Removal of choroidal neovascular membrane in a case of macular hole after anti-VEGF therapy for age-related macular degeneration

Full-Thickness Macular Hole Caused by Acute Subretinal Hemorrhage From Wet Age-Related Macular Degeneration

Purpose: To present a case of full-thickness macular hole (MH) that developed in association with acute subretinal hemorrhage from wet age-related macular degeneration (AMD). Methods: A retrospective observational review of a single case was performed. Results: An 84-year-old man with wet AMD presented with central vision loss and floaters and was noted to have a subretinal hemorrhage and an associated MH, which subsequently progressed to MH-associated macular detachment. The patient had a pars plana vitrectomy with internal limiting membrane peeling, gas tamponade, and prone positioning, resulting in closure of the MH and improvement in visual acuity. Conclusions: A full-thickness MH developed as a result of foveal dehiscence from an acute hemorrhage caused by choroidal neovascularization in wet AMD.

Contractility of temporal inverted internal limiting membrane flap after vitrectomy for macular hole

We investigated the postoperative visual outcomes and morphological changes of the internal limiting membrane (ILM) flap, in patients who underwent the temporal inverted ILM flap technique for macular hole (MH). Between August 2018 and February 2020, 22 eyes of 22 patients with idiopathic or myopic MH who underwent vitrectomy with ILM flap were included in this study and followed-up for more than 6 months. Postoperative MH status, comparison of best-corrected visual acuity (BCVA) before and 6 months after surgery, changes in the ILM flap area at 1 and 6 months postoperatively, and the factors related to changes in ILM flap size, were analyzed. MH closure was achieved in all of the patients. The BCVA at 6 months postoperatively (0.18 ± 0.15) was significantly better than the preoperative BCVA of 0.63 ± 0.37 (P < 0.001, paired t test). The area of the ILM flap decreased significantly from 3.25 ± 1.27 mm² at 1 month to 3.13 ± 1.23 mm² at 6 months (P = 0.024, Wilcoxon signed-rank test). Two eyes showed an ILM flap contraction of more than 20%, and one eye required reoperation due to an increase in metamorphopsia and decreased visual acuity. Among age, sex, ILM flap area at 1 month, preoperative BCVA, and axial length, ILM flap contraction was correlated with patient age and ILM flap area. Although vitrectomy with the inverted ILM flap technique confers a good visual outcome, the ILM flap may contract in younger patients.

Vitrectomy in full thickness macular holes on top of a pigment epithelial detachment in age-related macular degeneration (AMD). Surgical consideration and review of the literature

PURPOSE

To present the surgical treatment of a full thickness macular hole (MH) caused by a vitreomacular traction (VMT) on top of an adjacent subfoveal pigment epithelial detachment (PED) in age-related macular degeneration (AMD).

OBSERVATION

A 77-year-old female with a subfoveal PED receiving consecutive intravitreal injections noticed a sudden decreased visual acuity (VA) due to the development an occult MH in her right eye after 19 repeated intravitreal anti vascular endothelial growth factor (VEGF)-injections. Her initial VA declined from 20/50 to 20/400. The firm VMT induced a rupture of the multi-layered retina and may progress to an RPE-tear or possible to a subretinal haemorrhage. We discussed with the patient the risks of the natural progression and explained possible treatment options: We continued her anti-VEGF combined with air bubble injections to induce a posterior vitreous detachment, to stabilise the retinal architecture, reduce the subretinal fluid and avoid possible intraoperative bleeding. As injections did release the VMT, vitrectomy released the posterior vitreous from the optic nerve and trimmed it towards the central retina. Peeling with brilliant blue removed the internal limiting membrane without any signs of bleeding, rupture of the PED or enlargement of the MH, prior to the installation of 10% SF6 gas. The postoperative optical coherence tomography (OCT) on day 5 confirmed a closed MH, while the size, shape and pattern of the PED remained unchanged. Her VA increased from 20/400 to 20/50 (equal to her previous VA prior to the MH-formation). To avoid a potential progression of the PED, we maintained her retreatment intervals at 5 weeks for the next 6 months. A literature review presents similar intraoperative approaches and postoperative outcomes in 8 out of the 9 published cases.

CONCLUSIONS AND IMPORTANCE

VMT can induce an occult MH on top of a PED, causing a significant loss of vision. When gas injections are not successful, surgery may release the traction, restore the retinal architecture, and significantly improve and maintain the VA over a documented long-term observation. The epiretinal procedure should be assisted under regular anti-VEGF injections to maintain the subretinal architecture.

