Different modes of full-thickness macular hole formation

BROAD VITREOMACULAR ATTACHMENT-INDUCED MACULAR HOLE: Structural Changes and Surgical Outcome

PURPOSE

This study aims to describe the structural changes and surgical outcomes of full-thickness macular holes (FTMHs) induced by vitreomacular traction with broad vitreomacular attachment (VMA).

METHODS

A retrospective analysis of idiopathic FTMHs from October 2010 to May 2022 was conducted. Patients with FTMHs and no retinal detachment (RD) induced by broad VMA (the study group) were compared with a control group consisting of typical FTMHs with focal VMA.

RESULTS

Thirty-one eyes had broad VMA-associated FTMH, among which seven eyes (22%) were with concurrent RD. Among the total of 24 cases without RD, 8 (33%) exhibited schisis. The incidence of lamellar holes associated epithelial proliferation and multiple membrane traction was significantly higher in the study group. One hundred percent FTMH closure was observed postoperatively in both groups. Although the postoperative visual acuity was not significantly different, the study group showed a greater ellipsoid zone disruption length.

CONCLUSION

Broad VMA-induced FTMHs are characterized by diverse macular structural changes, including schisis and macular detachment. These FTMHs are associated with a higher incidence of lamellar holes associated epithelial proliferation and multiple membrane traction. Surgical outcomes for FTMHs induced by broad VMA are similar to those induced by typical focal VMA, with both groups demonstrating a 100% hole-closure rate.

Accuracy of generative deep learning model for macular anatomy prediction from optical coherence tomography images in macular hole surgery

This study aims to propose a generative deep learning model (GDLM) based on a variational autoencoder that predicts macular optical coherence tomography (OCT) images following full-thickness macular hole (FTMH) surgery and evaluate its clinical accuracy. Preoperative and 6-month postoperative swept-source OCT data were collected from 150 patients with successfully closed FTMH using 6 × 6 mm2 macular volume scan datasets. Randomly selected and augmented 120,000 training and 5000 validation pairs of OCT images were used to train the GDLM. We assessed the accuracy and F1 score of concordance for neurosensory retinal areas, performed Bland-Altman analysis of foveolar height (FH) and mean foveal thickness (MFT), and predicted postoperative external limiting membrane (ELM) and ellipsoid zone (EZ) restoration accuracy between artificial intelligence (AI)-OCT and ground truth (GT)-OCT images. Accuracy and F1 scores were 94.7% and 0.891, respectively. Average FH (228.2 vs. 233.4 μm, P = 0.587) and MFT (271.4 vs. 273.3 μm, P = 0.819) were similar between AI- and GT-OCT images, within 30.0% differences of 95% limits of agreement. ELM and EZ recovery prediction accuracy was 88.0% and 92.0%, respectively. The proposed GDLM accurately predicted macular OCT images following FTMH surgery, aiding patient and surgeon understanding of postoperative macular features.

Analysis of the progression rate of idiopathic macular holes and the optimal cut-off for baseline minimum linear diameter and base diameter

PURPOSE

To determine the cut-off points of minimum linear diameter (MLD) and base diameter (BD) at which the progression rate of idiopathic full-thickness macular holes (MHs) decreases before vitrectomy.

STUDY DESIGN

A retrospective study.

METHODS

We investigated the differences in MLD and BD between baseline and operation days in patients with stages 2, 3, and 4 MHs using optical coherence tomography (OCT). Each difference in OCT parameters was divided by the time interval to calculate the MH progression rates and the cut-off points of MLD and BD.

RESULTS

Overall, 269 patients (282 eyes) were included. It took an average of 36.02 ± 24.69 (7-197) days from baseline to operation. MLD and BD progressed faster in stages 2 and 3 without posterior vitreous detachment (PVD) than in stage 4 with PVD (MLD: p < 0.001 and p = 0.007; BD: p < 0.001 and p = 0.019, respectively). Simple linear regression showed the relationship between baseline MLD and BD, and the progression rate; the progression rate decreased as baseline MLD (p = 0.004) and BD increased ( p < 0.001). For baseline MLD and BD, the cut-off points where the progression rate decreased were 306.0 and 470.0 μm, respectively.

