Management of macular holes that develop after retinal detachment repair

CHARACTERISTICS, OUTCOMES, AND OPTICAL COHERENCE TOMOGRAPHY FEATURES OF MACULAR HOLE AFTER RHEGMATOGENOUS RETINAL DETACHMENT REPAIR

PURPOSE

To investigate full-thickness macular holes (FTMHs) that develop after rhegmatogenous retinal detachment (RRD) repair.

METHODS

Retrospective consecutive case series of patients who underwent RRD repair between 2015 and 2021 and subsequently developed FTMH. Twenty-three patients (23 eyes) were included. All eyes underwent pars plana vitrectomy + membrane peel for macular hole (MH) repair.

RESULTS

The mean age at RRD diagnosis was 62 years and 52% were male. In total, 78% were macula-off RRDs. Fourteen eyes (60.9%) underwent pars plana vitrectomy alone, 7 (30.4%) underwent pars plana vitrectomy and scleral buckling, 1 (4.3%) underwent scleral buckling only, and 1 (4.3%) underwent pneumatic retinopexy. Median time from RRD repair to MH diagnosis was 116 days. Macula-off RRDs had a significantly lower time to MH diagnosis (mean 154 days, P < 0.05) than macula-on RRDs (mean 875 days). Twenty-one MH (91%) had optical coherence tomography evidence of an epiretinal membrane. Mean logMAR visual acuity at MH diagnosis was 1.05 (∼20/224) and significantly improved to 0.66 (∼20/91) at the final follow-up ( P < 0.001); 100% of MHs closed by the final follow-up.

CONCLUSION

Pars plana vitrectomy for MH after RRD repair has a high closure rate and leads to significant VA improvement. MH formation after RRD repair may be associated with macula-off detachments and epiretinal membrane. Macula-off RRDs develop MH faster than macula-on RRDs.

Characteristics and surgery outcomes of macular hole diagnosed after rhegmatogenous retinal detachment repair

PURPOSE

To report the characteristics and the visual and anatomical outcomes of secondary macular holes (SMHs) diagnosed after rhegmatogenous retinal detachment (RRD) repair and their associated factors.

METHODS

Retrospective, interventional case series. All consecutive patients who were diagnosed with SMH after RRD repair at Beijing Tongren eye center from January 2016 to April 2021 were included. Patients who had their primary RRD repair in other hospitals and were referred to our center after diagnosis of SMH were also included. The minimum follow-up time after RRD repair was 6 months.

RESULTS

37 SMHs were diagnosed within a series of 5696 RRDs. Including 24 eyes referred from other hospitals after the diagnosis of SMH, 61 eyes were included. The type of primary RRD repair surgery included 22/61 (36%) eyes with scleral buckling procedure (SBP) and 39/61 (64%) eyes with pars plana vitrectomy (PPV). 21/61 (34%) eyes had recurrent RD. The median time to SMH diagnosis was 150 days (range, 7 ~ 4380 days). Macular hole (MH) closure was achieved in 77% eyes. Visual acuity (VA) improvement of at least 2 lines of Snellen's visual acuity was observed in 51% eyes. Final MH closure status was associated with preoperative MH diameter (for every 50 μm increment) (P = 0.046, OR = 0.875, 95%CI: 0.767 ~ 0.998). VA improvement was associated with final MH closure status (P = 0.009, OR = 8.742, 95%CI: 1.711 ~ 44.672). Final VA (logMAR) was associated with recurrent RD (P < 0.001, B = 0.663, 95%CI: 0.390 ~ 0.935), preoperative MH diameter (P = 0.001, B = 0.038, 95%CI: 0.017 ~ 0.058), VA at the time of SMH diagnosis (P < 0.001, B = 0.783, 95%CI: 0.557 ~ 1.009) and final MH closure status (P = 0.024, B = -0.345, 95%CI: -0.644 ~ -0.046). For patients without recurrent RD, VA improvement and final VA was associated with final MH closure status (P = 0.016 and P < 0.001, respectively), while for patients with recurrent RD, VA improvement or final VA did not associate with final MH closure status (P > 0.05).

CONCLUSION

For SMH diagnosed after RRD repair, final MH closure status was associated with preoperative MH diameter. Recurrent RD, larger preoperative MH diameter, worse VA at the time of SMH diagnosis and failed MH closure are predictive factors for worse final VA. Visual outcome is associated with final MH closure status in patients without recurrent RD, but not as so in patients with recurrent RD.

Macular hole following scleral buckling for rhegmatogenous retinal detachment: a case series

BACKGROUND

Macular hole (MH) development following scleral buckling (SB) surgery for rhegmatogenous retinal detachment (RRD) repair is rare. This study presents both full-thickness MH (FTMH) and lamellar MH (LMH) cases following SB for the treatment of RRD.

METHODS

Clinical records of patients undergoing SB surgery for treatment of RRD at the Xi'an People's Hospital (Xi'an Fourth Hospital) from January 2016 to December 2021 were reviewed, and cases with postoperative MH were selected. Clinical features and follow-up data were summarised, and possible causes were analysed.

