Modified technique of internal limiting membrane staining in idiopathic macular hole surgery

Meta-regression of idiopathic full-thickness macular holes diameter and anatomical closure rate: Implications to intraoperative technique

Purpose

Primary surgery failure of macular holes causes poor visual acuity outcomes. Several studies indicate that small-medium idiopathic full-thickness macular holes (iFTMH) have consistent and high anatomical closure rates after vitrectomy and internal limiting membrane (ILM) peeling, regardless of iFTMH diameters. However, there is no systematic analysis examining the relationship between iFTMH diameters and anatomical closure rates.

Methods

In this systematic review and meta-regression, we searched PubMed, Embase, and Web of Science databases on October 24th, 2022. We included studies regarding iFTMH, with ILM peeling/inverted flap technique, long-lasting gas tamponade, and face-down position after surgery. Univariable meta-regression with a restricted cubic spline model and component-plus-residual plot after covariables adjustment were used to explore non-linear association.

Results

A total of 7257 participants from 19 randomized controlled trials and 49 observational studies were included in this meta-analysis. In ILM peeling group, every 100-μm increment in diameter was associated with a 3.8 % (95 % confidence interval [CI], 1.8%-5.7 %, P < 0.001) relatively lower anatomical closure rate. Yet, among studies using the inverted flap technique, baseline iFTMH diameter was not associated with a lower anatomical closure rate (0.2 %, 95%CI, -4.2 %-4.5 %, P > 0.9). The restricted cubic spline model and component-plus-residual plot controlling for age, sex, and symptom duration prior to surgery showed no evident non-linearity in both surgical techniques.

Conclusions

The iFTMH diameter is linear and inversely associated with the anatomical closure rate after the ILM peeling technique, but not with the inverted flap technique. The present study supports the use of advanced techniques, e.g., inverted flap technique, in small-medium iFTMH to improve anatomical closure rates.

Modified perfluorocarbon liquid/internal limiting membrane interface staining in myopic macular hole retinal detachment

PURPOSE

To demonstrate a modified technique of perfluorocarbon liquid (PFCL)/internal limiting membrane (ILM) interface staining in patients affected by macular hole retinal detachment (MHRD) in the setting of high myopia.

METHODS

Two-surgeon retrospective case series and review of surgical videos with step-by-step technique analysis.

RESULTS

Our modified technique was proficiently employed to treat 9 highly myopic patients affected by MHRD. Successful staining and peeling of the ILM with the creation of an inverted flap was achieved in all cases. A limited number of dye injections required to stain the ILM was noted. No subretinal dye migration or other intra- and postoperative complications were recorded.

CONCLUSION

Modified PFCL/ILM interface staining is a surgically efficient technique potentially reducing the risk of iatrogenic damage, including the toxicity of vital dyes to the retinal pigment epithelium (RPE) in myopic MHRD.

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.

Internal limiting membrane flap technique in macular hole surgery

Vitrectomy combined with internal limiting membrane (ILM) peeling is popular for the treatment of macular hole (MH). However, the improvements of MH closure rate and postoperative visual acuity are not satisfactory especially in large and refractory MHs. Currently, the ILM flap technique has gradually been applied for the treatment of MH and achieved high MH closure rate. The ILM flap technique has many variations, including the difference of the size, shape, number, and manner in which the flaps put on the MHs. The ILM flap technique also has some auxiliary means including perfluoro-n-octane (PFO), dye, autologous blood and adhesive viscoelastics. There is controversy about the effects between several technique variations of ILM flap, and it needs to be explored in the future.