CONCLUSION

The group without PVD progressed faster than the group with PVD. Moreover, the progression rates were faster in MHs with MLD < 306.0 μm and BD < 470.0 μm. In these patients, vitrectomy without delay is expected to improve the visual prognosis.

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.

Natural History and Surgical Outcomes of Lamellar Macular Holes

PURPOSE

To assess the natural history and surgical outcomes of lamellar macular holes (LMHs).

DESIGN

Retrospective and consecutive case series.

SUBJECTS

Patients with LMHs from multiple tertiary care centers.

METHODS

Clinical charts and OCT scans were reviewed.

MAIN OUTCOME MEASURES

The visual acuity (VA) changes and the occurrence rate of full-thickness macular hole (FTMH) were studied in both groups. Within the operated group, factors associated with 6-month VA and development of FTMH were explored.

RESULTS

One hundred seventy-eight eyes were included, of which 89 were monitored and 89 underwent surgery. In the observation group, the mean VA decreased from 0.25 ± 0.18 to 0.28 ± 0.18 logarithm of the minimum angle of resolution (logMAR; P = 0.13), with 14 eyes (15.7%) that lost ≥ 0.2 logMAR VA, after 45.7 ± 33.3 months. Nine eyes (10.1%) spontaneously developed an FTMH. In the operated group, the mean VA increased from 0.47 ± 0.23 to 0.35 ± 0.25 logMAR at 6 months (P < 0.001) and 0.36 ± 0.28 logMAR (P = 0.001) after 24.1 ± 30.1 months. By multivariate analysis, better baseline VA (P < 0.001), the presence of an epiretinal membrane (P = 0.03), and the peeling of the internal limiting membrane (ILM; P = 0.02), with a greater effect of ILM perihole sparing, were associated with a greater 6-month VA. Perihole epiretinal proliferation sparing was associated with a better postoperative VA by univariate analysis (P = 0.03), but this was not significant by multivariate analysis. Eight eyes (9.0%) developed a postoperative FTMH. Using Cox proportional hazard ratios [HRs], pseudophakia at baseline (HR, 0.06; 95% confidence interval [CI], 0.00-0.75; P = 0.03) and peeling of the ILM (HR, 0.05; 95% CI, 0.01-0.39; P = 0.004) were protective factors, while ellipsoid zone disruption (HR, 10.5; 95% CI, 1.04-105; P = 0.05) was associated with an increased risk of FTMH.

CONCLUSION

Observed eyes with LMH experienced, on average, progressive VA loss. Patients with LMH and altered vision may benefit from surgery. Internal limiting membrane peeling, with perihole ILM sparing, represents a crucial step of the surgery associated with a greater VA and a lower risk of postoperative FTMH.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

MicroRNA-152-3p and MicroRNA-196a-5p Are Downregulated When Müller Cells Are Promoted by Components of the Internal Limiting Membrane: Implications for Macular Hole Healing

Müller cells play a critical role in the closure of macular holes, and their proliferation and migration are facilitated by the internal limiting membrane (ILM). Despite the importance of this process, the underlying molecular mechanism remains underexplored. This study investigated the effects of ILM components on the microRNA (miRNA) profile of Müller cells. Rat Müller cells (rMC-1) were cultured with a culture insert and varying concentrations of ILM component coatings, namely, collagen IV, laminin, and fibronectin, and cell migration was assessed by measuring cell-free areas in successive photographs following insert removal. MiRNAs were then extracted from these cells and analyzed. Mimics and inhibitors of miRNA candidates were transfected into Müller cells, and a cell migration assay and additional cell viability assays were performed. The results revealed that the ILM components promoted Müller cell migration (p < 0.01). Among the miRNA candidates, miR-194-3p was upregulated, whereas miR-125b-1-3p, miR-132-3p, miR-146b-5p, miR-152-3p, miR-196a-5p, miR-542-5p, miR-871-3p, miR-1839-5p, and miR-3573-3p were significantly downregulated (p < 0.05; fold change > 1.5). Moreover, miR-152-3p and miR-196a-5p reduced cell migration (p < 0.05) and proliferation (p < 0.001), and their suppressive effects were reversed by their respective inhibitors. In conclusion, miRNAs were regulated in ILM component-activated Müller cells, with miR-152-3p and miR-196a-5p regulating Müller cell migration and proliferation. These results serve as a basis for understanding the molecular healing process of macular holes and identifying potential new target genes in future research.