RESULTS

Among 483 identified cases (483 eyes), four eyes (three male patients, one female patient) had postoperative MH, with prevalence, mean age, and mean axial length of 0.83%, 43.5 ± 10.66 years, and 29.13 ± 3.80 mm, respectively. All patients did not undergo subretinal fluid (SRF) drainage. The mean time for detecting MH was 26 ± 15.5 days postoperatively. Macula-off RRD with high myopia and FTMH combined with retinal re-detachment were diagnosed in three patients. One patient had macula-on RRD with outer LMH. The average follow-up duration was 7.25 ± 1.5 months. The FTMH closed successfully after reoperation, while the outer LMH closed without intervention. Visual acuity insignificantly improved or slightly decreased in all patients.

CONCLUSIONS

Patients with high myopia combined with macula-off RRD might be more susceptible to FTMH, causing MH related retinal detachment. Additionally, LMH following SB was noted in patients with macula-on RRD. Therefore, we should raise awareness of MH following SB for RRD repair.

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.

Return to the Operating Room After Repair of Rhegmatogenous Retinal Detachment

Purpose

To report the rate of all-cause returns to the operating room (OR) after surgery for rhegmatogenous retinal detachment (RRD).

Patients and Methods

This was a retrospective consecutive case series; 1278 eyes underwent RRD repair from 1/1/2014 to 12/31/2016 at a tertiary care center. A total of 507 eyes returned to the OR. Surgical indication, procedure, number of reoperations, and final vision were recorded.

Results

At least one secondary procedure was performed in 24.9% at 6 months, 34.7% at 1 year, and 39.7% as of last follow-up. The most common indications for reoperation were cataract (43.9%) and recurrent RRD (12.8%). Cornea, glaucoma, and oculoplastic issues were rare (each <1.1%). There was no association between final visual outcome and number of reoperations (p > 0.05). SB/PPV had the highest rate of return to OR (p < 0.001) but lowest rate of recurrent RRD (p = 0.007).

Conclusion

To our knowledge, there are no other large studies that examine all-cause returns to the OR after primary RRD repair. This study provides important risk-benefit and prognostic information to patients undergoing RRD repair.

Full-thickness macular holes after surgical repair of primary rhegmatogenous retinal detachments: incidence, clinical characteristics, and outcomes

PURPOSE

Full-thickness macular hole (FTMH) formation following rhegmatogenous retinal detachment (RRD) repair may limit post-operative visual acuity and often requires a return to the operating room, but little is known about this phenomenon.

METHODS

This study included all patients with a FTMH that developed after RRD repair from January 1, 2015-July 31, 2020. The main outcome was the rate of FTMH formation following RRD repair as well as characteristics of FTMH following RRD repair that spontaneously close.

RESULTS

There were 470 eyes with a diagnosis of both a FTMH and a RRD during the study period. Of these, 27 (0.28%) developed a FTMH following RRD repair. The median time to FTMH diagnosis was 91 days (25th, 75th quartiles 40, 204 days). The mean minimum hole diameter was 514.5 ± 303.6 microns. There were 4 FTMHs (14.8%) that spontaneously closed without surgical intervention. The spontaneous closure was noted from 4 to 12 weeks after the initial diagnosis of the FTMH. These holes were smaller than the holes that did not close spontaneously (mean minimum diameter 161.8 ± 85.2 vs 588.7 ± 279.3 microns, p = 0.0058). Of the 27 post-operative FTMHs, there were 23 eyes (85%) that underwent surgical intervention with pars plana vitrectomy and internal limiting membrane peeling. Nineteen eyes (83%) closed with one surgery, 20 eyes (87%) ultimately closed, while 3 eyes (11.1%) did not close.

CONCLUSIONS

FTMH is relatively uncommon to occur following RRD repair with a prevalence of 0.28% in our series with 87% of these holes achieving closure following surgery or spontaneously. Approximately 15% of FTMHs following RRD repair closed spontaneously and these holes were significantly smaller.

Macular holes following vitrectomy for rhegmatogenous retinal detachment: epiretinal proliferation and spontaneous closure of macular holes

PURPOSE

To describe the characteristics and management of full-thickness macular holes (MHs) that develop after pars plana vitrectomy for rhegmatogenous retinal detachment (RD).

METHODS

Retrospective, interventional, consecutive case series. Patients who developed secondary full-thickness MHs after prior pars plana vitrectomy for RD over a 6-year period were included. The main outcome measures included optical coherence tomography (OCT) findings and the clinical course of full-thickness MHs.

RESULTS

A total of 11 eyes of 11 consecutive patients were included in the study. The mean age of the patients was 58.8 years (range, 47-70 years). The median time between RD repair and MH diagnosis was 36 months (range, 1 month-11 years). The fovea was attached to 10 eyes (91%) at the time of RD repair. OCT demonstrated epiretinal proliferation (EP) at the hole margin in 10 eyes (91%). MH spontaneously closed in 7 eyes (63%) but reopened in 5 eyes. A total of 7 eyes (63%) required a vitrectomy to repair the MHs. All MHs were closed at the last follow-up visit.

CONCLUSION

Full-thickness MHs after pars plana vitrectomy for RD have features that are distinct from that of typical idiopathic MH. The presence of EPs is common, and MHs are prone to spontaneous closure and reopening. These findings suggest that EP may be associated with spontaneous hole closure and that long-term follow-up is necessary even if the MHs close spontaneously.

Characteristics and management of macular hole developing after rhegmatogenous retinal detachment repair

PURPOSE

To report characteristics of patients developing full-thickness macular hole (MH) after rhegmatogenous retinal detachment (RRD) repair surgery. We also compared patients developing MH with and without accompanying RRD recurrence regarding anatomical and visual outcomes of MH repair.

