Long-term follow-up of lamellar macular holes and pseudoholes over at least 5 years

Outcomes of Pars Plana Vitrectomy With Membrane Peel for Lamellar Macular Holes and Related Conditions Using a New Optical Coherence Tomography Consensus Definition

Purpose: To characterize the change in visual acuity (VA) in eyes treated with vitrectomy using the 2020 international consensus-based optical coherence tomography (OCT) definition of lamellar macular hole (LMH), macular pseudohole (MPH), and epiretinal membrane with foveoschisis (ERMF). Methods: A retrospective chart review was performed from 2000 to 2022 of patients who had vitrectomy for symptomatic decreased VA from LMH, MPH, or ERMF performed by the same surgeon at a community hospital. Preoperative spectral domain (SD-OCT) was reviewed to classify patients using the consensus guidelines. Primary outcomes were the mean change in best-corrected VA at 3 months, 1 year, and the final postoperative examination. Results: Fifty-one patients were included, 30 with LMH, 14 with MPH, and 7 with ERMF. The VA was 20/63 at baseline, 20/62 (P = .79) 3 months postoperatively, 20/40 (P = .003) at 1 year, and 20/52 (P = .10) at the final examination for LMH; 20/64, 20/50 (P = .16), 20/40 (P = .040), and 20/40 (P = .02), respectively, for MPH; and 20/53, 20/50 (P = .42), 20/30 (P = .03), and 20/38 (P = .04), respectively, for ERMF. Subgroup analysis showed that eyes with LMH without ellipsoid zone (EZ) disruption on SD-OCT improved from 20/57 at baseline to 20/39 (P = .01) at the final examination. Conclusions: There was no significant improvement in VA at the final postvitrectomy examination in eyes with LMH, while there was significant improvement in eyes with MPH and ERMF. This supports surgery in selected eyes with MPH and ERMF but possibly not in eyes with LMH, unless OCT shows no EZ disruption.

Japan-epiretinal membrane (J-ERM) registry: A prospective cohort study protocol investigating the surgical outcome of epiretinal membrane

BACKGROUND

Epiretinal membrane (ERM) causes visual impairment such as reduction in visual acuity and metamorphopsia due to retinal traction. With the improvement of optical coherence tomography (OCT) and microincision vitrectomy surgery (MIVS), the surgery of ERM has significantly advanced. However, there have been no large-scale studies on the following: (1) how to evaluate visual impairment in ERM, (2) the relationship between OCT findings and visual function, (3) when is the optimal timing of surgery, and (4) the relationship between the surgical instruments as well as techniques and prognosis. The purpose of this study was to obtain evidence regarding these ERM surgeries.

METHODS AND DESIGN

This is a prospective, multicenter cohort study of ERM surgery in Japan from March 1, 2023, to March 31, 2027 (UMIN000048472, R-3468-2). Patients who underwent ERM surgery during the study period and agreed to participate in this study will be included. The goal is to have a total of 5,000 eyes surgically treated for ERM. The following data will be collected: age, gender, medical history, subjective symptoms, visual function before and 6 and 12 months after surgery, clinical findings, OCT data, surgical technique, instruments used in surgery, and complications.

DISCUSSION

The results of this study will support the surgical decisions and procedures in ERM practices.

Quantitative Analyses of Retinal Traction Force and Metamorphopsia in Lamellar Macular Hole and Related Diseases

Purpose

To investigate the involvement of retinal traction in the pathogenesis of lamellar macular hole (LMH) and related diseases based on OCT-based consensus definition.

Design

Retrospective, observational study.

Participants

Seventy-two eyes with LMH, epiretinal membrane foveoschisis (ERM-FS), or macular pseudohole (MPH).

Methods

To quantitatively evaluate the involvement and strength of retinal traction in their pathogenesis, retinal folds were visualized with en face OCT imaging, and the maximum depth of the parafoveal retinal folds (MDRF) was measured. Metamorphopsia was quantified by measuring the minimum visual angle of dotted lines needed to cause it to disappear using M-CHARTS (Inami).