AN EIGHT-YEAR RETROSPECTIVE STUDY OF THE ETIOLOGIES, CLINICAL CHARACTERISTICS, AND VISUAL OUTCOMES OF PEDIATRIC LAMELLAR MACULAR HOLE

PURPOSE

To explore the etiologies, characteristics, and prognosis of lamellar macular hole (LMH) in pediatric patients.

METHODS

A consecutive series of 59 patients (62 eyes) aged <16 years with MHs (lamellar and full-thickness) treated from 2013 to 2021 in a tertiary center was reviewed. Data collected included demographic and clinical characteristics, management, and outcomes of patients presenting with LMH.

RESULTS

Twelve eyes (19.4%) of 11 children had LMH. Seven patients were male, with an average age of 6.9 years. The primary pathologies included X-linked retinoschisis in six eyes (50%); familial exudative vitreoretinopathy in two (16.7%); and ocular toxocariasis, Coats disease, persistent hyperplastic primary vitreous, and idiopathic LMH with associated lenticonus in one eye (8.3%) each. Four eyes (36.4%) showed tractional appearance and seven (63.6%) degenerative. All degenerative LMH showed ellipsoidal zone defect, significantly higher than that in the tractional group (25%, 1/4) ( P = 0.024). Five eyes achieved closed LMH and limited visual gain, four underwent surgery, and one closed spontaneously.

CONCLUSION

X-linked retinoschisis was the most frequent primary cause in pediatric LMH. Two types of LMH can be classified: tractional and degenerative. The latter showed a higher rate of ellipsoidal zone defect. Vision improved after LMH closed, regardless of surgery or spontaneous closure.

Pathophysiology of Secondary Macular Hole in Rhegmatogenous Retinal Detachment

Purpose

To describe the pathophysiology of secondary macular hole (MH) in rhegmatogenous retinal detachment (RRD).

Methods

A retrospective cohort of 360 consecutive primary fovea-off RRDs presenting to St. Michael's Hospital, Toronto, from January 2012 to September 2022 were included. Preoperative OCT was assessed for bacillary layer detachment (BALAD) abnormalities. Histological sections of normal eyes were assessed to inform OCT interpretations. Primary outcome measure was the progression of BALAD to full-thickness MH (FTMH).

Results

Of the 360 patients, 22.5% (n = 81) had BALAD abnormalities at presentation. Eight percent (29/360) had associated MH, of which 79.3% (23/29) were a BALAD-lamellar hole and 20.7% (6/29) were FTMH. After reattachment, 62% of MHs persisted (18/29), of which 83% (15/18) had BALAD-lamellar holes that subsequently progressed to FTMH in a mean of 8.1 ± 3.2 days. BALAD-lamellar holes had significantly worse postoperative visual acuity (P < 0.001) when compared with other BALAD abnormalities (58/81) or with the rest of the cohort (279/360). OCT spectrum from BALAD to FTMH includes (1) cleavage planes extending from Henle fiber layer into the BALAD; (2) central outer nuclear layer thinning; (3) Müller cell cone loss with tissue remnants at the foveal walls; (4) retinal tissue operculum close to BALAD-MH; and (5) progressive thinning or degradation of the posterior band of BALAD-lamellar hole leading to FTMH. Histological specimens identified foveal regions of low mechanical stability.

Conclusions

BALAD plays a crucial role in the pathophysiology of MH in RRDs, which forms owing to sequential changes in four critical areas: RPE-photoreceptor interface, myoid zone, Henle fiber layer, and Müller cell cone with surrounding tissue. Timely management of fovea-off RRD with BALAD may be prudent to avoid the progression to BALAD-lamellar hole, subsequent FTMH, and worse functional outcomes.