DESIGN

Retrospective study.

METHODS

Medical records of patients who developed MH after RRD repair between January 2002 and January 2018 were reviewed.

RESULTS

We performed 1661 primary RRD operations during the study period and 14 of these developed MH, an incidence of 0.8%. Nine patients had their primary RRD repair surgery in another clinic and were referred to our clinic after development of MH. In total 23 patients with MH secondary to RRD repair were included in the study. The type of RRD repair surgery was scleral buckling only in 4 patients (17%), pars plana vitrectomy (PPV) only in 14 patients (61%), and sequential scleral buckling and PPV in 5 patients (22%). Nineteen patients (83%) had macula-off RRD. In 12 patients (52%), MH developed within 3 months after RRD repair. Surgery for MH repair was performed in 18 patients. Postoperative best corrected visual acuity (BCVA) was better than preoperative BCVA in the group with RRD recurrence as well as in the group without RRD recurrence (both P < 0.05). There wasn't a significant difference between these groups regarding postoperative visual gain and anatomical success (P > 0.05).

CONCLUSION

MH can develop after various surgical methods of RRD repair. Anatomic closure and visual acuity gain can be achieved even if patients have accompanying RRD recurrence.

MACULAR HOLE FORMATION FOLLOWED BY SPONTANEOUS CLOSURE AFTER PNEUMATIC RETINOPEXY IN A PATIENT WITH DIABETIC MACULAR EDEMA

PURPOSE

To report early formation and spontaneous closure of a full-thickness macular hole that developed after successful pneumatic retinopexy in a patient who had been undergoing treatment for diabetic macular edema.

METHODS

Case report of a 68-year-old man with bilateral nonproliferative diabetic retinopathy who was currently undergoing anti-vascular endothelial growth factor treatment for bilateral diabetic macular edema.

RESULTS

On presentation, visual acuity was 20/200 in the left eye, and examination revealed a bullous, macula-off retinal detachment with a single horseshoe tear at 12 o'clock in the left eye. Pneumatic retinopexy was performed followed by laser augmentation 3 days later. Three weeks postoperatively, he returned with visual acuity of 20/50 and a full-thickness macular hole in the left eye. Although he elected for initial observation, he returned 2 weeks later with visual acuity of 20/50 in both eyes and a retinal detachment with a single break at 10 o'clock in the right eye. The macular hole in the left eye had spontaneously resolved. Pneumatic retinopexy was performed to the right eye. Over 1 year after bilateral pneumatic retinopexy, his retina remains without recurrence of a macular hole in the left eye.

CONCLUSION

In the early postoperative period after pneumatic retinopexy to repair a retinal detachment, a macular hole can form and spontaneously close.

Chorioretinal Toxicity of Perfluorooctane (Ala Octa): Results From 48 Surgical Procedures in Geneva

PURPOSE

To compare outcomes of patient who underwent surgery using perfluorooctane (PFO; C₈F₁₈; Ala Octa) with those who underwent surgery with perfluorodecalin (F-Decalin).

DESIGN

Retrospective, consecutive, comparative, interventional case series.

METHODS

A total of 48 eyes that underwent vitrectomy with PFO were compared to 29 eyes that underwent vitrectomy with perfluorodecalin. Two experienced surgeons performed vitrectomies at the Geneva University Eye Clinic. Visual acuity before, at 8 and 24 weeks after surgery, was documented, and spectral domain optical coherence tomography (SD-OCT) images were analyzed for abnormalities.

RESULTS

Two patients experienced severe retinal toxicity, including 1 with severe vision loss. However, no statistical differences in VA were observed between the PFO and perfluorodecalin patients. Analysis of SD-OCT images showed differences in occurrence of several abnormalities, for example, inner segment-outer segment alterations were found in 60.4% of eyes treated with PFO and in 10.3% of perfluorodecalin-treated eyes; retinal atrophic areas were found in 41.7% of PFO and in none of the perfluorodecalin eyes; inner limiting membrane contraction was found in 58.4% of PFO and in none of perfluorodecalin eyes; inner retina cystic alterations were found in 58.3% of PFO eyes and 17.2% of perfluorodecalin eyes; outer retina cystic alterations were found in 39.6% of PFO eyes and 13.8% of perfluorodecalin eyes; retinal holes were found in 14.6% of PFO eyes and in none of the perfluorodecalin eyes; and outer retinal inclusions were found in 20.8% of PFO eyes and in 3.45% of perfluorodecalin eyes.

CONCLUSIONS

Perfluorooctane caused significantly more toxic damage than perfluorodecalin. Special consideration should be given to develop a central European Union (EU) control agency for medical devices and to reevaluate safety procedures currently accepted by the EU and International Organization for Standardization for intraocular surgery.

Full thickness macular hole formation and spontaneous closure associated with branch retinal vein occlusion in a vitrectomized eye: A case report

RATIONALE

Macular hole (MH) formation after vitrectomy is rare and it may be due to several mechanisms associated with change of foveolar anatomy by vitrectomy. If a MH develops after vitrectomy, surgical treatments including internal limiting membrane peeling and intravitreal gas injection are usually needed for repair of hole. Spontaneous closure of MH is much rarer.