Main Outcome Measures

Maximum depth of retinal folds and M-CHARTS scores.

Results

Of the 72 eyes, 26 were classified as having LMH, 25 as having ERM-FS, and 21 as having MPH. Parafoveal retinal folds were observed in 7 (26.9%) eyes with LMH, 25 (100%) with ERM-FS, and 21 (100%) with MPH. The MDRF (7.5 ± 17.6 μm) was significantly smaller in LMH than in ERM-FS (86.3 ± 31.4 μm) and MPH (74.5 ± 24.6 μm) (both P < 0.001), whereas no significant difference in MDRF between MPH and ERM-FS was observed (P = 0.43). A significant positive correlation between MDRF and M-CHARTS scores was observed in ERM-FS and MPH (P = 0.008 and 0.040, respectively) but not in LMH (P = 0.073).

Conclusions

Retinal traction was significantly weaker in the LMH group than in the ERM-FS and MPH groups. The MDRF was significantly associated with the degree of metamorphopsia in the ERM-FS and MPH groups. These results provide insights into the diseases' pathophysiology and treatment strategy.

Epiretinal proliferation embedding combined with internal limiting membrane flap inversion for secondary macular hole: Two case reports

Purpose

We describe the cases of two patients for whom we performed an epiretinal proliferation (EP) embedding technique combined with internal limiting membrane (ILM) flap inversion for a full-thickness macular hole (FTMH) with EP.

Observations

Patient 1 was a 69-year-old Japanese man with decreased vision in his left eye (20/40). He underwent pars plana vitrectomy (PPV) twice for rhegmatogenous retinal detachment and intraocular lens (IOL) dislocation in his left eye. B-scan optical coherence tomography (OCT) imaging revealed FTMH and EP on the surface of a macular hole (MH). We performed a vitrectomy, EP embedding, and ILM inversion (fill). Patient 2 was a 73-year-old Japanese man with decreased vision in his right eye (20/32). He underwent PPV for vitreous hemorrhage and proliferative diabetic retinopathy in his right eye. B-scan OCT imaging revealed FTMH and EP on the surface of an MH. We performed a vitrectomy, EP embedding, and ILM inversion (cover). Six months post-surgery, the FTMH in both patients had closed completely, and each patient's foveal contour and visual acuity (20/20) had improved.

Conclusions and importance

EP embedding combined with ILM flap inversion may be effective for treating secondary MHs with EP.

Formation and evolution of idiopathic lamellar macular hole-a pilot study

Background

The developmental pathways and subsequent evolutional processes of idiopathic lamellar macular hole (LMH) were studied with spectrum domain optical coherence tomography (SD-OCT).

Methods

Twenty-seven eyes of 26 patients of idiopathic LMH with pre-LMH SD-OCT available were retrospectively reviewed. Relevant OCT parameters and best-corrected visual acuity (BCVA) were collected and analyzed.

Results

Four types of developmental pathways of idiopathic LMH were noted. Type 1 (5 cases), involved disruption of a foveal cyst from vitreomacular traction. Type 2 (10 cases), demonstrated rupture of parafoveal cysts or schisis mainly from epiretinal membrane (ERM). In type 3 pathway (5 cases), a central intraretinal cyst formed under tight ERM with subsequent cyst roof dehiscence. Type 4 (7 cases), showed gradual loss of foveal tissue without cystic lesions from ERM traction. There was no statistically significant change in BCVA during LMH formations or subsequent evolutional processes in any types of the developmental pathways. Three cases developed epiretinal proliferation (EP) during evolution, which showed tendency of decrease in BCVA. Among the three cases, one later developed the degenerative configuration.

Conclusions

In summary, four types of tractional developmental pathways of idiopathic LMH were identified. BCVA was relatively stable during LMH formation and follow-up. Deterioration of visual acuity were found in cases that developed EP during evolution. Transformation into degenerative configuration might be possible after LMH formation.

