Comparative evaluation of anatomical and functional outcomes using brilliant blue G versus triamcinolone assisted ILM peeling in macular hole surgery in Indian population

Presumed phototoxicity from macular vital staining with Brilliant Blue G and Trypan Blue: A post-market surveillance study, systematic review, and synthesis of the literature

Vital dyes are used to help visualize the retinal surface during macular surgery; however, they have been associated with phototoxicity. We synthesize and collate post-market surveillance data in two of the most commonly used dyes, Brilliant Blue G and Trypan Blue. We identified 69 cases, 59 of which were from the literature and 10 from manufacturer post-market surveillance. Of 69 vitrectomies, 39 were for macular hole, 24 for epiretinal membrane, 2 for vitreomacular traction, and 4 were not specified. The incidence of dye-mediated phototoxicity is likely rare, but is not possible to quantify, due to potential reporting and publication bias favouring dissemination of unusual safety events, but conversely underreporting is possible. Additionally, phototoxicity was reported prior to the introduction of vital stains, so it can be difficult to establish whether vital staining was contributory. Prolonged surgery and repeat staining were identified as risk factors. Characteristic clinical features were macular pigmentary change with hypo- and hyper-autofluoresence, often sparing the fovea. Final visual acuity tended to be worse than preoperatively, with some cases reduced to counting fingers. A reporting template is provided to encourage complete and standardised toxicity reporting and help build a robust evidence base.

Refractory full thickness macular hole: current surgical management

This review aims to collect the proposed surgical techniques for treating full thickness macular hole (FTMH) refractory to pars plana vitrectomy and internal limiting membrane (ILM) peeling and to analyse and compare anatomical and functional outcomes in order to evaluate their efficacy. The articles were grouped according to the surgical techniques used. Refractory FTMH closure rate and best-corrected visual acuity (BCVA) gain were the two analysed parameters. Thirty-six articles were selected. Ten surgical technique subgroups were defined: autologous platelet concentrate (APC); lens capsular flap transplantation (LCFT); autologous free ILM flap transplantation (free ILM flap); enlargement of ILM peeling, macular hole hydrodissection (MHH), autologous retinal graft (ARG), silicon oil (SO), human amniotic membrane (hAM), perifoveal relaxing retinotomy, arcuate temporal retinotomy. Refractory FTMH closure rate was similar among subgroups, not significant heterogeneity emerged (p = 0.176). BCVA gain showed a significant dependence on surgical technique (p < 0.0001), significant heterogeneity among subgroups emerged (p < 0.0001). Three sets of surgical technique subgroups with a homogeneous BCVA gain were defined: high BCVA gain (hAM); intermediate BCVA gain (APC, ARG, LCFT, MHH, SO); low BCVA gain (free ILM flap, enlargement of peeling, arcuate temporal retinotomy). In terms of visual recovery, the most efficient technique for treating refractory FTMH is hAM, lens capsular flap and APC that allow to obtain better functional outcomes than free ILM flap. MHH, ARG, perifoveal relaxing and arcuate temporal retinotomy require complex and unjustified surgical manoeuvres in view of the surgical alternatives with overlapping anatomical and functional results.

Evaluation of retinal functional changes after macular hole surgery using heavy brilliant blue G dye for internal limiting membrane staining: A prospective, single blind, randomized controlled trial

Purpose:

To evaluate retinal functional changes after idiopathic macular hole (MH) surgery using heavy brilliant blue G (hBBG) dye for internal limiting membrane (ILM) staining.

Methods:

Forty-four eyes with idiopathic MH were randomized into two groups – 24 eyes undergoing vitrectomy with ILM peeling using hBBG staining and 20 eyes without staining; anatomical and functional status (with microperimetry (MP)) at baseline and during postoperative follow-up were noted and compared.

Results:

All eyes had closure of MH postoperatively and overall baseline MP indices (average threshold, AT; foveal sensitivity, FS) improved significantly at 6 weeks and 6 months of follow-up. AT and FS showed significant improvement at 6 weeks and 6 months from baseline in both individual groups (P < 0.001). Intergroup comparison showed that there was no statistically significant difference in AT and FS values at any point of time (baseline, 6 weeks, 6 months) between staining and no-stain group. No eyes in our cohort had any unexplained visual loss.