CLINICAL CHARACTERISTICS AND SURGICAL OUTCOMES IN STAGE 4 MACULAR HOLE WITH EPIRETINAL PROLIFERATION

PURPOSE

To investigate the clinical characteristics and surgical outcomes of Stage 4 macular holes (MHs) with epiretinal proliferation (EP) and explore the pathogenesis of MH formation.

METHODS

This retrospective study included consecutive patients who underwent pars plana vitrectomy for Stage 4 MH. Patients were divided into two groups based on the presence or absence of EP. Baseline characteristics, optical coherence tomography features of MHs, and surgical outcomes were compared between the groups.

RESULTS

EP was detected in 31 of 102 eyes with Stage 4 MH (30%). Patients with EP were older ( P = 0.044), predominantly male ( P = 0.047), had a greater axial length ( P = 0.008), and had better preoperative visual acuity ( P < 0.001) than those without EP. On optical coherence tomography, eyes with EP had more epiretinal membrane and intraretinal splitting ( P = 0.002 and P < 0.001, respectively) than those without EP. The hole closure rate after primary surgery was comparable, and visual acuity at 6 months after surgery was significantly better in eyes with EP than those without EP ( P = 0.036). In 9 eyes with EP, the medical record documented the presence of complete posterior vitreous detachment before MH development.

CONCLUSION

Patients of Stage 4 MH with EP were older, predominantly male, and had better preoperative and postoperative visual acuity compared with those without EP. The differences in demographic characteristics and optical coherence tomography findings suggest that the pathogenesis of Stage 4 MH with EP is different from that of Stage 4 MH without EP.

Internal limiting membrane peeling combined with mouse nerve growth factor injection for idiopathic macular hole

BACKGROUND

The study was intended to confirm whether Pars Plana Vitrectomy (PPV) with Internal Limiting Membrane (ILM) peeling and intravitreal injection mouse Nerve Growth Factor(mNGF) was effective for the treatment of Idiopathic Macular Hole(IMH) by Optical Coherence Tomography Angiography(OCTA) and microperimetry.

METHODS

A retrospective study was performed in adults' patients. A total of 44 eyes (March 2021-October 2021) with IMH who received surgical treatment in the Affiliated Eye Hospital of Nanchang University in Nanchang City, Jiangxi Province were selected. The subjects were treated using PPV combined with ILM peeling and intravitreal mNGF (combined group) or PPV combined with ILM peeling (placebo group). The Best Corrected Visual Acuity (BCVA), Optical Coherence Tomography Angiography (OCTA) and MP-3 microperimetry were carried out and observed at baseline, 1 week(1W), 1,3 and 6 months (1 M,3 M,6 M) postoperatively.

RESULTS

The minimum diameter of MH were (568.650 ± 215.862)μm and (533.348 ± 228.836)μm in the Placebo and Combine group pre-operative. During the observation, the macular hole closure rate in the placebo group and combined group were 90% and 95.8% respectively and the difference was not statistically significant(p = 0.583). Compared to pre-surgery, the perimeter and circularity of Foveal Avascular Zone (FAZ) in the placebo group decreased at 1,3,6 M (p = 0.001, < 0.001, < 0.001) and 1W,1,6 M (p = 0.045,0.010, < 0.001) post-surgery respectively. And the perimeter and circularity of FAZ showed significant reduction in the combined group at 1,3,6 M (p = 0.005,0.004, < 0.001) and at each follow-up time point (all values of p < 0.001). The vascular density of SCP increased at 1W(p = 0.031) and 6 M(p = 0.007), the perfusion density of SCP was significantly improved at each follow-up time point (p = 0.028, 0.011, 0.046, 0.004) in the combined group. The BCVA in the combined group was more obvious than that in the placebo group at 1 M, 3 M and 6 M after operation (t₁ = 2.248, p₁ = 0.030; t₃ = 3.546, p₃ = 0.001; t₆ = 3.054, p₆ = 0.004). The changes of BCVA in the combined group was more conspicuous than that in the placebo group at each follow-up time point, and the difference was statistically significant (t₁ = 2.206,p₁ = 0.033;t₂ = 2.54,p₂ = 0.015;t₃ = 3.546,p₃ = 0.001;t₆ = 3.124,p₆ = 0.003).At 1 M, 3 M and 6 M, the MRS of 2° and 4° in the combined group was better than that in the placebo group(t = -2.429,-2.650,-3.510,-2.134,-2.820,-3.099 p = 0.020,0.011,0.001,0.039,0.007,0.004). During various time points, the MRS of 12°in the combined group was better than that in the placebo group, the difference was statistically significant (t = -3.151, -3.912, -4.521, -4.948, p₁ = 0.003, < 0.001, < 0.001 < 0.001). The integrity of External Limiting Membrane (ELM) in combination group was better than that in placebo group at 6 M postoperative(p = 0.022) and that of Ellipsoid Zone(EZ) was preferable in the combined group at 3 M and 6 M after surgery(p = 0.012,0.004). Correlation analysis showed that the integrity of EZ was correlated with 12°MRS at 1 M, 3 M and 6 M after surgery(r = -0.318, -0.343,-0.322;p = 0.023,0.033, < 0.001). There was no correlation between postoperative ELM integrity and postoperative BCVA and 12°MRS(p > 0.05).