Primary Lamellar Macular Holes: To Vit or Not to Vit

There is a wide spectrum of macular conditions that are characterized by an irregular foveal contour caused by a break in the inner fovea. These include full-thickness macular hole (FTMH), foveal pseudocyst, lamellar macular hole (LMH) and macular pseudohole (MPH). Clinical examination of vitreomacular interface disorders is notoriously poor in differentiating these conditions. These conditions were initially described with slit-lamp biomicroscopy, and the main goal was to distinguish an FTMH from the others. The introduction of optical coherence tomography (OCT) has revolutionized our understanding of the foveal microstructural anatomy and has facilitated differentiating these conditions from an FTMH. However, the definitions of the other conditions, particularly LMH, has evolved over the past two decades. Initially the term LMH encompassed a wide spectrum of clinical conditions. As OCT became more widely used and observations became more refined, two different phenotypes of LMH became apparent, raising the question of different pathogenic mechanisms for each phenotype. Tractional and degenerative pathological mechanisms were proposed. Epiretinal membranes (ERMs) associated with each phenotype were identified. Typical ERMs were associated with a tractional mechanism, whereas an epiretinal proliferation was associated with a degenerative mechanism. Epiretinal proliferation represents Müller cell proliferation as a reactive process to retinal injury. These two types of ERM were differentiated by their characteristics on SD-OCT. The latest consensus definitions take into account this phenotypic differentiation and classifies these entities into LMH, MPH and ERM foveoschisis. The initial event in both ERM foveoschisis and LMH is a tractional event that disrupts the Müller cell cone in the foveola or the foveal walls. Depending on the extent of Müller cell disruption, either a LMH or an ERM foveoschisis may develop. Although surgical intervention for LMH remains controversial and no clear guidelines exist for pars plana vitrectomy (PPV), eyes with symptomatic, progressive ERM foveoschisis and LMH may benefit from surgical intervention.

Structural and functional outcomes of pars plana vitrectomy in patients with lamellar macular hole

PURPOSE

To investigate the short-term functional and microstructural outcomes of pars plana vitrectomy (PPV) without gas tamponade in lamellar macular holes (LH).

MATERIALS AND METHODS

In this prospective case series, LH cases diagnosed by optical coherence tomography (OCT) underwent PPV with epiretinal membrane (ERM) removal and internal limiting membrane peeling without gas tamponade. All patients underwent a complete ophthalmologic examination, including best-corrected visual acuity (BCVA) and OCT imaging preoperatively and 3 months after the surgery.

RESULTS

Among 22 eyes, 10 degenerative (Deg) LH, 8 tractional (Trac) LH, and 4 mixed-type LH were assessed. After the surgery, anatomical closure occurred in 20 eyes (91%) without any significant difference between LH subgroups. Comparing preoperative and postoperative values, no significant changes was detected regarding BCVA neither totally (P = 0.5) nor in subgroups (P for Deg = 1.0, Trac = 0.71, Mix = 0.18). The overall central foveal thickness was increased significantly after surgery (P < 0.01), but in subgroup analysis, the increase was significant only for Trac LH (P = 0.02). The tractional LH eyes had less ellipsoid zone (EZ) disruptions compared to Deg or mixed subgroups before surgery. There were no changes in EZ integrity before and after the surgery. In regression analysis, no correlation was found between demographic or clinical characteristics and anatomical closure or BCVA improvement postoperatively.

CONCLUSION

PPV resulted in 91% anatomical closure of all cases of LH but without functional improvement in short-term. Further prospective clinical trials with larger sample size and longer follow-up would be required to confirm the clinical significance of these findings.

Outcomes from the Retrospective Multicenter Cross-Sectional Study on Lamellar Macular Hole Surgery

Purpose

To analyze the functional and anatomical parameters of lamellar macular hole (LMH) surgery with internal limiting membrane peeling and determine which surgical technique provides the best visual outcome.

