Macular hole surgery in high myopia

Biological ultrathin amniotic membrane flap to close refractory macular holes associated with high myopia

PURPOSE

To propose an ultrathin biological amniotic membrane (btAM) thinner than 10 μm as the graft to treat highly myopic macular holes (MH).

METHODS

This pilot study included 14 patients affected by refractory macular holes associated with high myopia. btAM was used as a bandage covering the holes. The best-corrected visual acuity (BCVA), fundus photography, and optical coherence tomography (OCT) before and after surgery were compared.

RESULTS

The mean MH size was 865.93 ± 371.72 μm and all the MHs achieved anatomical closure. The btAM located centrally and fully on MHs from fundus photography yet no obvious visual masking was complained. The average BCVA 1 month, 3, and 6 months after surgery were 0.95 ± 0.24, 0.92 ± 0.23, 0.92 ± 0.23 logMAR, respectively, improved significantly compared to pre-operative BCVA (1.24 ± 0.42 logMAR, all P < 0.05). Ten out of 14 (71.4%) exhibited 2C closure patterns (formally closed and no bare RPE) on OCT.

CONCLUSION

The btAM thinner showed a favorable anatomical success with less risk of parafoveal atrophy or iatrogenic injuries and shortened the dissolving time.

Swept Source-Optical Coherence Tomography-Guided Facedown Posturing to Minimize Treatment Burden and Maximize Outcome after Macular Hole Surgery

We evaluated the closure of full-thickness macular holes (MHs) the day after surgery in minimizing the burden and maximizing patient outcomes. Herein, 25-gauge pars plana vitrectomy, internal limiting membrane peeling, and fluid-gas (20% sulfur hexafluoride) were performed for the treatment. Patients were instructed to remain in the facedown position until the confirmation of MH closure, and the position was discontinued in cases where the closure was confirmed. In total, 43 eyes of 43 patients, whose average age was 69.7 ± 8.6 years, were enrolled in this study. We used swept source (SS)-optical coherence tomography (OCT) for the confirmation of MH closure for gas-filled eyes and used spectral domain (SD)-OCT for the reconfirmation of MH closure after the gas volume was reduced to less than half of the vitreous cavity. MH closure was confirmed in 40 eyes (93%, the closure group) on the next day after surgery. The time from surgery to SS-OCT imaging was 24.7 h. Although facedown positioning was terminated in cases where MH closure was confirmed, there were no cases in which the MH was re-opened afterward. The basal and minimum MH size was significantly larger in the non-closure group than that in the closure group (p = 0.027, p = 0.043, respectively). Therefore, checking with SS-OCT the day after surgery and terminating facedown positioning in cases where MH closure was confirmed would be a useful method, removing a great burden for the elderly without sacrificing the MH closure rate.

Internal Limiting Membrane Peeling and Gas Tamponade For Full-Thickness Macular Holes of Different Etiology - Is It Still Relevant?

Background

Despite the abundance of novel surgical approaches proposed for full thickness macular hole (FTMH) treatment, the choice of the optimal technique remains debatable Vitrectomy with «classic» internal limiting membrane peeling and gas tamponade remains the standard of FTMH surgery in many cases, but there are still very limited recent publications on the outcomes of such surgery.

Purpose

To investigate the anatomical and functional result and to analyze the significance of outcome-related risk factors of the classic 25-gauge pars plana vitrectomy (PPV) with ILM peeling and gas tamponade (GT) for treatment of FTMH of different etiology.

Patients and methods

Thirty-eight eyes of thirty-seven patients with FTMH who underwent 25-gauge PPV, ILM peeling and GT were recruited for this retrospective, consecutive, interventional study. Four eyes with persistent holes underwent a re-operation. Outcome-related factors were discussed.