CONCLUSIONS

Our results manifested that PPV combined with ILM peeling and intravitreal injection mNGF might be more effective for initial IMH. This method increased the blood flow, MRS and promoted the recovery of ELM and EZ in the macular and might improve the visual function of patients postoperatively.

FULL-THICKNESS MACULAR HOLE WITH PERSISTENT BROAD VITREOMACULAR ATTACHMENT: Clinical Characteristics and Surgical Outcomes

PURPOSE

To describe the characteristics and surgical outcomes of full-thickness macular holes (FTMHs) with persistent broad vitreomacular attachment.

METHODS

This was a retrospective, observational case series. Consecutive patients undergoing pars plana vitrectomy for FTMHs with persistent broad vitreomacular attachment (study group) were reviewed. Clinical charts, optical coherence tomography (OCT) features of macular holes, and surgical outcomes were reviewed and compared with those with typical FTMH with focal vitreomacular traction (control group).

RESULTS

A total of 15 eyes of 14 consecutive patients (eight males and six females with a mean age of 60.6 years) were included in the study group. OCT showed a zone of at least 1,500 µm all around the circumference of the fovea where the vitreous was attached. On OCT, epiretinal membrane and epiretinal proliferation were observed in 73% and 87% of cases, respectively. Compared with the control group, the study group was younger (P = 0.027) and had better preoperative visual acuity (P = 0.007). All FTMHs closed after one surgery in both groups, and the postoperative visual acuity of the study group was better than that of the control group (P = 0.002).

CONCLUSION

Full-thickness macular holes may have developed under the condition that the vitreous cortex was broadly attached around the hole. These FTMHs were associated with younger age, better baseline visual acuity, and a higher incidence of epiretinal membranes and epiretinal proliferations compared with macular hole with focal vitreomacular traction. The surgical outcome was favorable, but the pathogenesis of FTMH development remains unclear.

Surgical classification for large macular hole: based on different surgical techniques results: the CLOSE study group

BACKGROUND

The CLOSE study group proposes an updated surgical classification for large macular holes based on a systematic review of new treatments. Recently, many new techniques have been introduced to treat large full-thickness macular holes (FTMH); although the indications are not clear. An updated surgical classification is needed to help surgical decision-making.

METHODS

We gathered published series by the CLOSE Study Group members and from literature search until June 2021. Techniques included: internal limiting membrane peeling (ILM peeling), ILM flaps, macular hydrodissection (macular hydro), human amniotic membrane graft (hAM), and autologous retinal transplantation (ART). Within each technique, chi-square test assessed association between the minimal linear diameter (MLD) (in µm) and closure rate; the postoperative best-corrected visual acuity (BCVA) gains were compared among groups.