Methods

This is a retrospective multicenter cross-sectional study on patients who underwent pars plana vitrectomy (PPV) for LMH with or without combined phaco-vitrectomy, as well as gas-, air- or BSS-tamponade. Pre- and postoperative examination included best corrected visual acuity (BCVA) measurements for functional comparison and optical coherence tomography (OCT) scans to determine the contributing anatomical parameters.

Results

A total of 66 consecutive patients were included (age: 71.79 ± 8.52 years), of which 47 (71.2%) were diagnosed as tractional type LMH, and 19 patients (28.8%) as degenerative type. An epiretinal membrane (ERM) was present in 63 of the patients (95.5%), LMH-associated epiretinal proliferation (LHEP) was present in 19 patients (28.8%), and 16 patients (24.2%) had concomitant ERM and LHEP. In the group of tractional LMH, the mean central foveal thickness (CFT) was 81.1% thicker (P < 0.05) than in the degenerative group. Thirty-one patients (47.0%) underwent a combined phaco-vitrectomy procedure, while the rest underwent 23G, 25G or 27G PPV. Seventeen of the 66 patients received gas-tamponade (25.7%)-either SF₆ or C₃F₈, 26 received air-tamponade (39.4%), while the remaining 23 patients received balanced salt solution (BSS)-tamponade (34.9%) during vitrectomy. The total BCVA showed significant improvement postoperatively (p < 0.001) and accordingly in the following groups: tractional LMH type (p < 0.001), degenerative type (p < 0.001), simple PPV (p < 0.001), phaco-vitrectomy (p < 0.001), BSS injection (p < 0.01), gas-tamponade (p < 0.05). None of the patients included in the study developed a full thickness macular hole postoperatively.

Conclusion

PPV provided a high success rate and functional improvement for treating LMH for both tractional and degenerative types, as well as combined phaco-vitrectomy treatment when cataract was present.

[Regression of idiopathic epiretinal membrane-Case report and consideration of the possible mechanism]

In the presence of a symptomatic epiretinal gliosis, pars plana vitrectomy with membrane peeling to remove the membrane is usually indicated in clinical practice. According to common clinical experience, almost no independent regression of such an epiretinal membrane and thus healing of the pathology alone exists. Therefore, the unusual case of bilateral independent regression of idiopathic epiretinal gliosis and formation of a lamellar macular hole in a 73-year-old male patient is described. Considerations of the possible mechanism are presented based on the existing literature. These include separation of inflammatory versus noninflammatory membranes, possible separation of individual layers depending on the status of the posterior vitreous limiting membrane and also the possible action of proteolytic systems in the posterior vitreous region. Finally, the question arises, whether patients have to be informed about this fact before possible surgery.

Visual acuity and anatomical changes following vitrectomy for epiretinal membrane foveoschisis: a case series

Purpose

To evaluate the visual outcome and macular anatomic structures on spectral-domain optical coherence tomography (SD-OCT) of patients with epiretinal membrane (ERM) foveoschisis who underwent vitrectomy.

Methods

A retrospective cohort, interventional, case series.

Participants

Fourteen patients (14 eyes) with central vision loss from an ERM foveoschisis underwent vitrectomy at Chiang Mai University Hospital from 2017 to 2018 and had a follow-up period of 12 months.

Interventions

The 23G vitrectomy with ERM and internal limiting membrane (ILM) peeling was performed by a single surgeon.

Main outcomes

Best-corrected visual acuity (BCVA) and anatomic appearance on SD-OCT were assessed at the time of preoperative evaluations and post-operative follow-ups at 1, 3, 6, and 12 months.