PATIENT CONCERNS

A 66-year-old patient had a vitrectomy for rhegmatogenous retinal detachment not involving the macula of the right eye. Eight months after the vitrectomy, the visual acuity decreased and full-thickness defect of macula, epiretinal membrane progression, intraretinal cysts, and flame shape hemorrhage along with superior temporal vascular arcade were observed on fundus examination and optical coherence tomography.

DIAGNOSES

MH and branch retinal vein occlusion (BRVO) accompanying cystoid macular edema (CME) were both present on her right eye. Thus, we planned a surgery for MH repair.

INTERVENTIONS

The status of MH was observed while waiting the surgery schedule. At 2 weeks after detection of the MH, optical coherence tomography showed that intraretinal cysts had decreased in extent and the inner wall of the MH had contracted; 4 weeks later, the MH was closed with a subtle subretinal space.

OUTCOMES

The fovea was well-maintained with a complete closure for 9 months.

LESSONS

MH formation and spontaneous closure occurred in association with BRVO accompanying CME in a patient who had a vitrectomy. In vitrectomized eyes, physicians should consider the possibility of MH development in association with BRVO, and possible spontaneous closure of the MH in accordance with CME resolution.

ATYPICAL MACULAR HOLES

PURPOSE

To study the etiology, clinical features, management options, and visual prognosis in various types of atypical macular holes (MHs).

METHODS

A review of the literature was performed, which focused on the etiopathogenesis of atypical or secondary MHs, their differentiating clinical features, management strategies, and varied clinical outcomes. Idiopathic or age-related, myopic, and traumatic MHs were excluded.

RESULTS

Atypical or secondary MHs arise out of concurrent ocular pathologies (dystrophy, degeneration, or infections) and laser/surgery. The contributing factors may be similar to those responsible for idiopathic or typical MHs, i.e., tangential or anteroposterior vitreofoveal traction or cystoid degeneration. The management is either observation or treatment of the underlying cause. The prognosis depends on the background pathology, duration of disease, and baseline visual acuity governed by the size of MH and morphologic health of underlying RPE and photoreceptors. The closer the morphology of atypical MH is to that of an idiopathic MH, the better the surgical outcome is.

CONCLUSION

With the advancements in retinal imaging, atypical MHs are now more frequently recognized. With increasing understanding of the underlying disease processes, and improvement in investigations and surgical treatment, management of atypical MHs may improve in the future.

Macular optical coherence tomography findings after vitreoretinal surgery for rhegmatogenous retinal detachment

The primary aim of this study was to summarize and illustrate the main structural cross-sectional optical coherence tomography findings encountered after vitreoretinal surgery for rhegmatogenous retinal detachment. This was a non-systematic review of literature on structural cross-sectional optical coherence tomography findings after vitreoretinal surgery for rhegmatogenous retinal detachment. Adequate illustrations of the main findings described were found after a retrospective analysis of imaging and charts of patients operated at the department where this study was performed. The main structural cross-sectional optical coherence tomography findings after vitreoretinal surgery for rhegmatogenous retinal detachment included persistent subretinal fluid, subretinal blebs, retinal folds, subretinal perfluorocarbon liquids, macular alterations related to silicone oil, epiretinal membranes, proliferative vitreoretinopathy, cystoid macular edema, macular holes, and recurrent retinal detachment. In conclusion, optical coherence tomography was a useful tool after vitreoretinal surgery for rhegmatogenous retinal detachment. Some optical coherence tomography findings may not be evident on fundus examination, and optical coherence tomography can reveal essential details for the clinical management and the visual prognosis. Other findings, despite being visible on funduscopic examination, may be better assessed with the aid of optical coherence tomography. All these elements contribute to support the importance of tomographic assessment in the follow-up of eyes treated for vitreoretinal conditions.

Clinical characteristics, risk factors, and surgical outcomes of secondary macular hole after vitrectomy

Secondary macular hole(MH) formation after vitrectomy is rare and its risk factors and pathogenesis are not clearly understood. This retrospective study was conducted to identify the risk factors of this complication and assess outcomes at 2 tertiary centres. The primary outcomes were the clinical characteristics associated with development of secondary MH, which included the primary diagnosis for initial vitrectomy, features on optical coherence tomography, and adjuvant surgical techniques used during the initial surgery. Secondary outcomes included the change in best-corrected visual acuity(BCVA), clinical factors associated with the need for re-operations for MH closure and prognostic factors for the visual outcomes. Thirty-eight eyes out of 6,354 cases (incidence 0.60%) developed secondary MH after undergoing vitrectomy for various vitreoretinal disorders over an 11-year period, most frequently after initial surgery for retinal detachment(RD) (9 eyes) and secondary epiretinal membrane (6 eyes). The mean age was 57.1 years (range: 17.8-76.7), and the mean follow-up was 51.1 months (range: 6.8 to 137.6). Prior to secondary MH formation, development of ERM was the most common OCT feature (19 eyes, 50%), and no cases of cystoid macular oedema (CME) were observed. A greater proportion of eyes with secondary MH had long axial lengths (32% ≥26 mm vs 5% of eyes ≤22 mm). MH closure surgery was performed in 36 eyes and closure was achieved in 34 (success rate 94%, final BCVA 20/86), with ≥3-line visual gain in 18 cases. BCVA at MH onset (OR = 0.056, P = 0.036), BCVA at post-MH surgery month 3 (OR = 52.671, P = 0.011), and axial length ≥28 mm (OR = 28.487, P = 0.030) were associated with ≥3-line visual loss; a history of macula-off RD (OR = 27.158, P = 0.025) was associated with the need for multiple surgeries for MH closure. In conclusion, secondary MH occurs rarely but most commonly after vitrectomy for RD. Patients with axial length ≥28 mm and poor BCVA at 3 months post-operation may have limited visual prognosis; those with a history of macula-off RD may require multiple surgeries for hole closure.

