interquartile ranges (IQRs) throughout. Mann-Whitney U and independent-samples Kruskal-Wallis test were used to compare 2 and 3 independent groups, respectively (age and VA). Wilcoxon signed rank test was used for 2-paired VA data. Fisher exact test and χ2 test were used for nominal variables. Bonferroni correction was applied for multiple statistical analysis. Best-corrected VA was used, and records in Snellen were converted to logMAR. Low VA corresponding to count fingers, hand movements, perception of light, and no PL were substituted with 2.10, 2.40, 2.70, and 3.00 logMAR, respectively, in keeping with previous publications from the national ophthalmology database group [9] using a tool by Moussa et al. [10].

A multivariate Cox regression survival analysis was performed to risk stratify the re-detachment rate. As covariates, we included gender, high myopia (defined as >6 dioptres of myopia), operator grade (first-year fellow, second-year fellow, and consultant), tamponade gas used, whether the surgery was performed on a BHWE, and if the case was supervised or not.

In our cohort, we included 435 PPV cases presenting with a straightforward macula-on RRD; 5 (15.7%) cases were operated under supervision and 140 (32.2%) were done on a BHWE. The overall average success rate for primary RD surgery was (402, 92.4%). A summary of demographics and clinical characteristics of macula-on RRD is found in Table 1. When comparing F1 to F2, we found no statistical significance difference in the proportion of unsupervised cases performed during BHWE (F1: 54 [93.1%], F2: 73 [91.3%], p = 0.761), within office hours (F1: 66 [83.5%], F2: 103 [76.9%], p = 0.295), and overall (F1: 120 [87.6%], F2: 176 [82.2%], p = 0.228). Table 1 shows no statistically significant difference between grade of surgeon and the use of SF6 (p = 0.245) and C3F8 (p = 0.385) gas. However, consultants used more C2F6 compared to F1 and F2 (p = 0.008).

Table 1.

Demographics and clinical characteristics of macula-on RRD repair

 Demographics and clinical characteristics of macula-on RRD repair
 Demographics and clinical characteristics of macula-on RRD repair

Table 2 summarizes the factors affecting the 6-month re-detachment rate. No significant difference was found in 6-month re-detachment rate between supervised and unsupervised cases performed during BHWE (p = 1.000), mid-week (p = 0.757), and overall (p = 1.000). We found that C3F8 tamponade was linked to a higher re-detachment rate (Table 2, p = 0.032). No association was found between grade of surgeon and re-detachment rate (Table 2). Table 2 and Figure 1a–d also illustrate the 6-month re-detachment rate according to the surgeon’s grade, demonstrating no significant difference in primary failure rate when considering all patients, those operated on a BHWE, and/or with or without supervision (p = 0.821).

Table 2.

Comparing factors affecting re-detachment rate 6 months post-op

 Comparing factors affecting re-detachment rate 6 months post-op
 Comparing factors affecting re-detachment rate 6 months post-op
Fig. 1.

Re-detachment rate at 6 months by grade: subgroup analysis: *χ2 test; Fisher exact test; consultant cases excluded. a Re-detachment rate at 6 months versus grade for all cases. b Re-detachment rate at 6 months versus grade for cases operated on bank holiday and weekend. c Re-detachment rate at 6 months versus grade for supervised and unsupervised cases (consultants excluded). d Re-detachment rate at 6 months versus mid-week and BHWE for unsupervised cases. No significant difference between all grades in all subgroups.

Fig. 1.

Re-detachment rate at 6 months by grade: subgroup analysis: *χ2 test; Fisher exact test; consultant cases excluded. a Re-detachment rate at 6 months versus grade for all cases. b Re-detachment rate at 6 months versus grade for cases operated on bank holiday and weekend. c Re-detachment rate at 6 months versus grade for supervised and unsupervised cases (consultants excluded). d Re-detachment rate at 6 months versus mid-week and BHWE for unsupervised cases. No significant difference between all grades in all subgroups.

Close modal

Subgroup Analysis of Supervision of Fellows and 6-Month Re-Detachment Rate

When comparing F1 and F2, there was no difference in 6-month re-detachment rate between supervised (Fig. 1c, p = 0.272) and unsupervised (Fig. 1c, p = 0.299) cases. When considering the 6-month re-detachment rate and the level of supervision of different fellow grades independently, we found no difference between the subgroups: F1: supervised primary success (17 [100%]) compared to unsupervised primary success (108 [90.0%], p = 0.361); F2: supervised primary success (34 [89.4%]) compared to unsupervised primary success (165 [93.8%], p = 0.313).