Results

Fourteen patients with a mean (SD) age of 67.9 (7.9) years and a mean (SD) visual acuity (VA) of 0.6 (0.1) LogMAR units were included in this study. Significant VA improvements were observed at the 3-month (0.43 (0.14) LogMAR unit), 6-month (0.45 (0.16) LogMAR unit) and 12-month (0.37 (0.21) LogMAR unit) post-operative visits compared to baseline, all with P-values < 0.001. At month 12, there were vision improvements of ≥3 lines in 8 (57.2%) patients, vision improvements of 1 or 2 lines in 2 (14.3%) patients, vision remained at the same line of pre-operation in 3 (21.4%) patients, and vision decreased by 1 line in 1 (7.1%) patient. Regarding the anatomical outcomes, 13 (92.9%) patients achieved anatomical foveal restoration, while one had persistent intraretinal schisis at the 12-month follow-up. The median time to achieve a foveal restoration was 3 months. No significant visual impairments were observed post-operatively.

Conclusion

In patients with central vision loss from ERM foveoschisis, vitrectomy with ILM stripping tended to improve both visual and anatomical outcomes.

Improving morphological outcome in lamellar macular hole surgery by using highly concentrated autologous platelet-rich plasma

Purpose

To evaluate the use of highly concentrated autologous platelet-rich plasma (PRP) in lamellar macular hole (LMH) surgery with regard to function and morphology.

Methods

We included 12 eyes of 12 patients with progressive LMH in this interventional case series. After 23/25-gauge pars plana vitrectomy, 0.1ml highly concentrated autologous platelet-rich plasma was applied under air tamponade. Induction of posterior vitreous detachment and peeling of tractive epiretinal membranes were performed whenever present. Phacovitrectomy was undertaken in cases of phakic lens status. Postoperatively, all patients were instructed to rest in a supine position for the first two postoperative hours. Best-corrected visual acuity (BCVA) testing, microperimetry, spectral-domain optical coherence tomography (SD-OCT), and fundus photography were carried out preoperatively and 6 months postoperatively.

Results

Foveal configuration was restored in 10 of 12 patients (83.3%) at 6 months postoperatively. Two patients who had not undergone ILM peeling showed a recurring defect at 6-month follow-up. Best-corrected visual acuity improved significantly from 0.29 ± 0.08 to 0.14 ± 0.13 logMAR (Wilcoxon: p=0.028). Microperimetry remained unchanged (23.38 ± 2.53 preoperatively; 23.0 ± 2.49 dB postoperatively; p=0.67). No patient experienced vision loss after surgery, and no significant intra- or postoperative complications occurred.

Conclusion

The application of PRP in the surgical therapy of LMH results in good morphological and functional outcomes. Additional peeling of the ILM seems to be mandatory when using PRP to prevent the recurrence of LMH. Strict postoperative supine positioning for 2 h avoids PRP dislocation. Larger sample sizes are needed to confirm the results.

Highly Concentrated Autologous Platelet-Rich Plasma Restores Foveal Anatomy in Lamellar Macular Hole Surgery

BACKGROUND

Lamellar macular holes (LMHs) are an entity of a progressive disease in which the efficacy of the therapy of choice, vitrectomy, seems to be reduced. It is unknown whether highly concentrated autologous platelet-rich plasma (PRP) is of value in the therapy of LMHs. The purpose of this study was to gauge the potential of highly concentrated PRP to restore foveal anatomy in LMH surgery.

PATIENTS AND METHODS

In this interventional case series, eight eyes of eight patients with progressive LMH were included. All patients underwent a 23-gauge pars plana vitrectomy with induction of a posterior vitreous detachment and peeling of tractive epiretinal membranes whenever present. Under air tamponade, 0.1 mL of highly concentrated autologous PRP was applied. Subsequently, a gas or air tamponade was performed. All patients were instructed to rest in the supine position for the first 1 to 2 postoperative hours. Best-corrected visual acuity (BCVA) testing, microperimetry, spectral-domain optical coherence tomography (SD-OCT) and fundus photography were performed prior to and 3 months after surgery.