Office-based intravitreal injection of expansile gas for management of macular hole in previously vitrectomized eyes

Purpose

To report the successful closure of full-thickness macular hole (MH), using an office-based intravitreal gas injection, in two eyes having undergone prior pars plana vitrectomy (PPV).

Observations

Patient 1 presented with acute loss of visual acuity to 20/300 in the left eye 5 months following PPV for fovea-off rhegmatogenous retinal detachment; MH was confirmed by examination and optical coherence tomography (OCT). 0.6 cc of 100% C3F8 gas was injected, with subsequent MH closure following one week of face-down positioning. Patient 2 presented with right eye visual acuity of 20/60 one month following PPV for optic nerve pit-associated maculopathy; MH was confirmed by examination and OCT. 0.85 cc of 100% C3F8 gas was injected in the office, with subsequent MH closure following one week of face-down positioning.

Conclusions and importance

MH management in previously vitrectomized eyes has traditionally been repeat PPV with internal limiting membrane peeling, fluid-air exchange, and expansile gas exchange. Intravitreal gas injection, in an office-based setting, is a viable clinical approach to close MH in some previously vitrectomized eyes.

Pneumatic retinopexy: patient selection and specific factors

Pneumatic retinopexy is a minimally invasive, non-incisional procedure for repairing retinal detachment. This procedure is associated with reduced morbidity, reduced cost and faster postoperative recovery compared to pars plana vitrectomy and scleral buckling. Superior visual acuity outcomes have also been reported. Intraoperative complications are primarily related to the intraocular pressure rise caused by gas injection, or the misdirection of the gas. There is a low rate of postoperative complications. Anatomic success rates of over 90% can be achieved when strict selection criteria are applied. However, a number of studies have revealed good outcomes in cases with expanded clinical indications. Pneumatic retinopexy is currently underutilized. With appropriate patient selection, a high success rate can be achieved, and therefore, this procedure has an important role in the armamentarium of the vitreoretinal surgeon.

MACULAR HOLE AFTER PARS PLANA VITRECTOMY FOR RHEGMATOGENOUS RETINAL DETACHMENT

PURPOSE

To report the clinical features, possible associations and treatment outcomes of patients with macular hole after pars plana vitrectomy (PPV) (single or multiple) for rhegmatogenous retinal detachment (RD).

METHODS

Retrospective consecutive case series from July 2009 to July 2014.

RESULTS

In the 15 study patients, the average time from RD surgery to macular hole diagnosis was 119 days (range: 41-398 months). Possible associations include epiretinal membrane (73%, 11/15 patients), macula-off RD (60%, 9/15 patients), recurrent RD (47%, 7/15 patients), and high myopia (56%, 5/9 patients). Single surgery was successful in hole closure in 8/15 patients (Group A) while 7/15 patients underwent multiple surgeries (Group B). Macular hole closure was achieved in 7/8 (87.5%) patients in Group A compared to 4/7 (57.1%) patients in Group B. Improvement of at least two lines of Snellen's visual acuity was achieved in 4/8 (50.0%) and 4/7 (57.1%) patients in Group A and B, respectively.

CONCLUSION

In patients with macular hole formation after pars plana vitrectomy for RD, possible associations were epiretinal membrane, macula-off RD, recurrent RD, and high myopia. Even when macular hole closure was achieved, limited visual improvement occurred.

RAPID MACULAR HOLE FORMATION, SPONTANEOUS CLOSURE, AND REOPENING AFTER PARS PLANA VITRECTOMY FOR MACULA-SPARING RETINAL DETACHMENT

BACKGROUND/PURPOSE

To report a single case of macular hole (MH) opening, spontaneous closure, and reopening in the 3-month period after pars plana vitrectomy for rhegmatogenous retinal detachment (RRD).

METHODS

Case report.

RESULTS

A 59-year-old man with a macula-sparing RRD underwent uncomplicated pars plana vitrectomy with gas tamponade. The patient developed a FTMH 2 months postoperatively. The hole was noted to spontaneously close 3 months postoperatively, but then reopened 4 months postoperatively and required repeat pars plana vitrectomy and inner limiting membrane peel for definitive closure. The rapidity with which the MH developed after pars plana vitrectomy for macula-sparing RRD and its dynamic behavior have not been previously reported.

CONCLUSION

Full-thickness macular holes may rarely develop rapidly, spontaneous close, and reopen after pars plana vitrectomy for RRD, even in macula-sparing cases.