Bank Holiday and Weekend Subgroup Analysis of 6-Month Re-Detachment Rate

We found no statistical significance when comparing supervised to unsupervised cases performed on BHWE (Table 2, p = 1.000). When considering only unsupervised cases performed on BHWE (generally consultant available from home, available within 30 min) versus mid-week (generally consultant on site, but not actively supervising), we detected no significant difference (p = 1.000, Fig. 1d). Even when comparing unsupervised BHWE cases (n = 127, re-detachment rate: 117 [92.1%]) to PPVs performed supervised during mid-week (n = 44, re-detachment rate: 40 [90.9%]), the analysis did not reach statistical significance (p = 0.757).

Due to the high number of confounding factors which could affect the 6-month re-detachment rate, a multivariate Cox survival regression analysis was performed (Table 3). High myopia was the only risk factor identified to increase the re-detachment rate in our cohort (p = 0.041). Cases requiring C2F6 tamponade relative to C3F8 had a better primary success rate (p = 0.028). Figure 2 reports a Cox proportional hazards survival plot for re-detachment rate and covariates.

Table 3.

Multivariate Cox regression survival model assessing the risk of retinal re-detachment

 Multivariate Cox regression survival model assessing the risk of retinal re-detachment
 Multivariate Cox regression survival model assessing the risk of retinal re-detachment
Fig. 2.

Visual outcomes pre-op and after 6 months post-op by grade: subgroup analysis: F1, fellow 1; F2, fellow 2; box and whisker plot. “X” denotes mean. *Independent-samples Kruskal-Wallis test; Mann-Whitney U. Statistical significance in bold. a No difference between grades. b Primary failure linked to worse visual acuity.

Fig. 2.

Visual outcomes pre-op and after 6 months post-op by grade: subgroup analysis: F1, fellow 1; F2, fellow 2; box and whisker plot. “X” denotes mean. *Independent-samples Kruskal-Wallis test; Mann-Whitney U. Statistical significance in bold. a No difference between grades. b Primary failure linked to worse visual acuity.

Close modal

Visual Outcomes

Pre- and post-operative VA as well as paired logMAR gain in VA is summarized in Table 2, presented by grade in Figure 3a and reported according to the primary success in Figure 3b. We found no difference between pre- and post-operative VA and in logMAR VA gain depending on the surgeon’s grade. Overall, primary success was associated with better visual outcomes.

Fig. 3.

Cox proportional hazards survival plot for re-detachment at 6 months. Multivariate Cox survival regression model with the dependent variable as retinal re-detachment within 6 months following primary macula-on retinal detachment repair. Covariates include gender, high myopia, operator grade, bank holiday and weekend operating, supervision, and intraocular tamponade used at time of surgery. High myopia was identified as the only risk factor for higher re-detachment rate (p = 0.041). Cases requiring C2F6 tamponade relative to C3F8 had a better primary success rate (p = 0.028).

Fig. 3.

Cox proportional hazards survival plot for re-detachment at 6 months. Multivariate Cox survival regression model with the dependent variable as retinal re-detachment within 6 months following primary macula-on retinal detachment repair. Covariates include gender, high myopia, operator grade, bank holiday and weekend operating, supervision, and intraocular tamponade used at time of surgery. High myopia was identified as the only risk factor for higher re-detachment rate (p = 0.041). Cases requiring C2F6 tamponade relative to C3F8 had a better primary success rate (p = 0.028).

Close modal

This study showed that unsupervised first- and second-year VR fellows operating straightforward macula-on RRDs OOH achieve non-inferior outcomes compared to supervised fellows or consultants. The inclusion criteria were selected to mirror the RRD operations performed in the OOH setting. To the best of our knowledge, no study has assessed the effect of supervision and OOH surgery on the retinal re-detachment rate of VR fellows yet.

The overall average success rate in our series was 402 (92.4%) which is comparable to previous reports [7, 8, 11]. However, there is a wide variation of reported failure rates following primary RRD repair in the current literature (62.6%–91%) [12‒21]. This is due to several factors including the definition of primary RRD failure, the inclusion and exclusion criteria, and the timeframe for reporting failure. Our results showed a similar re-detachment rate among all grades, with F2 marginally achieving the best outcomes. However, when looking at the risk-adjusted multivariate regression model, consultants had the lowest risk-adjusted re-detachment rate (Fig. 2), although the difference did not reach statistical significance. In addition, we reported no significant difference in re-detachment rate between surgical grades irrespective of subgroup analysis, including unsupervised and OOH surgery. Only a limited number of studies assessed the surgical outcomes of RRDs operated by VR fellows in the past, reporting similar results to those of experienced specialists, as it was the case in our series [20, 22‒27].

Mason et al. [23] demonstrated that VR fellows had similar complication and reoperation rates compared to faculty surgeons. Additionally, the fellow’s experience did not affect the complications’ rate and the final outcome, a finding shared with our cohort [23]. However, the number of RRD cases included in their series was much smaller compared to our study (95 RRD cases performed by VR fellows compared to 61 eyes operated by attendings). In addition, all fellows’ operations were supervised by an attending, and therefore the safety of independent operating could not be assessed.