Results

The primary closure rate was 89.5% (34/38). All eyes that underwent the repeated surgery (4 cases) obtained final closure. A hole size of >500 μm has a statistically significant effect on the primary macular hole closure (F = 0.048; φ = 0.38; p ˂ 0.05). In the general group (N = 38), the duration of symptoms directly correlated with age (ρ = 0.34; p = 0.04), size of the hole (ρ = 0.66; p ˂ 0.001) and BCVA before surgery (ρ = 0.59; p ˂ 0.001), after 1 month (ρ = 0.36; p = 0.03), and after 3 months (ρ = 0.35; p = 0.03). Preoperative BCVA was better in initially closed cases (Group 1) (U = 26.0; p = 0.05). In the Group 2 with primary unclosed holes, 75% of the eyes (3/4) had an axial length (AL) >26 mm, while in Group 1 such eyes were 12.5 times less (2/34) 5.9% (F = 0.004; φ = 0.63; р ˂ 0.01). The ELM recovery rate at 3 months was 92% (35/38 eyes) and the restoration of EZ at 3 months was 47% (18/38 eyes). Best-corrected visual acuity of all individuals improved significantly from 0.72 ± 0.35 (logMAR) (Me = 0.7; IQR: 0.5-0.8) to 0.25±0.14 (logMAR) (Me = 0.2; IQR: 0.2 - 0.3) at 1 month and 0.17 ± 0.13 (logMAR) (Me = 0.2; IQR: 0.1 - 0.2) at 3 months after surgery (P = 0.0001).

Conclusion

25G PPV with ILM and GT for FTMH of different etiology provide satisfactory morphologic and functional outcomes. Elongated AL, large diameter of MH and long duration of symptoms are the risk factors for initial closure. Proper second surgery can obtain satisfactory outcomes for persistent holes.

Outcomes of Vitrectomy with Fovea-Sparing and Inverted ILM Flap Technique for Myopic Foveoschisis

Surgical treatment of myopic foveoschisis (MF) can result in a macular hole in 11−17% of patients that may lead to poor visual outcomes and progression to macular hole retinal detachment. We evaluated the benefit of vitrectomy to treat MF using the inverted internal limiting membrane (ILM) flap and fovea-sparing ILM techniques. We studied 20 eyes of 20 patients (7 men, 13 women) with high MF (mean axial length, 29.3 ± 1.7 mm). MF was classified by optical coherence tomography findings: retinoschisis (7 eyes) or foveal detachment (13 eyes). Between October 2013 and June 2021, we performed vitreous surgery in all 20 patients, employing both techniques. Air tamponade was used in 4 eyes, SF6 gas in 10 eyes, and C3F8 gas in 6 eyes. All patients stayed in the face-down position for one full day postoperatively. Visual acuity and foveal contour were analyzed using optical coherence tomography before surgery and at 3 and 6 months postoperatively. LogMAR visual acuity was 0.46 before surgery, with a significant improvement at 3 months (0.34) and at 6 months (0.2) postoperatively (p = 0.024, p < 0.001, respectively). In all patients, the foveal contour showed improvement without macular hole formation after surgery. These results show that vitrectomy, performed using the inverted ILM flap and fovea-sparing ILM technique, is effective for treating MF.

Factors Associated with Anatomic Failure and Hole Reopening after Macular Hole Surgery

A macular hole (MH), particularly an idiopathic macular hole (IMH), is a common cause of central vision loss. Risk factors for nonidiopathic MH include high myopia, cystoid macular edema, inflammation, and trauma. MH is primarily diagnosed using slit-lamp microscopy and optical coherence tomography (OCT). Half of the patients with stage I MHs are treated conservatively and may show spontaneous resolution. The main treatment methods for MHs currently include vitrectomy and stripping of the internal limiting membrane (ILM). However, in some patients, surgery does not lead to anatomical closure. In this review, we summarize the factors influencing the anatomical closure of MHs and analyze the potential underlying mechanisms.

HUMAN AMNIOTIC MEMBRANE TO CLOSE RECURRENT, HIGH MYOPIC MACULAR HOLES IN PATHOLOGIC MYOPIA WITH AXIAL LENGTH OF ≥30 mm

PURPOSE

To assess the effectiveness of the human amniotic membrane plug for recurrent high myopic macular hole (MH) that already underwent pars plana vitrectomy with internal limiting membrane peeling and gas endotamponade.

METHODS

Sixteen eyes of 16 patients with recurrent high myopic MH were enrolled. A 23-gauge pars plana vitrectomy was performed. Human amniotic membrane plugs were implanted under the neuroretina inside the MH. Twenty percent sulfur hexafluoride or air was used as endotamponades. The patients were instructed to maintain facedown position for 5 days after surgery.

RESULTS

Optical coherence tomography examinations showed that the MHs closed in 15 of the 16 patients (93.75%) 2 weeks after one surgical intervention, and in 100% of patients after second intervention. Mean best-corrected visual acuity improved from 1 logarithm of the minimum angle of resolution (20/200) to 0.67 logarithm of the minimum angle of resolution (20/100) 6 months after surgery. Best-corrected visual acuity remained stable during the 12-month follow-up. One patient had human amniotic membrane plug dislocation after gas absorption that needed a second intervention with new AM plug implantation. No adverse events were reported during the 12-month follow-up.