Conclusion:

Functional parameters of macula improved significantly after successful MH surgery using hBBG for staining the ILM.

Long-Term Outcomes of Macular Hole Repair with Triamcinolone Acetonide Visualization

Purpose

To evaluate the long-term anatomic and visual outcomes of macular hole (MH) repair utilizing triamcinolone acetonide (TA) visualization of the internal limiting membrane (ILM) treated at a tertiary care retina practice.

Methods

Retrospective chart review of eyes undergoing MH repair with ILM peel utilizing TA visualization followed by gas tamponade and facedown positioning between 2014 and 2020. Pre- and post-operative visual acuity (VA), IOP, and anatomic closure based on optical coherence tomography were documented.

Results

Seventy-eight eyes were followed for 2.3±0.2 years after primary repair with anatomic closure in 73 (94%) eyes at their final visit and excluding eyes with pathologic myopia, 97%, and for stage 2 and small MHs, 100%. In all eyes, VA significantly improved from 0.97±0.04 (Snellen: 20/187) to 0.66±0.06 (20/91) logMAR (p < 0.0001). There were 16 eyes with 4 years of follow-up, 10 (63%) eyes achieving a VA ≥20/30 at that follow-up visit. Stage 2 and 3 MHs had significantly greater improvements in VA than Stage 4 MHs, −0.46 ± 0.06 versus −0.11 ± 0.11 logMAR (p = 0.021). Of the 13 (17%) eyes with recurrent MHs, 6 (46%) had pathologic myopia and 8 (61.5%) had associated cystoid macular edema. Cataract progression was reported in 52 (96%) phakic eyes and 2 eyes required Ahmed valve placement for management of pre-existing glaucoma.

Conclusion

Long-term results of MH repair with TA for ILM visualization demonstrate that it is safe and effective. Visual acuity continued to improve throughout the follow-up. Pre-existing glaucoma may progress and recurrence is associated with pathologic myopia and macular edema.

Efficacy of different doses of dye-assisted internal limiting membrane peeling in idiopathic macular hole: a systematic review and network meta-analysis

PURPOSE

Pars plana vitrectomy is the gold standard for the treatment of idiopathic macular hole. Several chromovitrectomy dyes have been used to improve the visualization of the internal limiting membrane (ILM), including indocyanine green, trypan blue (TB), brilliant blue G (BBG), and triamcinolone acetonide (TA). We conducted a network meta-analysis (NMA) to establish the optimum concentration of chromovitrectomy dye-assisted ILM peeling for IMH.

METHODS

We searched PubMed, Embase, and Cochrane Library for relevant studies before January 2020. We performed a random-effects NMA using STATA version 15.1 to assess mean difference and odds ratios with 95% confidence intervals.

RESULTS

We identified twelve retrospective trails and five randomized controlled trials (RCTs), comprising 1 492 patients of IMH on stage II-IV for ILM peeling. The results of IMH closure rate show that the effect of ILM peeling without dye was better than 0.25% ICG, the effects of ILM peeling with 0.5% ICG or TA were better than without dye, and the effects of ILM peeling with 0.05% BBG, 0.15% TB, 0.5% ICG or 0.05% ICG were better than 0.25% ICG. Ranking probability analysis shows that the rates of IMH closure after ILM peeling with 0.15% TB or 0.05% BBG were better than nine other concentrations of chromovitrectomy dyes.

CONCLUSION

The 0.15% TB and 0.05% BBG were recommended as the better efficient treatment-assisted ILM peeling for IMH closure. For retina specialists who prefer to use ICG to assist ILM peeling, 0.05% ICG may be a good choice. However, high-quality large-scale RCTs are recommended to confirm the NMA results.

LATE-ONSET OCULAR HYPERTENSION AFTER VITRECTOMY: A Multicenter Study of 6,048 Eyes

PURPOSE

To determine the incidence and risk factors for late-onset ocular hypertension (LOH) after vitrectomy.