The largest and most recent UK national database study, conducted by Sallam et al. [22], evaluated the anatomical failure rate following primary RRD in 1,347 fellow-operated and 3,025 consultant-operated eyes. The results showed no statistically significant difference in failure rate between surgeons’ grade [22]. Moreover, the authors observed similar outcomes among individual surgeons, despite a wide variation of number of surgeries performed annually. Although the number of cases included in this study was higher than in our series, the authors did not describe the level of supervision and whether the operations were performed OOH or within office hours. In addition, the case complexity was not risk adjusted between groups.

Mazinani et al. [26] reported the outcomes of non-complex RRDs repaired via PPV in 215 patients. However, only 16 patients did not have an encircling band, and therefore the results are not comparable to our series. This reflects the shift in surgical approach from their study period (1997–2002) to the present [26]. Although the authors could not find a correlation between better primary anatomical success and the number of VR procedures performed, they observed a certain degree of learning effect among individual surgeons. As in the other previous studies, the effect of supervision and OOH surgery was not evaluated.

Thompson et al. [28] in a national study of RRD clinical outcomes published in 2002 commented that the degree of supervision does not play a role on re-detachment rate [28]. The fellow’s subgroup, however, only had 43 procedures, including 9 (21%) consultant-supervised cases and 13 (30%) cases where the level of supervision was not specified. Therefore, the numbers were too small to draw meaningful conclusions. Their results are also not directly comparable to our study due to the use of 20-gauge PPV and scleral buckling in their series.

Ehrlich et al. [20] compared the outcomes of 159 RRD eyes operated by VR fellows to 53 cases repaired by consultants. The study found differences in the choice of tamponade and retinopexy used but no variation in the overall re-detachment rate. Although the authors commented on which fellows were likely to be supervised, no data were reported neither on the effect of supervision nor on OOH surgery.

In our cohort, the good surgical outcomes achieved by VR fellows may be explained by the fact that during the first few months, they were intensively exposed to RRD cases and provided with structured teaching and constructive feedback. In addition, fellows had to perform a minimum of 100 VR procedures before being allowed to operate unsupervised. This number, however, varied depending on individual surgical ability and attitude. Differently than in the USA and some other countries where fellows almost exclusively operate under supervision, fellows in the UK, once deemed safe, are encouraged to perform cases independently [29]. This approach is supported by the bodies overseeing training across different surgical specialities [1, 4, 30]. Most trainers in the UK believe that gradually gaining independence while guaranteeing a certain degree of supervision boosts the surgeon’s confidence and independent thinking which facilitates the transition to consultancy. Our study showed that this approach is not detrimental to patients’ safety, even when VR fellows endure the stressful situation of operating unsupervised OOH.

Study Limitations and Strengths

The limitations of our study include its retrospective nature and lack of case randomization. Additionally, we used re-operations to calculate the re-detachment rate at 6 months. Patients may have had an unrelated event that led to a further detachment which may falsely increase our proposed re-detachment rate. Alternatively, patients may have declined further surgery after suffering a re-detachment. Patients may have had repeated surgery at other units, although we excluded patients from postcodes outside our catchment area to minimize this possibility. Moreover, our data did not include some risk factors for re-detachment such as the extent of RRD and the number or position of the breaks.

Despite this, our study has several strengths. A retrospective analysis allowed us to collate a large case series with adequate numbers to perform subgroup analysis which enabled us to produce the first series examining the effect of supervision and OOH surgery on the surgical outcomes of primary RRDs operated by VR fellows. Including only straightforward primary macula-on RRDs, in addition to representing the typical case-mix encountered OOH, also helped to adjust for confounding variables and case complexity. This increased our confidence that the groups operated on OOH and within hours were comparable. Finally, the use of an EPR system allowed the collection of consecutive cases.

The laboured road to becoming a competent VR surgeon requires great dedication and a robust surgical training. In this study, we showed that VR fellows in our unit, following an initial period of intensive supervised exposure to RRDs, had a comparable retinal reattachment rate to consultants when supervised and unsupervised during the working week and OOH, in our patient cohort of straightforward macula-on RRD. We therefore demonstrated that gradually gaining surgical independence does not compromise patients’ safety. This is reassuring for both clinicians and patients.

This study was registered in our local clinical effectiveness team (Reference No. 1593). As this was a retrospective anonymized study, as per our local protocol, this study had ethical approval exemption. Patients were diagnosed and treated according to local guidelines and agreements, and this study does not report on the use of new or experimental protocols.

All authors have no conflicts of interest in the production of this manuscript.

There are no external funders that have played a role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

All authors have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be submitted.

Data are available upon reasonable request.

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