RESULTS

SD-OCT showed closure of the macular defect with restoration of a normal foveal configuration in all (8 of 8) patients 3 months postoperatively. BCVA improved significantly, from 0.28 ± 0.08 to 0.12 ± 0.14 logMAR (Wilcoxon: p = 0.03). Microperimetry remained unchanged (24.13 ± 1.96 vs. 23.7 ± 1.54 dB; p = 0.46). No clinically significant intra- or postoperative complications were observed.

CONCLUSION

The use of highly concentrated PRP enables excellent anatomical and functional outcomes in the surgical therapy of LMH. Further prospective comparative trials are warranted to compare this promising technique with existing surgical strategies.

Vitreomacular disorders: a review of the classification, pathogenesis and treatment paradigms including new surgical techniques

This review explores how optical coherence tomography has guided our assessment of vitreomacular disorders. Vitreomacular disorders (VMD), such as macular holes and epiretinal membranes are common and potentially sight threatening. The introduction and widespread use of optical coherence tomography (OCT) imaging technology has transformed our ability to visualise the vitreoretinal interface. This review discusses the pathogenesis and updated classification scheme for VMD in the OCT era. Imaging biomarkers and the treatment algorithm, including the role of novel therapeutics, for managing patients with VMD are presented.

Surgical outcomes in patients with lamellar macular holes selected based on the optical coherence tomography consensus definition

Purpose

The surgical indication for lamellar macular holes (LMH) is controversial due to a misclassification of different macular diseases. A consensus based on an optical coherence tomography (OCT) definition has recently been suggested. The aim of this study was to investigate the surgical outcomes of patients with LMH selected based on this OCT-based consensus definition.

Methods

Retrospective review of patients who underwent surgery for LMH with a follow-up of at least 3 months. Anatomical OCT criteria for the diagnosis of LMH were the presence of an irregular foveal contour with foveal cavitation and a loss of retinal tissue. Cases of macular pseudoholes and epiretinal membrane foveoschisis were excluded. Surgery consisted in pars plana vitrectomy with centripetal peri-hole peeling of epiretinal proliferation and internal limiting membrane. Pre- and postoperative visual acuities (VA) were compared, and changes in OCT anatomical features, including the restoration of the foveal profile and outer retinal layers, were assessed.

Results

Eleven eyes of 11 patients were included, of which 9 eyes (81.8%) showed proliferation on preoperative OCT. The mean VA improved from 0.44 ± 0.19 LogMAR (20/55 Snellen equivalent) to 0.16 ± 0.08 LogMAR (20/28 Snellen equivalent), after a mean follow-up of 7.2 ± 2.9 months (P = 0.02). Postoperatively, all eyes showed a restored foveal profile. The mean central foveal thickness increased from 127.6 ± 29.9 μm to 209.0 ± 44.0 μm (P = 0.001). At baseline, ellipsoid zone disruption and external limiting membrane disruption were found in 9 and 7 eyes, respectively. Postoperatively, the ellipsoid zone and external limiting membrane were restored in respectively 6/9 eyes (66.7%) and 5/7 eyes (71.4%). No cases of postoperative full-thickness macular hole were found.

Conclusion

In patients with LMH carefully selected based on the recent OCT-based criteria and showing a loss of retinal tissue, the foveal architecture was restored and the VA was improved after vitrectomy with peri-hole peeling for epiretinal proliferation.

Supplementary information

The online version contains supplementary material available at 10.1186/s40942-021-00297-6.

Rapid Morphological Restoration of Normal Foveal Contour After Spontaneous Epiretinal Membrane Separation from Retina in Eye with Macular Pseudohole: A Case Report

Purpose

This study aims to report a case of idiopathic epiretinal membrane (ERM) spontaneously separated from the retinal surface even in eyes with a macular pseudohole, which was immediately followed by resolution of visual deterioration and morphological findings.

