title: Who should manage primary retinal detachments?
abstract: OBJECTIVE
  To determine whether the outcome of primary retinal reattachment surgery in a subregion is improved by surgery being performed in a specialist vitreoretinal unit (VRU).
  
  
  METHODS
  A subregional, population-based, retrospective audit cycle of primary retinal reattachment surgery was conducted by independent investigators. The subregion was defined as the catchment area of a teaching hospital (TH) with a specialist VRU and three neighbouring district general hospitals (DGHs). During the initial audit period (January 1989 to December 1990), 142 cases were treated at all four hospitals: TH/VRU (83), DGH-A (15), DGH-B (13), and DGH-C (31). Policy changes after the initial audit led to primary retinal reattachment surgery being predominantly performed by the VRU. During the re-audit period (September 1995 to August 1997), 160 cases were treated at two hospitals: VRU (148) and DGH-C (12). The outcome measure employed was complete retinal reattachment after a single procedure with a minimum follow-up of 12 months.
  
  
  RESULTS
  The success rate for primary retinal reattachment surgery in the subregion improved from 76.1% to 88.8% (p = 0.006) following the policy changes. The success rate of the vitreoretinal specialists in the VRU (90%) was greater than the general ophthalmologists in the DGHs (ranging from 47% to 77%), despite case selection by the general ophthalmologists. The number of cases treated by the VRU increased by 156% in the 6.5 year interval between the two audits due to a widespread change in the model of care for primary retinal detachments (both within and outside the subregion). During the re-audit period, the VRU treated 348 primary retinal detachments (including referrals from outside the subregion), achieving a success rate of 86.8% with a single procedure and 97.4% with further surgery. This primary success rate included 35 cases (10%) treated by vitrectomy with silicone oil tamponade who did not undergo silicone oil removal.
  
  
  CONCLUSIONS
  The outcome of primary retinal reattachment surgery can be improved if surgery is performed by a specialist VRU. It is suggested that the current standard for retinal reattachment with a single procedure should be set in the region of 85% to 90%. Changing the model of care so that primary retinal reattachment surgery is predominantly performed by a specialist VRU has important resource implications.
authors.affiliation: Department of Ophthalmology, Addenbrooke's Hospital, Cambridge, UK.
authors.forename: M B
authors.initials: MB
authors.lastname: Comer
authors.forename: D K
authors.initials: DK
authors.lastname: Newman
authors.forename: N D
authors.initials: ND
authors.lastname: George
authors.forename: K R
authors.initials: KR
authors.lastname: Martin
authors.forename: B D
authors.initials: BD
authors.lastname: Tom
authors.forename: A T
authors.initials: AT
authors.lastname: Moore
mesh_terms: D004739:England; D005500:Follow-Up Studies; D006757:Hospital Units / Q000592:standards*; D006801:Humans; D008485:Medical Audit; D009885:Ophthalmology / Q000458:organization & administration*; D012163:Retinal Detachment / Q000601:surgery*; D012189:Retrospective Studies; D012591:Scleral Buckling; D013038:Specialization; D016896:Treatment Outcome; D014821:Vitrectomy; D016526:Workload