Spontaneous Closure of Full-Thickness Macular Hole With Epiretinal Membrane in Vitrectomized Eyes: Case Series and Review of Literature

The authors describe three vitrectomized eyes that each subsequently developed a full-thickness macular hole (FTMH) that then spontaneously closed and summarize the current literature reporting these rare events. Clinical history, imaging, and course of three patients were reviewed and compiled. All three cases in this series developed a FTMH less than 7 months following vitrectomy (for epiretinal membrane [ERM], n = 1) and retinal detachment (n = 2) that demonstrated spontaneous resolution within 2 months of symptom onset, without intervention. All three vitrectomized eyes had small holes ranging from 48 µm to 189 µm in inner opening diameter and had an ERM or lamellar hole epiretinal proliferation documented before FTMH formation. These cases demonstrate that spontaneous closure of FTMH is possible in vitrectomized eyes with small holes despite the presence of ERM. On reviewing similar cases reported in the current literature, the presence of a mild ERM with a small FTMH may even be a favorable characteristic for spontaneous closure. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:183-190.].

Impact of Age on Scleral Buckling Surgery for Rhegmatogenous Retinal Detachment

Purpose

The purpose of this study is to investigate new prognostic factors in associated with primary anatomical failure after scleral buckling (SB) for uncomplicated rhegmatogenous retinal detachment (RRD).

Methods

The medical records of patients with uncomplicated RRD treated with SB were retrospectively reviewed. Eyes with known prognostic factors for RRD, such as fovea-on, proliferative vitreoretinopathy, pseudophakia, aphakia, multiple breaks, or media opacity, were excluded. Analysis was performed to find correlations between anatomical success and various parameters, including age.

Results

This study analyzed 127 eyes. Binary logistic regression analysis revealed that older age (≥35) was the sole independent prognostic factor (odds ratio, 3.5; p = 0.022). Older age was correlated with worse preoperative visual acuity (p < 0.001), shorter symptom duration (p < 0.001), presence of a large tear (p < 0.001), subretinal fluid drainage (p < 0.001), postoperative macular complications (p = 0.048), and greater visual improvement (p = 0.003).

Conclusions

Older age (≥35) was an independent prognostic factor for primary anatomical failure in SB for uncomplicated RRD. The distinguished features of RRD between older and younger patients suggest that vitreous liquefaction and posterior vitreous detachment are important features associated with variation in surgical outcomes.

Macular hole formation in rhegmatogenous retinal detachment after scleral buckling

Purpose

To describe early macular hole (MH) development in rhegmatogenous retinal detachment (RRD) after scleral buckling (SB) based on optical coherence tomography (OCT) findings.

Methods

The medical records and spectral domain OCT images of patients in whom MH developed after RRD repair were evaluated retrospectively.

Results

A postoperative MH was detected in five eyes that underwent SB during a 6-year period. All had fovea-off RRD without MH at the time of surgery. OCT showed partial loss of the inner retina with a preserved photoreceptor layer in early postoperative days. On average, 7 days (range,5 to 8 days) after surgery, outer retinal tissues disappeared, resulting in the full-thickness MH.

Conclusions

Serial OCT findings revealed that partial-thickness lamellar holes progressed to full-thickness MHs, which were formed by the degeneration of the outer retina in eyes with preceding loss of the glial cone in the fovea.

Risk factors for development of full-thickness macular holes after pars plana vitrectomy for myopic foveoschisis

PURPOSE

To identify risk factors for development of secondary full-thickness macular holes after pars plana vitrectomy with internal limiting membrane (ILM) peeling for myopic foveoschisis.

DESIGN

Retrospective, interventional case series.

METHODS

We retrospectively reviewed the records of 42 eyes (42 patients) treated with pars plana vitrectomy (vitreous separation, internal limiting membrane peeling, and gas tamponade) for myopic foveoschisis with and without a retinal detachment but without a macular hole from January 2002 through June 2012. Cataract surgery was performed in all phakic eyes. Patients were followed up for 6 months after the initial surgery, and optical coherence tomography images were obtained at every visit. The factors associated with development of postoperative full-thickness macular holes were investigated.

RESULTS

A postoperative macular hole developed in 8 (19.0%) eyes. No significant correlations of age (P = .369), axial length (P = .113), visual acuity (P = .859), foveal status (P = .331), posterior staphyloma (P = 1.000), or chorioretinal atrophy (P = .837) were found between patients with and without secondary macular holes. Among the characteristics seen on the optical coherence tomography images, the percentage of eyes with an inner segment/outer segment junction defect was significantly (P = .013, Fisher exact test) higher in patients with a macular hole than in those without a macular hole. Logistic regression analysis showed that only an inner segment/outer segment junction defect (P = .018) was a significant risk factor for development of secondary macular holes.

CONCLUSIONS

Secondary macular holes can develop in myopic foveoschisis after pars plana vitrectomy with internal limiting membrane peeling. A preoperative inner segment/outer segment junction defect can be a risk factor for development of a macular hole.

Rhegmatogenous retinal detachment treatment guidelines

This paper outlines general guidelines following the initial diagnosis of rhegmatogenous retinal detachment. These include preoperative evaluation, treatment, possible intra- and post-operative complications, retinal re-detachment, and all therapeutic options available for each case. Treatment of the traumatic retinal detachment is also described, due to its importance and peculiarities. Treatment or prophylactic guidelines are suggested for the different types of retinal detachment described. These are based on both the experience of the ophthalmologists that have participated in preparing the guidelines, and also on evidence-based grading linked to bibliographical sources. However, these guidelines should not be interpreted as being mandatory. Given that there is a wide spectrum of options for treatment of retinal detachment, the surgeons' experience with one or other surgical technique will be of utmost importance in obtaining the best surgical result. As guidelines, they are intended as an additional aid to the surgeon during the decision-making process, with the expectation that the final choice will still be left to the surgeon's judgment and past experience.