Case Report

A 66-year-old man presented with visual deterioration and metamorphopsia in the right eye. An ERM with a macular pseudohole in the right eye was shown by fundus examinations and optical coherence tomography (OCT) images. We intended to perform vitrectomy to remove the ERM, but within 2 months after the initial visit, the ERM spontaneously separated from the retina. Fundus photograph showed that the ERM and the macular pseudohole were absent and the fundus looked almost normal, and OCT image showed no ERM and an almost normal appearance of the retina without remaining undulations. After the ERM separation, his vision improved to 20/15.

Conclusion

Cases with an ERM-associated macular pseudohole should be carefully monitored for the possibility of a spontaneous separation of the ERM from the retina.

[Biomarkers in full-thickness and lamellar defects of the macula]

BACKGROUND

Biomarkers are characteristic biological measurable signs and objective parameters to detect the state of health. Besides functional and temporal factors, imaging biomarkers play an increasingly important role. In full-thickness and lamellar defects of the macula numerous imaging parameters have been described. This knowledge resulted in new classifications for both clinical pictures, which are based on important biomarkers of these clinical pictures and characteristic features of described subtypes.

METHODS

Imaging biomarkers for full-thickness and lamellar macular defects are described with respect to the classification and their functional prognostic importance. The importance of these biomarkers is presented.

RESULTS

The current classification of full-thickness and lamellar macular defects is based on structural biomarkers. Biomarkers are important for prognostic and therapeutic evaluation and they have an impact on the surgical strategy. There are various surgical strategies for treatment of full-thickness macular holes depending on the size of the foramen and other biomarkers. The inverted ILM flap technique improves the closure rate of large macular holes. In lamellar macular holes showing signs of progression an early surgical intervention results in a good anatomical and functional prognosis.

CONCLUSION

Multimodal diagnostics provide important preoperative, intraoperative, and postoperative features for macular holes and lamellar macular holes, which are essential biomarkers for the exact classification, the therapeutic strategy and for assessment of the prognosis.

Clinical characteristics and long-term evolution of lamellar macular hole in high myopia

Purpose

To evaluate the clinical characteristics and evolution of lamellar macular hole (LMH) in high myopia and the parameters associated with structural worsening, defined as the development of foveal detachment or full-thickness macular hole.

Methods

Patients with high myopia and LMH were retrospectively recruited. The clinical characteristics and various parameters of optical coherence tomography were identified at baseline and during follow-up visits. Cox regression analysis was used to evaluate the hazard ratios for foveal detachment and full-thickness macular hole.

Results

Among 112 eyes (98 patients), 64.3% were female; the mean axial length of all eyes was 29.6 ± 1.9 mm. The ‘LMH without retinoschisis’ group accounted for 39.3% of the eyes. Forty-two percent developed structural worsening within a median follow-up of 67 months. Multivariable regression on all cases showed elevated tissue inside the LMH (P = 0.003) protected against structural worsening while V-shaped LMH (P = 0.006) predicted it. In the “LMH with retinoschisis group”, ellipsoid zone disruption (P = 0.035), and V-shaped LMH (P = 0.014) predicted structural worsening, while elevated tissue inside the LMH (P = 0.028) protected against it. In the “LMH without retinoschisis group”, no associated factor was identified.

Conclusions

LMHs in high myopia are unstable, especially those with V-shaped LMH. Elevated tissue inside LMHs have a protective effect against further structural worsening.

Optical coherence tomography-based consensus definition for lamellar macular hole

BACKGROUND

A consensus on an optical coherence tomography definition of lamellar macular hole (LMH) and similar conditions is needed.

METHODS

The panel reviewed relevant peer-reviewed literature to reach an accord on LMH definition and to differentiate LMH from other similar conditions.