Macular pucker formation after macular hole surgery with inverted internal limiting membrane flap technique and silicone oil tamponade

Purpose

The inverted internal limiting membrane (ILM) technique was recently introduced for refractory macular hole. Here, we evaluate a case of macular pucker formation after macular hole surgery using the inverted ILM flap technique and silicone oil tamponade. After undergoing vitrectomy combined with ILM removal, the patient had a good visual prognosis.

Observations

A 49-year-old male with macular hole affecting both of his eyes underwent vitrectomies. Three months after the first surgery in his right eye, macular pucker formation was observed in the macula, which was associated with the ILM flap used to cover the macular hole. After peeling the ILM, the macula returned to a normal contour and visual acuity improved. Examination of the removed ILM revealed macrophage-like cells containing silicone oil particles that were responsible for the ILM contraction.

Conclusions and Importance

When using the inverted ILM flap technique and silicone oil, macular pucker may occur after macular hole surgery. Peeling of the ILM flap restored the macular shape and did not reopen the macular hole, thereby improving visual acuity. Thus, silicone oil should be used with caution when performing macular hole surgery with the ILM flap technique.

Complement factor B knockdown by short hairpin RNA inhibits laser-induced choroidal neovascularization in rats

AIM

To evaluate whether recombinant complement factor B (CFB) short hairpin RNA (shRNA) reduces laser-induced choroidal neovascularization (CNV) in rats.

METHODS

Laser-induced rat CNV model was established, and then the animals underwent fundus fluorescence angiography (FFA) and hematoxylin and eosin (HE) staining. On day 3 and 7 after photocoagulation, the expression of CFB and membrane attack complex (MAC) was detected by immunhischemistry. A recombinant CFB-shRNA plasmid was constructed. CFB and scrambled shRNA plasmids were intravenous injected into rats via the tail vein on the day of laser treatment, respectively. On day 7, the incidence of CNV was determined by FFA, and the expression of CFB and vascular endothelial growth factor (VEGF) in retinal pigment epithelium (RPE)/choroidal tissues was detected by immunhischemistry, Western blot and/or semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR) in CFB and scrambled shRNA groups. The possible adverse effects of CFB-shRNA injection were assessed by transmission electron microscopy and electroretinography.

RESULTS

FFA and HE results indicated that a laser-induced rat CNV model was successfully established on day 7 after photocoagulation. The expression of CFB and MAC was extremely weak in normal retina and choroid, and increased on day 3 after photocoagulation. However, it started to reduce on day 7. CFB shRNA plasmid was successfully constructed and induced CFB knockdown in the retinal and choroidal tissues. FFA showed CFB knockdown significantly inhibited incidence of CNV in rats. Moreover, CFB knockdown significantly inhibited the expression of VEGF in RPE/choroidal tissues. CFB shRNA caused no obvious side effects in eyes.

CONCLUSION

CFB knockdown significantly inhibits the formation and development of CNV in vivo through reducing the expression of VEGF, which is a potential therapy target. The alternative pathway of complement activation plays an important role in CNV formation.

Macular hole retinal detachment after intravitreal Conbercept injection for the treatment of choroidal neovascularization secondary to degenerative myopia: a case report

BACKGROUND

We report a case of macular hole (MH) formation and retinal detachment after intravitreal conbercept injection for the treatment of choroidal neovascularization (CNV) secondary to degenerative myopia.

CASE PRESENTATION

A 60-year-old woman presented with blurred vision in her left eye was diagnosed as CNV secondary to degenerative myopia. Intravitreal injection of conbercept, an anti -vascular endothelial growth factor (VEGF) agent, was uneventfully performed in the left eye. Unfortunately, a full thickness MH and retinal detachment was found three weeks postoperatively by ophthalmoscopy and spectral-domain optical coherence tomography. Vitrectomy, internal limiting membrane peeling and silicone oil tamponade were then performed, and macular retina was reattached soon after surgery. However, MH still kept open during three months' follow-up.

CONCLUSION

MH is a quite rare complication of intravitreal anti- VEGF agent injection, tangential contraction secondary to CNV shrinkage and regression caused by anti-VEGF agent is proposed to be the major pathogenesis of MH formation.