CONCLUSION

The first case series of recurrent high myopic MH was reported, assessing the effectiveness of the human amniotic membrane plug to close recurrent MHs in pathologic myopia. All the cases were successful with encouraging best-corrected visual acuity recovery.

Surgical Management of Recurrent and Persistent Macular Holes: A Practical Approach

Primary surgery for macular hole (MH) closure has a high success rate with current methods of pars plana vitrectomy and internal limiting membrane (ILM) peeling. When primary surgery fails, there are several options available for secondary repair, including extension of the ILM peel, creation of an ILM flap, pedunculated ILM flap, lens capsule flap transplantation, autologous retinal transplantation, use of a human amniotic membrane plug, adjuvant autologous platelet concentrate, induction of macular detachments with subretinal blebs, and creation of retinal incisions. In this review, we discuss the practical approach to each of these surgical techniques for the management of recurrent or persistent MHs.

Therapeutic Efficacy of Autologous Platelet Concentrate Injection on Macular Holes with High Myopia, Large Macular Holes, or Recurrent Macular Holes: A Multicenter Randomized Controlled Trial

We aimed to evaluate the anatomical and functional outcomes of pars-plana vitrectomy (PPV) with or without autologous platelet concentrate (APC) injection in patients with recurrent macular holes (MHs), large MHs, or MHs with high myopia. This multicenter, prospective, interventional randomized controlled trial was conducted from March 2017 to April 2020. Participants were randomly allocated to a PPV group or a PPV+APC group. All participants underwent standard 25-gauge PPV, and eyes in the PPV+APC group underwent PPV with intravitreal APC injection before air-gas exchange. A total of 117 patients were enrolled (PPV group: n = 59, PPV+APC group: n = 58). Hole closure was achieved in 47 participants (79.7%) in the PPV group and 52 participants (89.7%) in the PPV+APC group. There were no between-group differences in the anatomical closure rate or functional outcomes including best-corrected visual acuity, metamorphopsia, pattern-reversal visual evoked potential, or Visual Function Questionnaire-25 score. The use of APC injection does not improve the anatomical and functional outcomes of surgery for large MHs, recurrent MHs, or MHs with high myopia. The adjunctive use of APC can be considered in selected cases because it is not inferior to conventional MH surgery, is relatively simple to perform, and is not affected by the surgeon’s skill.

Long-Term Outcomes of Macular Hole Repair with Triamcinolone Acetonide Visualization

Purpose

To evaluate the long-term anatomic and visual outcomes of macular hole (MH) repair utilizing triamcinolone acetonide (TA) visualization of the internal limiting membrane (ILM) treated at a tertiary care retina practice.

Methods

Retrospective chart review of eyes undergoing MH repair with ILM peel utilizing TA visualization followed by gas tamponade and facedown positioning between 2014 and 2020. Pre- and post-operative visual acuity (VA), IOP, and anatomic closure based on optical coherence tomography were documented.

Results

Seventy-eight eyes were followed for 2.3±0.2 years after primary repair with anatomic closure in 73 (94%) eyes at their final visit and excluding eyes with pathologic myopia, 97%, and for stage 2 and small MHs, 100%. In all eyes, VA significantly improved from 0.97±0.04 (Snellen: 20/187) to 0.66±0.06 (20/91) logMAR (p < 0.0001). There were 16 eyes with 4 years of follow-up, 10 (63%) eyes achieving a VA ≥20/30 at that follow-up visit. Stage 2 and 3 MHs had significantly greater improvements in VA than Stage 4 MHs, −0.46 ± 0.06 versus −0.11 ± 0.11 logMAR (p = 0.021). Of the 13 (17%) eyes with recurrent MHs, 6 (46%) had pathologic myopia and 8 (61.5%) had associated cystoid macular edema. Cataract progression was reported in 52 (96%) phakic eyes and 2 eyes required Ahmed valve placement for management of pre-existing glaucoma.

Conclusion

Long-term results of MH repair with TA for ILM visualization demonstrate that it is safe and effective. Visual acuity continued to improve throughout the follow-up. Pre-existing glaucoma may progress and recurrence is associated with pathologic myopia and macular edema.

Results of Pars Plana Vitrectomy for Different Types of Macular Holes

Purpose

To compare different types of macular holes regarding the anatomic and functional success following pars plana vitrectomy (PPV) and internal limiting membrane (ILM) removal.