RESULTS

The panel reached a consensus on the definition of three clinical entities: LMH, epiretinal membrane (ERM) foveoschisis and macular pseudohole (MPH). LMH definition is based on three mandatory criteria and three optional anatomical features. The three mandatory criteria are the presence of irregular foveal contour, the presence of a foveal cavity with undermined edges and the apparent loss of foveal tissue. Optional anatomical features include the presence of epiretinal proliferation, the presence of a central foveal bump and the disruption of the ellipsoid zone. ERM foveoschisis definition is based on two mandatory criteria: the presence of ERM and the presence of schisis at the level of Henle's fibre layer. Three optional anatomical features can also be present: the presence of microcystoid spaces in the inner nuclear layer (INL), an increase of retinal thickness and the presence of retinal wrinkling. MPH definition is based on three mandatory criteria and two optional anatomical features. Mandatory criteria include the presence of a foveal sparing ERM, the presence of a steepened foveal profile and an increased central retinal thickness. Optional anatomical features are the presence of microcystoid spaces in the INL and a normal retinal thickness.

CONCLUSIONS

The use of the proposed definitions may provide uniform language for clinicians and future research.

The Management of Lamellar Macular Holes: A Review

This literature review aims to provide the retina specialist with answers to patient's questions related to the management of lamellar macular holes (LMHs). Most LMHs are stable over time, but 13–21% present an anatomic decline after 18–24 months of follow-up. Nineteen point five percent of the eyes may experience a visual acuity (VA) loss of more than 5 letters after 3 years. Many surgeons choose to perform surgery when there is significant metamorphopsia or documented decline in VA over time. The typical surgery is phacovitrectomy with the epiretinal membrane and the internal limiting membrane peeling in previously phakic eyes (41.9 to 85.3% of the eyes). In the eyes that remained phakic, cataract surgery was often necessary within the first year of follow-up (19.2 to 40% of eyes). After surgery, a VA gain was recorded in 63–94% of eyes, but some eyes (between 0 and 20%) suffered some VA loss. Progression to full-thickness macular hole may occur after surgery, and thus a second surgical intervention may be needed.

[Vitreomacular Interface Diseases: Vitreomacular Adhesion, Vitreomacular Traction, Epiretinal Membranes, and Macular Hole]

Posterior vitreous detachment (PVD) is a common phenomenon in the aging eye. This review presents the sequence of events due to complicated persistent symptomatic vitreomacular adhesions that exert tractional forces on the macula (vitreomacular traction, VMT; macular hole, MH; epiretinal membrane). Pathologic aspects, clinical features, diagnostic implications, and current management strategies are described. Observation, pharmacologic vitreolysis with Ocriplasmin, and surgical treatment are positioned as treatment options for different diseases.

A Double Inverted Flap Surgical Technique for the Treatment of Idiopathic Lamellar Macular Hole Associated with Atypical Epiretinal Membrane

OBJECTIVES

To propose a new technique of a double inverted epiretinal membrane (ERM) and internal limiting membrane (ILM) flap (double flap group) for the treatment of idiopathic lamellar macular hole (LMH) with atypical ERM (AERM) and to compare surgical outcomes to those of the standard technique of ERM and ILM peeling of the fovea including LMH (control group).

METHODS

AERM was tomographically defined as a medium reflective thickened membrane above the retinal fiber layers without retinal traction signs. A series of patients affected by LMH with AERM were recruited. Preoperative parameters were: intraretinal cysts (IRC), intraretinal splitting diameter, residual foveal thickness, and ellipsoid zone integrity. Postoperative findings were: full-thickness macular hole (FTMH) development, and persistence or new appearance of IRC. Best-corrected visual acuity (BCVA) at baseline, first, third, and sixth postoperative month was evaluated.

RESULTS

A total of 48 eyes of 48 patients were included in this study. In the double flap group (30 eyes), a clear improvement of BCVA was noted (p = 0.004), and there were no complications. In the control group (18 eyes), BCVA did not improve and 3 patients developed postoperative FTMH.

CONCLUSIONS

The double inverted flap technique is associated with better functional recovery compared to the standard technique and reduces the risk of postoperative FTMH development.