RESULTS

Data extraction included 31 published articles: total of 1135 eyes. Eyes were divided into the following groups: ILM peel (n: 683), ILM Flap (n: 233), macular hydrodissection (n: 64), hAM (n: 59), and ART (n: 96). The initial BCVA and size were heterogenous between the groups. ILM peel showed the best results in large FTMH ≤ 535 µm (closure rate 96.8%); adjusted mean BCVA: 0.49 (LogMAR) with a statistical difference among groups. Large FTMH between 535 and 799 µm: ILM flap technique showed better results (closure rate 99.0%); adjusted mean BCVA: 0.67(LogMAR); also with a statistical difference. For large FTMH ≥ 800 µm more invasive techniques are required. Use of hAM, macular hydrodissection and ART showed higher closure rates for this category (100%, 83.3% and 90.5% respectively), and adjusted mean BCVA varied from 0.76 to 0.89. Although there was no statistical difference between those techniques for this group due to the smaller number of cases.

CONCLUSIONS

The CLOSE study group demonstrated the potential usefulness of a new surgical classification for large FTMHs and propose OCT biomarkers for use in clinical practice and future research. This new classification demonstrated that Large (400-550 µm) and X-Large (550-800 µm) holes can be treated highly successfully with ILM peel and ILM flap techniques, respectively. Further studies are necessary for the larger FTMHs (XX-Large and Giant), using the CLOSE classification, in order to determine which technique is better suited for each hole size and characteristics.

Vitrectomy for macular retinoschisis associated with peripapillary intrachoroidal cavitations in a moderately myopic eye

Background

Peripapillary intrachoroidal cavitation (PICC), a cavernous change in the peripapillary choroid, may present with macular lesions. Here, we present a rare case of PICC with outer lamellar macular hole and macular retinoschisis.

Case presentation

A 69-year-old man presented with metamorphopsia in the left eye. Fundus examination revealed macular retinoschisis and PICCs. Pars plana vitrectomy with fovea sparing internal limiting membrane peeling (FSIP) was performed. Three weeks postoperatively, the patient developed rhegmatogenous retinal detachment and underwent a second vitrectomy. The macular retinoschisis resolved without macular hole formation and the patient’s visual acuity improved. There were no recurrent macular lesions over the three years of postoperative follow-up. Postoperative spectral-domain optical coherence tomography scan revealed a communication between the PICC and the vitreous cavity.

Conclusions

This case shed light on understanding development of PICC in non-highly myopic eyes and a rare complication of macular retinoschisis. Vitrectomy with FSIP may effectively resolve macular retinoschisis.

INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE FOR MACULAR HOLE COEXISTENT WITH RHEGMATOGENOUS RETINAL DETACHMENT

PURPOSE

To report the clinical features and treatment outcomes of patients with macular hole coexistent with rhegmatogenous retinal detachment surgically treated with pars plana vitrectomy and inverted internal limiting membrane flap technique.

METHODS

Eleven consecutive patients with rhegmatogenous retinal detachment and macular hole who underwent vitrectomy and internal limiting membrane peeling with the inverted flap technique between December 2017 and February 2021 were retrospectively evaluated. The main outcome measures were retinal reattachment rate, macular hole closure rate, and postoperative best-corrected visual acuity. A nonsystematic literature review was performed to compare the study outcomes with those previously reported.

RESULTS

The primary retinal reattachment rate was 90% (10/11) with one surgery and 100% with 2 surgical procedures. Macular hole closure was achieved in all patients (11/11). All patients showed an improvement in visual acuity at the final postoperative visit, and the mean postoperative best-corrected visual acuity was 0.60 ± 0.32 logarithm of the minimum angle of resolution (20/80 Snellen equivalent).

CONCLUSION

Vitrectomy with the inverted internal limiting membrane flap technique achieved not only favorable anatomical retinal reattachment rates but also an encouraging recovery of central macular anatomy and visual function in patients with macular hole coexistent with rhegmatogenous retinal detachment.

Progression rate analysis of idiopathic macular hole using optical coherence tomography before vitrectomy: short-term results

PURPOSE

While the postoperative closure rate of idiopathic macular holes (IMH) is quite high, its success rate and visual prognosis differ depending on macular hole (MH) characteristics. This study investigated the IMH progression rate before vitrectomy.