METHODS

From the electronic medical records of consecutive patients who underwent primary vitrectomy, from January 2010 to December 2015, at 5 tertiary vitreoretinal centers in Italy, patient demographics, systemic, ophthalmic, operative, and postoperative data were drawn. Main outcome measure was the presence of LOH, defined as intraocular pressure >21 mmHg detected more than 2 months after vitrectomy on at least 2 consecutive visits.

RESULTS

Among 6,048 patients, LOH was found in 294 (4.9%) vitrectomized eyes and in 87 (1.4%) fellow eyes, (chi square; P < 0.001). Multivariable logistic regression showed that significant risk factors for developing LOH included intraoperative triamcinolone use (odds ratio [OR], 7.62; P < 0.001), longer axial length (OR, 1.55; P = 3.023), preoperative higher intraocular pressure (OR, 1.81; P = 0.003), and postvitrectomy pseudophakic/aphakic status (OR, 2.04; P < 0.001). Decision-tree analysis showed that the stronger predictor of LOH was intraoperative triamcinolone use (P < 0.001). Secondary predictors were a preoperative intraocular pressure more than 15 mmHg (P < 0.001) in eyes that use triamcinolone, and postvitrectomy pseudophakic/aphakic status (P = 0.007) in eyes that did not use triamcinolone.

CONCLUSION

Late-onset ocular hypertension occurred in 4.9% of vitrectomized eyes. The main risk factors were intraoperative use of triamcinolone and postvitrectomy pseudophakic/aphakic status.

Outcomes of Idiopathic Full-Thickness Macular Hole Surgery: Comparing Two Different ILM Peeling Sizes

Purpose

This study aimed to show the impact of different extents of internal limiting membrane (ILM) peeling on visual and anatomical outcomes following idiopathic full-thickness macular hole (FTMH) surgery.

Methods

In this single-center prospective study, patients with idiopathic FTMH underwent standard pars plana vitrectomy with two different extents of ILM peeling: 2-disc diameters (DD) or 4 DD. The main outcome measures were the closure rate of the holes based on optical coherence tomography (OCT) findings at three months after surgery.

Results

Forty eyes from 39 patients were enrolled in the study. After three months, anatomical closure was achieved in 78% and 76% eyes in 2 DD peel and 4 DD peel groups, respectively. From 29 eyes with macular hole index (MHI) ≤ 0.5, type 1 closure was achieved in 42% eyes receiving a 2 DD ILM peel, compared to 66% eyes receiving a 4 DD peel (p=0.041). In comparison, this significant difference was not seen in the subgroup of MHI > 0.5 (p=061). In the subgroup of subjects with baseline MHI ≤ 0.5, visual improvement was significantly more in eyes with 4 DD ILM peeling (p=0.034), which was not seen in the MHI > 0.5 subgroup (p=0.61).

Conclusion

In patients with idiopathic full‐thickness macular hole (MHI ≤ 0.5), a larger ILM peel of 4 DD appears to yield better anatomical outcomes than a more limited 2 DD peel.

Vitrectomy for the removal of idiopathic epiretinal membrane with or without internal limiting membrane peeling: a meta-analysis

Purpose:

The aim of this study is to analyze the effect of internal limiting membrane peeling in removal of idiopathic epiretinal membranes through meta-analysis.

Methods:

We searched PubMed for studies published until 30 April 2018. Inclusion criteria included cases of idiopathic epiretinal membranes, treated with vitrectomy with or without internal limiting membrane peeling. Exclusion criteria consisted of coexisting retinal pathologies and use of indocyanine green to stain the internal limiting membrane. Sixteen studies were included in our meta-analysis. We compared the results of surgical removal of epiretinal membrane, with or without internal limiting membrane peeling, in terms of best-corrected visual acuity and anatomical restoration of the macula (central foveal thickness). Studies or subgroups of patients who had indocyanine green used as an internal limiting membrane stain were excluded from the study, due to evidence of its toxicity to the retina.