Understanding macular holes that develop after repair of retinal detachment

OBJECTIVE

To present the characteristics and outcomes of macular holes (MHs) that arise in eyes that have been treated for retinal detachment (RD).

DESIGN

Retrospective, interventional, consecutive case series.

PARTICIPANTS

We studied 18 eyes that developed a MH following RD repair.

METHODS

We report the demographic and clinical characteristics, MH closure rates, and best corrected visual acuity (BCVA) following MH repair.

RESULTS

We detected 18 full-thickness MHs in 985 eyes. In 14 of 18, the original RD involved the macula, and in 16 of 18, the BCVA was 20/200 or worse. Of the RDs, 8 of 18 required multiple procedures to achieve reattachment. Post-RD BCVA was 20/200 or worse in 15 of 18 patients. The median time to MH diagnosis after RD repair was 1 month (range, 2 days to 53 months), and from MH diagnosis to MH repair, the median time was 1.75 months (range, 3 weeks to 8 months). Of 16 eyes (89%) that underwent surgical repair of the MH, 14 achieved MH closure, 1 requiring multiple pars plana vitrectomy, and 11 saw at least 1 Snellen line of improvement (median, 1; range, 1 to 6); 2 lost vision (1 and 2 Snellen lines, respectively); and 3 remained unchanged at a median follow-up of 3 months (range, 1 month to 25 months). Of the 18 patients, 6 had at least 20/80 BCVA at last follow-up.

CONCLUSIONS

MHs following RDs (incidence 1.9%) are likely to be macula-off RDs requiring multiple interventions for RD repair. Post-MH-repair closure rates are similar to the rates for idiopathic MHs. BCVA outcomes are moderate and are dependent on impairment post-RD repair. The findings suggest other pathogenic mechanisms besides vitreofoveal traction may be leading to these MHs.

Lamellar macular hole formation following vitrectomy for rhegmatogenous retinal detachment repair

BACKGROUND

The purpose of this study was to investigate lamellar macular hole formation in six patients after rhegmatogenous retinal detachment repair.

METHODS

A retrospective review of medical records of patients who underwent primary pars plana vitrectomy for rhegmatogenous retinal detachment repair was performed. Optical coherence tomography characteristics and best-corrected visual acuity were evaluated. Patients who developed lamellar macular hole after pars plana vitrectomy for rhegmatogenous retinal detachment repair were identified.

RESULTS

A total of 1185 eyes underwent pars plana vitrectomy for retinal detachment between 2004 and 2009. Optical coherence tomography evaluation was available in 450 cases. Six of these cases demonstrated lamellar macular hole formation, which was diagnosed by OCT-3. The mean time from retinal detachment surgery to lamellar hole diagnosis was 4.1 months. The presence of an epiretinal membrane on the surface of the juxtafoveal retina was a common finding in all six patients. Visual acuity was improved after successful retinal reattachment and remained unchanged after lamellar hole formation.

CONCLUSION

Lamellar macular holes developing after pars plana vitrectomy is a rare complication. Stability of optical coherence tomography findings and best-corrected visual acuity after lamellar macular hole formation may be observed for at least two years.

Development of macular holes after rhegmatogenous retinal detachment repair in Japanese patients

Purpose. To determine the factors associated with the development of a macular hole (MH) after successful rhegmatogenous retinal detachment (RRD) surgery. Methods. Of 1260 eyes that underwent surgery for RRD between April 2005 and March 2010 in our hospital, the medical records of 4 cases from our hospital and one case from another hospital that had undergone RRD surgery and later developed MH were reviewed. This is a retrospective study. Results. 837 eyes underwent pars plana vitrectomy (PPV) with or without scleral buckling (SB), and 423 eyes underwent SB. The four cases that developed MH had PPV alone and one case had PPV with SB. After including the results of three earlier reports, the mean interval for the MH to develop after SB alone was significantly shorter than after PPV alone or after PPV with SB. Conclusions. The SB procedures might accelerate the development of MH after RRD surgery.

Treatment of leber congenital amaurosis due to RPE65 mutations by ocular subretinal injection of adeno-associated virus gene vector: short-term results of a phase I trial

Leber congenital amaurosis (LCA) is a group of autosomal recessive blinding retinal diseases that are incurable. One molecular form is caused by mutations in the RPE65 (retinal pigment epithelium-specific 65-kDa) gene. A recombinant adeno-associated virus serotype 2 (rAAV2) vector, altered to carry the human RPE65 gene (rAAV2-CBSB-hRPE65), restored vision in animal models with RPE65 deficiency. A clinical trial was designed to assess the safety of rAAV2-CBSB-hRPE65 in subjects with RPE65-LCA. Three young adults (ages 21-24 years) with RPE65-LCA received a uniocular subretinal injection of 5.96 x 10(10) vector genomes in 150 microl and were studied with follow-up examinations for 90 days. Ocular safety, the primary outcome, was assessed by clinical eye examination. Visual function was measured by visual acuity and dark-adapted full-field sensitivity testing (FST); central retinal structure was monitored by optical coherence tomography (OCT). Neither vector-related serious adverse events nor systemic toxicities were detected. Visual acuity was not significantly different from baseline; one patient showed retinal thinning at the fovea by OCT. All patients self-reported increased visual sensitivity in the study eye compared with their control eye, especially noticeable under reduced ambient light conditions. The dark-adapted FST results were compared between baseline and 30-90 days after treatment. For study eyes, sensitivity increases from mean baseline were highly significant (p < 0.001); whereas, for control eyes, sensitivity changes were not significant (p = 0.99). Comparisons are drawn between the present work and two other studies of ocular gene therapy for RPE65-LCA that were carried out contemporaneously and reported.