METHODS

This retrospective study compared optical coherence tomography (OCT) taken at baseline and on operation day for patients with stage 2, 3 and 4 IMH to determine the changes in minimum linear diameter (MLD), base diameter (BD), height and MH index (MHI). The IMH progression rate was calculated by dividing each difference in OCT parameters by the time interval.

RESULTS

A total of 224 eyes of 216 patients were included. The average time interval from baseline to operation was 35.59 ± 23.43 (7-137) days. Final visual acuity was related to preoperative MLD, BD, best-corrected visual acuity and time interval between baseline and operation (p = 0.005, p = 0.003, p <0.001 and p = 0.005 respectively). Between baseline and operation, the average MLD and BD increased significantly (all p <0.001). The average progression rates of MLD and BD assessed by simple regression analysis were 0.698 μm/day (R²  = 0.066, p <0.001) and 1.368 μm/day (R²  = 0.097, p <0.001) respectively. When patients were classified according to the MH stage, the progression rates of MLD and BD in those with stage 2 MH were significantly faster than those with stage 3 or 4 MH.

CONCLUSION

The relatively smaller MHs in stage 2 progress faster than those in stages 3 and 4. Therefore, it would ultimately be beneficial to perform vitrectomy without delay in patients with stage 2 MH.

Progression Patterns of Myopic Traction Maculopathy in the Fellow Eye After Pars Plana Vitrectomy of the Primary Eye

Purpose

This retrospective study investigated the patterns and risk factors of progression of myopic traction maculopathy (MTM) of fellow eyes after pars plana vitrectomy (PPV) of primary eyes.

Methods

The study population comprised 153 patients with MTM in both myopic eyes who sequentially underwent PPV (2006–2021). Observation periods were from PPV of the primary eye (baseline) to PPV of the fellow (end). MTM was graded based on optical coherence tomography (OCT) images and the ATN (atrophy [A], traction [T], and neovascularization [N]) system. An increase in T grade was considered MTM progression.

Results

MTM progressed in 43.8% of fellow eyes during 34.57 ± 34.08 months. The progression of fellow eyes correlated with T grade of primary eyes (P < 0.001). Risk factors for the progression of MTM in fellow eyes were primary eyes in T4–T5, age at baseline <60 years, and fellow eyes with partial posterior vitreous detachment (PVD; P < 0.001, P = 0.042, and P = 0.002, respectively). Fellow eyes in T1/T2 at baseline progressed faster compared with those in T0 (P < 0.001); the annual rate of progression to T3–T5 of the T0 (T1–T2) groups was 9.98% (24.59%).

Conclusions

Risk factors for the progression of MTM in fellow eyes included PPV when relatively young, primary eye at high T grade, and partial PVD of the fellow eye. Personalized follow-up for fellow eyes should be based on the severity of MTM of both eyes.

Optical coherence tomography features and risk of macular hole formation in the fellow eye

Background

To investigate the risk of primary macular hole (MH) in the fellow eye, and to evaluate baseline characteristics and optical coherence tomography (OCT) features that precede MH formation in the fellow eye.

Methods

A retrospective review of 229 patients treated for primary MH at Stavanger University Hospital, Norway, from January 2008 through December 2018. The patients were categorised into two groups according to subsequent development of MH in the fellow eye. The OCT findings of the two groups were compared, and associated risk factors for MH formation assessed.

Results

Twenty cases of bilateral MH were identified. The overall bilateral disease risk was 8.8% (95% CI, 5.8–13.2%). Two patients were previously operated in the fellow eye, six patients presented with bilateral MH, and 12 patients subsequently developed MH in the fellow eye. The risk of subsequent MH development was 5.7% (95% CI, 3.3–9.8%). Although the extent of posterior vitreous detachment (PVD) tended to be more progressed in the bilateral group compared with the unilateral group, the difference was not statistically significant. In the bilateral group, 41.7% had outer retinal defects vs 6.6% in the unilateral group (p = 0.001), and 33.3% in the bilateral group had intraretinal pseudocysts vs 10.2% in the unilateral group (p = 0.036, not significant after multiple testing correction).