Results:

Regarding best-corrected visual acuity levels, the overall mean difference was –0.29 (95% confidence interval: –0.319 to –0.261), while for patients with internal limiting membrane peeling was –0.289 (95% confidence interval: –0.334 to –0.244) and for patients without internal limiting membrane peeling was –0.282 (95% confidence interval: –0.34 to –0.225). Regarding central foveal thickness levels, the overall mean difference was –117.22 (95% confidence interval: –136.70 to –97.74), while for patients with internal limiting membrane peeling was –121.08 (95% confidence interval: –151.12 to –91.03) and for patients without internal limiting membrane peeling was –105.34 (95% confidence interval: –119.47 to –96.21).

Conclusion:

Vitrectomy for the removal of epiretinal membrane combined with internal limiting membrane peeling is an effective method for the treatment of patients with idiopathic epiretinal membrane.

Outcomes of 4 surgical adjuvants used for internal limiting membrane peeling in macular hole surgery: a systematic review and network Meta-analysis

AIM

To compare the outcomes of four adjuvants used for internal limiting membrane (ILM) peeling in macular hole surgery, including indocyanine green (ICG), brilliant blue G (BBG), triamcinolone (TA) and trypan blue (TB), through systematic review and random-effects Bayesian network Meta-analysis.

METHODS

PubMed, Cochrane library databases and Web of Science were searched until August 2018 for clinical trials comparing the above four adjuvants. ORs for postoperative best corrected visual acuity (BCVA) improvement and primary macular hole closure rates were compared between the different adjuvants.

RESULTS

Twenty-seven eligible articles were included. For postoperative BCVA improvement, results of BBG-assisted peeling were significantly more favorable than those of ICG (WMD 0.08, 95% credible interval 0.01-0.16) and TA ranked highest. No significant differences were found between any other two groups in postoperative BCVA improvement. For postoperative primary macular hole closure rates, BBG ranked highest. However, no significant differences were shown between any two groups.

CONCLUSION

TA and BBG are the optimum adjuvants for achieving postoperative BCVA improvement macular hole surgery with adjuvant-assisted ILM peeling. Among all adjuvants, the use of BBG is associated with the highest postoperative macular hole closure rate.

Internal limiting membrane peeling with different dyes in the surgery of idiopathic macular hole: a systematic review of literature and network Meta-analysis

AIM

To evaluate the effect of internal limiting membrane (ILM) peeling with indocyanine green (ICG), brilliant blue G (BBG), triamcinolone acetonide (TA), trypan blue (TB), or without dye for the treatment of idiopathic macular hole (IMH).

METHODS

A search was conducted using PubMed, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) for related studies published before October 2018.

RESULTS

A total of 29 studies and 2514 eyes were included in this network Meta-analysis. For IMH closure, the rank from the best to the worse treatment was: BBG, TB, TA, ICG, and no dye. There was a significant difference in postoperative IMH closure rate between BBG and no dye. The rank of the best to the worse treatment to improve visual acuity was: BBG, TB, no dye, TA, and ICG. The improvement rate of visual acuity after using BBG was significantly higher than ICG. The improvement rate of visual acuity was more favorable with TB than ICG, TA, and no dye.

CONCLUSION

BBG can contribute to better anatomical and functional outcomes compared to other dyes for ILM peeling in patients with IMH. The results show that the best treatment of ILM peeling with dyes is BBG.

Feasibility and Safety of Intraoperative Optical Coherence Tomography-Guided Short-Term Posturing Prescription after Macular Hole Surgery

PURPOSE

To assess closure rate and visual outcome of a court of patients with macular hole (MH) who underwent surgical repair with intraoperative optical coherence tomography (iOCT)-confirmed MH closure and short-term postoperative face-down posturing (FDP). Secondary aim was to assess the correlation between iOCT and postoperative OCT at day 1.

METHODS

Retrospective clinical study conducted in the Miulli Hospital Acquaviva delle Fonti (Italy), enrolling patients with idiopathic MH who underwent 25-G pars plana vitrectomy plus internal limiting membrane peeling. During surgery, closure of MH was confirmed by iOCT and short-term FDP (12-24 h, until day-1 visit) was prescribed. All patients had measurement of best-corrected visual acuity (BCVA) and spectral domain-OCT before the surgery and during follow-up (at 1 day, 1 month, 3 months).