Pneumatic retinopexy for the repair of retinal detachments: a comprehensive review (1986-2007)

Pneumatic retinopexy has become an important surgical technique in the modern era of retinal surgical management for retinal detachments. It is primarily indicated for uncomplicated retinal detachments with retinal breaks involving the superior 8 clock hours of the fundus, although more complex retinal detachments may be successfully managed with this technique on a selected basis. Qualified candidates must be willing to maintain a specific head posture for five or more days for optimal outcome with pneumatic retinopexy. Basic surgical steps of pneumatic retinopexy include retinopexy of retinal breaks with cryotherapy or laser, intraocular gas injection before or after retinopexy, and maintenance of proper head posture by the patient for the required time period after surgery. Phakic eyes fared better than nonphakic eyes for pneumatic retinopexy, with the single-operation successes of 71-84% for the former and 41-67% for the latter. Despite lower single-operation successes with pneumatic retinopexy in comparison to sclera buckling, the multicenter pneumatic retinopexy trial and other published reports have shown that the final anatomical and visual outcomes are not disadvantaged by the initial pneumatic retinopexy. An extensive discussion of complications associated with pneumatic retinopexy is presented. In addition, a key feature of this review is a comprehensive update in the outcome of pneumatic retinopexy in published reports from 1986 to the present in chronological order not available in the current literature. This comprehensive summary shows updated average surgical outcomes for the 4,138 eyes in the 21-year period to be similar to previous reports: single-operation successes (74.4%), final operation successes (96.1%), new retinal breaks (11.7%), and proliferative vitreoretinopathy (5.2%).

Spontaneous closure of macular holes developed after pars plana vitrectomy

PURPOSE

To report a small, retrospective, noncomparative case series (3 patients) of idiopathic macular holes with spontaneous closure in previously vitrectomized eyes.

METHODS

The first patient developed a macular hole 14 months after vitrectomy for penetrating ocular trauma. In the rest of the patients, the macular holes were documented ten days and two months after vitrectomies for retinal detachment.

RESULTS

In all cases the macular holes resolved spontaneously 2 years, 6 and 9 months after their documentation, respectively.

CONCLUSIONS

Despite the limitations placed by the small sample of studied patients, it seems that spontaneous closure of macular holes developed after vitrectomy can happen as part of their natural course. Both pathogenetic and repair factors involved in macular hole can act spontaneously in a vitrectomized eye.

Pars plana vitrectomy versus combined pars plana vitrectomy-scleral buckle for primary repair of pseudophakic retinal detachment

PURPOSE

To evaluate pars plana vitrectomy (PPV) versus a combined PPV and scleral buckle (PPV/SB) for repair of noncomplex, pseudophakic retinal detachment.

DESIGN

Retrospective, nonrandomized, comparative interventional study.

PARTICIPANTS

One hundred fifty-two eyes of 152 patients followed up for a mean of 10 months. The case series included 68 consecutive patients who underwent PPV and 84 consecutive patients who underwent a PPV/SB for primary repair of primary pseudophakic retinal detachment at Wills Eye Hospital between 2002 and 2004.

METHODS

All primary PPV cases were performed by 2 surgeons who perform primary vitrectomy without regard to location of detachment, number and location of break(s), refractive error, or macula status. All primary PPV/SB were performed by a group of surgeons who solely perform PPV/SB on pseudophakic retinal detachments. All eyes underwent a standard 3-port 20-gauge PPV under wide-field viewing and scleral depression. Endolaser photocoagulation was applied either around the retinal tears or 360 degrees to the vitreous base region followed by gas tamponade. Patients with proliferative vitreoretinopathy grade C or worse were excluded from the study.

MAIN OUTCOME MEASURES

(1) Single surgery anatomic success rates, (2) preoperative and postoperative visual acuity, and (3) complications.

RESULTS

The single surgery anatomic success rate in the primary PPV group was 63 of 68 eyes (92.6%; 95% confidence interval [CI], 84%-98%) and in the primary PPV/SB group was 79 of 84 eyes (94.0%; 95% CI, 87%-98%). Both groups obtained 100% final reattachment rate. There was no statistically significant difference between the success rates (P = 0.75, Fisher exact test). The PPV group's best-corrected postoperative visual acuity demonstrated a +0.10 logarithm of the minimum angle of resolution improvement over the PPV/SB group (P = 0.07). The PPV group had a smaller incidence of postoperative complications (13/68 patients [19.1%] vs. 27/84 patients [32.1%]; P = 0.10, Fisher exact test).

CONCLUSIONS

Primary PPV and PPV/SB seem to have similar efficacy in the repair of a matched group of patients with primary noncomplex pseudophakic retinal detachment. There was no statistically significant difference in complication rate between the 2 groups.