Conclusion

Outer retinal defects and intraretinal pseudocysts are associated with an increased risk of MH formation in the fellow eye, and complete PVD indicates a decreased risk of MH formation.

Müller cells and astrocytes in tractional macular disorders

Tractional deformations of the fovea mainly arise from an anomalous posterior vitreous detachment and contraction of epiretinal membranes, and also occur in eyes with cystoid macular edema or high myopia. Traction to the fovea may cause partial- and full-thickness macular defects. Partial-thickness defects are foveal pseudocysts, macular pseudoholes, and tractional, degenerative, and outer lamellar holes. The morphology of the foveal defects can be partly explained by the shape of Müller cells and the location of tissue layer interfaces of low mechanical stability. Because Müller cells and astrocytes provide the structural scaffold of the fovea, they are active players in mediating tractional alterations of the fovea, in protecting the fovea from such alterations, and in the regeneration of the foveal structure. Tractional and degenerative lamellar holes are characterized by a disruption of the Müller cell cone in the foveola. After detachment or disruption of the cone, Müller cells of the foveal walls support the structural stability of the foveal center. After tractional elevation of the inner layers of the foveal walls, possibly resulting in foveoschisis, Müller cells transmit tractional forces from the inner to the outer retina leading to central photoreceptor layer defects and a detachment of the neuroretina from the retinal pigment epithelium. This mechanism plays a role in the widening of outer lameller and full-thickness macular holes, and contributes to visual impairment in eyes with macular disorders caused by conractile epiretinal membranes. Müller cells of the foveal walls may seal holes in the outer fovea and mediate the regeneration of the fovea after closure of full-thickness holes. The latter is mediated by the formation of temporary glial scars whereas persistent glial scars impede regular foveal regeneration. Further research is required to improve our understanding of the roles of glial cells in the pathogenesis and healing of tractional macular disorders.

Spontaneous Conversion of Lamellar Macular Holes to Full-Thickness Macular Holes: Clinical Features and Surgical Outcomes

PURPOSE

To describe the clinical features and surgical outcomes of patients experiencing a spontaneous conversion of a lamellar macular hole (LMH) to a full-thickness macular hole (FTMH).

DESIGN

Retrospective, multicenter, observational case series.

PARTICIPANTS

Patients with LMH who experienced a spontaneous conversion to FTMH and underwent FTMH surgery.

METHODS

Clinical charts and OCT features of 20 eyes of 20 patients were reviewed.

MAIN OUTCOME MEASURES

OCT features and surgical outcomes of FTMH derived from LMH.

RESULTS

The mean baseline visual acuity (VA) was 0.21 ± 0.19 logarithm of the minimum angle of resolution (logMAR) (20/32 Snellen equivalent [SE]). Epiretinal proliferation was noted in 18 eyes (90%), and 14 eyes (75%) had an epiretinal membrane. At the diagnosis of FTMH, the mean VA decreased to 0.61 ± 0.50 logMAR (20/81 SE) (P = 0.001). The mean FTMH diameter was 224.4 ± 194.8 μm, with 15 (75%) small (≤250 μm), 2 (10%) medium (>250-≤400 μm), and 3 (15%) large (>400 μm) FTMHs. Eighteen (90%) FTMHs were sealed after 1 surgery, and 2 (10%) required an additional procedure. At the last follow-up, the mean VA was increased to 0.29 ± 0.23 logMAR (20/38 SE) (P = 0.003), but did not significantly differ from the baseline VA (P = 0.071).

CONCLUSIONS

Patients with LMH may develop an FTMH with no evidence of vitreomacular traction. A tangential traction from an epiretinal membrane may contribute to its genesis, but a progressive loss of retinal tissue and an inherent weakness of the foveal architecture in LMH eyes could be sufficient. Most FTMHs derived from LMH had a small diameter, showed epiretinal proliferation, showed limited retinal hydration, and were associated with relatively poor surgical outcomes compared with idiopathic FTMH.