RESULTS

Twenty-nine eyes of 29 patients (14 males, 62.1%) were enrolled in the study. MH mean size was 451.7 ± 139.7 µm and baseline BCVA was 0.77 ± 0.26 logarithm of the minimum angle of resolution (LogMAR). MH was confirmed to be closed in 100% of patients intraoperatively (iOCT) and at OCT during early follow-up (1-3 days). Mean time of FDP was 18 ± 2.6 h. At 3 months, MH closure rate was 93%; 2 eyes -underwent secondary MH repair surgery. Final BCVA was 0.39 ± 0.22 LogMAR (p < 0.0001).

CONCLUSION

iOCT-based confirmation of MH closure could be a safe and useful tool for prescribing short-term FDP after surgery, with high closure rate and no additional complication. The execution of an OCT in the immediate postoperative days could be potentially unnecessary.

Management of recurrent rhegmatogenous retinal detachment

Rhegmatogenous retinal detachment (RRD) repair is one of the most common vitreoretinal surgeries a surgeon performs. In an ideal scenario, RRD can be repaired with a single surgical intervention; however, despite excellent skill, flawless technique, and the introduction of high-end technology, up to 10% of cases require additional interventions to ultimately repair recurrent detachments. It is thus important to study the outcomes of multiple interventions to understand whether performing repeat vitrectomy on patients with a history of failed surgeries is worthwhile. Thus, recurrent retinal detachment (re-RD) remains a significant challenge for vitreoretinal surgeons as well as the patients considering the economic and the emotional burden of undergoing multiple interventions. The advent of microincision vitrectomy system, perfluorocarbon liquids, and effective intraocular tamponades has opened new doors for managing re-RDs. In this article, we have reviewed and summarized the various causes and approaches for management for optimal anatomical and functional outcomes.

Macular hole surgery: an analysis of risk factors for the anatomical and functional outcomes with a special emphasis on the experience of the surgeon

Purpose

The aim of this study was to evaluate risk factors for the anatomical and functional outcomes of macular hole (MH) surgery with special emphasis on the experience of the surgeon.

Methods

A total of 225 surgeries on idiopathic MHs (IMHs) performed by 6 surgeons with a mean follow-up period of 20.5 months were reviewed in this retrospective study. Outcome parameters focused on IMH closure, complications and visual acuity improvement. The results of MH surgeries performed by experienced surgeons were compared to those of surgeons in training.

Results

The average MH size was 381 µm (standard deviation [SD]=168). Brilliant blue G (BBG) for internal limiting membrane (ILM) staining was used in 109 (48%) eyes and indocyanine green (ICG) in 116 (52%) eyes. As endotamponade, 20% SF6 was used in 38 (17%) cases, 16% C2F6 in 33 (15%) cases and 16% C3F8 in 154 (68%) cases. IMH closure was achieved in 194 eyes (86%). Mean preoperative visual acuity was 0.84 logarithm of the minimum angle of resolution (log MAR; SD=0.29, range: 0.3–1.5); surgery led to a mean improvement of 0.40 (SD=0.37) log MAR. Although the MH closure rate was the same using BBG or ICG for ILM peeling, visual acuity improvement was better in eyes peeled with BBG compared to eyes peeled with ICG (log MAR: BBG: 0.38 [95% CI: 0.32, 0.44] vs ICG: 0.48 [95% CI: 0.42, 0.54], P=0.029). Surgeons with previous experience in vitreoretinal surgery of ≥6 years achieved better visual outcomes compared to surgeons with 0–3 years of experience, regardless of the MH size, preoperative visual acuity, time to follow-up or dye used for ILM peeling (0–3 years [0.27, Δlog MAR] vs ≥6 years [0.43, Δlog MAR], P=0.009).

Conclusion

Our results indicate that vitrectomy with ILM peeling performed by non-experienced surgeons is a safe procedure leading to good anatomical and functional results. Very experienced surgeons may achieve even better functional outcomes.

Evaluation of predictors for anatomical success in macular hole surgery in Indian population

Purpose:

The aim was to evaluate outcomes and predictors for anatomical success in macular hole (MH) surgery.

Materials and Methods:

This was a prospective cohort study of patients operated for idiopathic MH with stages II, III or IV. Patients underwent pars plana vitrectomy with internal limiting membrane (ILM) peeling, internal gas tamponade, and postoperative face down positioning. The primary outcome measure was anatomical closure of MH, while secondary outcome measure was postoperative external limiting membrane (ELM) continuity. Effect of MH size, duration of MH, size of ILM peel, type of gas tamponade (SF6 vs. C3F8) and macular hole index (MHI) on anatomical MH closure was also evaluated.

Results:

Of the 62 eyes operated, anatomical closure of MH was achieved in 55 eyes (88.7%). The median duration of follow-up was 8 months (range: 6–15 months). Mean BVCA improved from 0.94 ± 0.26 at baseline to 0.40 ± 0.23 logMAR at last follow-up (P = 0.01). There was a statistically significant association between size of ILM peel and anatomical closure of MH (P = 0.04). Duration of symptoms, size of MH, type of gas tamponade, MHI had no effect on anatomical closure (P = 0.22, 0.28, 0.40 respectively, Chi-square test). Postoperative continuity of the ELM was significantly associated with a shorter symptom duration (<6 months) before surgery.

Conclusion:

Acceptable anatomical closure could be attained with the defined technique. Size of ILM peel is a new predictor of anatomical success while symptom duration affects postoperative ELM continuity.

A preliminary study of Heavy Brilliant Blue G for internal limiting membrane staining in macular hole surgery

Context:

Surgical outcomes of vitrectomy for idiopathic macular hole using a “heavy” Brilliant Blue G (HBBG) solution for staining and removal of the internal limiting membrane (ILM).

Settings and Design:

Prospective interventional case series conducted in a tertiary eye care hospital.

Materials and Methods:

Nineteen patients (20 eyes) with idiopathic macular hole were enrolled to undergo vitrectomy with ILM peeling using HBBG. BBG dye was made heavy by mixing with 10% dextrose normal saline (DNS) solution in 2:1 ratio. The adequacy of ILM staining was noted intraoperatively. The closure rates of macular hole and visual improvement were recorded. Patients were followed up postoperatively on day 1, week 1, and subsequently at 1, 3, and 6 months, and every 6th month thereafter.

Statistical Analysis:

Wilcoxon signed-rank test was used; P < 0.05 was considered significant.

Results:

Preoperative best-corrected visual acuity (BCVA) ranged from 20/1000 to 20/63 (median: 20/100). Intraoperatively, the ILM stained very well in all eyes, and was easily removed. All macular holes closed postoperatively. The mean follow-up was 6.15 ± 2 months (range: 4-10; median: 6 months). Final BCVA ranged from 20/20 to 20/80 (median: 20/40), amounting to a significant visual improvement (P = 0.0001). BCVA improved by 1-8 Snellen lines in 19 eyes (95%); 16 eyes (80%) improved by ≥2 lines; 13 eyes (65%) achieved a final BCVA of 20/40 or better.

Conclusions:

Addition of 10% DNS to BBG dye allowed good ILM staining with less dye during macular hole surgery, and provided excellent anatomic and visual outcomes.

Chromovitrectomy: update

The basic concept for the application of vital dyes during vitreoretinal surgery is to assist in highlighting preretinal membranes and tissues which are very thin and semitransparent and thus difficult to detect. The vital dyes may be classified according to different criteria, where the most commonly applied includes chemical classification. In ophthalmic surgery, vital dyes are widely used in cataract and vitreoretinal surgery. The vital dyes, indocyanine green, infracyanine green, and brilliant blue stain the internal limiting membrane, and trypan blue and triamcinolone acetonide help to visualize epiretinal membranes and vitreous, respectively. This review exhibits the current literature regarding the properties of vital dyes, techniques of application, indications, and toxicities during vitreoretinal surgery and, also suggests that the field of chromovitrectomy represents an expanding area of research.

Hyperautofluorescent ring in eyes with macular holes

Background

Fundus autofluorescence studies in eyes with macular holes (MHs) have shown a hyperautofluorescent spot corresponding to the hole and a hypoautofluorescent ring corresponding to the fluid cuff surrounding the hole. The purpose of this report is to present three cases of MH with a different fundus autofluorescence pattern.

Case reports

Case 1 was a 62-year-old woman who did not know the duration of the MH in her left eye. Her decimal best-corrected visual acuity (BCVA) was 0.08. The left eye had a one-half disc diameter MH with a depigmented ring surrounding the area of the fluid cuff. Fundus autofluorescence showed a hyperautofluorescent ring corresponding to the depigmented ring. After vitrectomy, fundus autofluorescence showed the same size hyperautofluorescent ring despite the decreased size of the opened MH. Case 2 was a 69-year-old woman who had been diagnosed with MH in the right eye 13 years earlier. Her decimal BCVA was 0.1. The right eye had a one-half disc diameter MH with a depigmented ring surrounding the area of the fluid cuff. Fundus autofluorescence showed a hyperautofluorescent ring corresponding to the depigmented ring. Postoperative fundus autofluorescence showed the same size hyperautofluorescent ring despite the hole being closed. The decimal BCVA was 0.2 in her right eye 6 months after vitrectomy. Case 3 was a 71-year-old woman who had been diagnosed with MH in the right eye 15 years earlier. Her decimal BCVA was 0.1. The right eye had a one-half disc diameter MH with a depigmented ring which corresponded with a hyperautofluorescent ring. Postoperative fundus autofluorescence showed the same size hyperautofluorescent ring despite the hole being closed. The decimal BCVA was 0.2 in her right eye 6 months after vitrectomy.

Conclusion

Our findings suggest that a hyperautofluorescent ring in eyes with MHs may be an indicator of a poor surgical prognosis both anatomically and functionally.

Morphological and functional outcome after brilliant blue G-assisted macular hole surgery

PURPOSE OF THE STUDY

To investigate the outcome of brilliant blue G (BBG)-assisted internal limiting membrane peeling in macular hole surgery after a follow-up of 6 months.

PROCEDURES

In this retrospective study 20 eyes have been treated with BBG-assisted macular hole surgery. After a follow-up of 6 months, the functional and anatomical outcomes have been analyzed.

RESULTS

The mean preoperative best-corrected visual acuity (BCVA) was 0.7 logMAR units (mean ± SD 0.66 ± 0.27). After 3 months, the mean BCVA increased not significantly to 0.4 (0.54 ± 0.30), but a significant improvement to 0.2 logMAR units (0.28 ± 0.23) could be detected after 6 months compared to baseline (p < 0.01). Primary macular hole closure after a single surgery was found in 17 of 20 eyes.

CONCLUSION AND MESSAGE

BBG exhibits sufficient staining qualities and safety profile leading to a significant functional improvement after successful macular hole surgery.

Morphologic characteristics of chronic macular hole on optical coherence tomography

PURPOSE

To investigate the morphologic characteristics of chronic macular holes (MHs) using optical coherence tomography.

METHODS

We retrospectively reviewed optical coherence tomographic images of consecutive patients who had been diagnosed with MH. Chronic MH was defined as MH that was observed without being surgically treated for at least 1 year. Optical coherence tomographic parameters were compared between chronic and acute MH.

RESULTS

Thirteen eyes of 13 patients were classified as chronic MH, and 67 eyes of 67 patients were classified as controls. While the basal hole diameter of chronic MH was not different from that of controls (P = 0.146), the minimum hole diameter (781.8 μm) of chronic MH was larger than that of controls (448.4 μm; P < 0.001). The hole height and MH index were smaller in the chronic MH group (380.6 μm; 0.31) than in control group (469.9 μm, 0.53; P = 0.033, P = 0.003). Intraretinal fluid was less frequently observed in chronic MH than in controls (P < 0.001). Retinal pigment epithelial atrophy was only observed in chronic MH.

CONCLUSION

Chronic MH has features distinct from those of acute symptomatic MH on optical coherence tomography. These findings provide useful insight for the differentiation of chronic MH from acute MH.

Quantitative analysis of vitreous and plasma concentrations of brilliant blue g after use as a surgical adjuvant in chromovitrectomy

PURPOSE

To measure the concentration of brilliant blue G (BBG) in vitreous and plasma after use as a surgical adjuvant for staining and peeling of the internal limiting membrane to determine potential systemic adverse effects.

METHODS

This study was designed as a prospective, interventional, clinical, case series. Five eyes from five patients with macular hole or epiretinal membrane underwent BBG-assisted internal limiting membrane and epiretinal membrane removal. The vitreous samples were obtained and stored at the end of surgery in all five cases. The plasma specimens were extracted and stored at the end of the operation, after 4 hours, and after 7 days post operation. For BBG analysis of plasma and vitreous, high-performance liquid chromatography coupled with tandem mass spectrometric detection was used.

RESULTS

Brilliant blue G was not detected in plasma from all five cases at the three points of measurement. The mean vitreous BBG concentration was 34.5 ± 23.7 ng/mL (range, 11.3-70.9 ng/mL). Postoperative progress was good, and adverse effects were not observed in any of the five cases.

CONCLUSION

Brilliant blue G, which remained at low levels in the vitreous cavity, was not found in the systemic blood flow after the operation. Thus, any adverse effects of systemic BBG would be avoided.

Critical involvement of extracellular ATP acting on P2RX7 purinergic receptors in photoreceptor cell death

Stressed cells release ATP, which participates in neurodegenerative processes through the specific ligation of P2RX7 purinergic receptors. Here, we demonstrate that extracellular ATP and the more specific P2RX7 agonist, 2'- and 3'-O-(4-benzoylbenzoyl)-ATP, both induce photoreceptor cell death when added to primary retinal cell cultures or when injected into the eyes from wild-type mice, but not into the eyes from P2RX7(-/-) mice. Photoreceptor cell death was accompanied by the activation of caspase-8 and -9, translocation of apoptosis-inducing factor from mitochondria to nuclei, and TUNEL-detectable chromatin fragmentation. All hallmarks of photoreceptor apoptosis were prevented by premedication or co-application of Brilliant Blue G, a selective P2RX7 antagonist that is already approved for the staining of internal limiting membranes during ocular surgery. ATP release is up-regulated by nutrient starvation in primary retinal cell cultures and seems to be an initializing event that triggers primary and/or secondary cell death via the positive feedback loop on P2RX7. Our results encourage the potential application of Brilliant Blue G as a novel neuroprotective agent in retinal diseases or similar neurodegenerative pathologies linked to excessive extracellular ATP.

Optical coherence tomography findings in idiopathic macular holes

Purpose. To describe the characteristics of idiopathic macular holes (MH) on optical coherence tomography (OCT) and correlate OCT with clinical assessment. Design. Cross-sectional chart review and OCT assessment. Participants. Sixty-seven eyes with a clinically diagnosed idiopathic MH with available OCT data. Methods. A retrospective chart review and OCT assessment. Results. Based on OCT grading, 40 eyes had a full-thickness macular hole (FTMH) and 21 eyes had a lamellar macular hole (LMH). Clinical exam and OCT assessment agreed in 53 (87%) eyes when assessing the extent of MH. Six eyes (14.6%) in the FTMH group, and 3 eyes in the LMH group (14.3%) had persistent vitreomacular traction. Thirty-seven eyes (92.5%) in the FTMH group and 11 eyes (52.4%) in the LMH group had associated intraretinal cysts. Two eyes (5.0%) in the FTMH group and zero eyes in the LMH group had subretinal fluid. Intraretinal cysts were found to be more frequently associated with FTMH than with LMH (P < 0.001). Conclusion. This paper described OCT findings in a group of patients with clinically diagnosed MH. A high level of correlation between clinical assessment and OCT findings of LMH and FTMH was observed, and intraretinal cysts were often present in FTMH.