Methods

A retrospective review of all patients with macular holes treated by PPV, ILM removal with gas tamponade from January 2014 to July 2017 in Magrabi Eye Hospital.

Results

One hundred fifty-seven eyes of 153 patients were analyzed. The eyes were classified according to the etiology of macular hole into four groups: 79 eyes with idiopathic macular hole (IMH), 51 eyes with traumatic macular hole (TMH), 16 eyes with macular hole in diabetic patients (DMH) and 11 eyes with myopic macular hole (MMH). We classified the IMH group based on the International Vitreomacular Traction Study Classification according to size into 3 subgroups; subgroup 1: ≤250µ, subgroup 2: >250 to 400µ and subgroup 3: ≥400 µ. All types of macular hole showed statistically significant postoperative improvement in BCVA compared to the baseline except cases with MMH. Anatomic postoperative hole closure was achieved in 86.1%, 60.7%, 43.65%, an 45.46% of eyes with IMH, TMH, DMH and MMH, respectively. In eyes with IMH, closure rate in subgroup 1 was significantly higher than in subgroups 2, and 3.

Conclusion

PPV, ILM peel and C2F6 technique yielded variable anatomic and functional outcomes in different types of macular holes. Anatomic results were most favorable in IMH and least favorable in MMH. The smaller the diameter of the hole the better the results. The underlying pathogenetic mechanisms that lead to different types of macular holes are pivotal in determining the final outcome.

MORPHOLOGIC CHARACTERISTICS OF MACULAR HOLE AND MACULAR HOLE RETINAL DETACHMENT ASSOCIATED WITH EXTREME MYOPIA

PURPOSE

To investigate the surgical results and morphologic characteristics of macular hole (MH) and macular hole retinal detachment (MHRD) associated with extreme myopia.

METHODS

We retrospectively reviewed consecutive cases with axial length ≥28 mm who were treated with pars plana vitrectomy for MH or MHRD. The choroidal and scleral thickness at the fovea, presence of dome-shaped macula, and the height of posterior staphyloma 3 mm from the fovea were measured from postoperative optical coherence tomography images.

RESULTS

Significant improvement in visual acuity was obtained postoperatively in both MH (16 eyes; 15 patients) and MHRD (19 eyes; 18 patients) groups (P < 0.05). Final MH closure rate was not significantly different between the groups (MH: 15/16, MHRD: 14/19, P = 0.19). Axial length was not significantly different between the groups (MH: 30.5 ± 1.5 mm, MHRD: 29.6 ± 1.3 mm, P = 0.098). Eyes with MH had significantly greater choroidal thickness (MH: 61.9 ± 66.0 μm, MHRD: 24.1 ± 19.8 μm, P = 0.045), greater scleral thickness (MH: 294 ± 77 μm, MHRD: 232 ± 89 μm, P = 0.008), higher frequency of dome-shaped macula (MH: 6/16, MHRD: 1/19, P = 0.032), and lower staphyloma height (MH: 190 ± 113 μm, MHRD: 401 ± 156 μm, P < 0.001).

CONCLUSION

Surgical outcomes were generally favorable. The pathogenetic differences between the two conditions may be attributable to differences with respect to eye morphology.

Comparisons of surgical outcomes after epiretinal membrane peeling in the myopic eyes with long to that with normal axial length

PURPOSE

To compare the outcomes of vitrectomy with removal of an idiopathic epiretinal membrane (ERM) in the myopic eyes with long axial length (AL) to that in the eyes with normal AL.

METHODS

This was a retrospective, observational, case-control study. Fifty-six eyes of 56 patients with an idiopathic ERM were studied. Twenty-eight of these eyes had an axial length longer than 26.0 mm (Group A), and the other 28 eyes had axial lengths < 26.0 mm (Group B). The age and visual acuity of the two groups were not significantly different. All subjects were treated by vitrectomy and peeling of the ERM with a 25- or 27-gauge system. The postoperative best-corrected visual acuity (BCVA) and optical coherence tomographic findings were determined at 3 and 6 months postoperatively.

RESULTS

The mean BCVA improved from 0.35 ± 0.25 to 0.15 ± 0.25 logMAR units in the eyes with the long AL and from 0.35 ± 0.25 to 0.10 ± 0.21 logMAR units in the eyes with normal AL at 6 months postoperatively (both P < 0.001). The postoperative BCVA was not significantly different between the two groups at 6 months (P = 0.221). The central macula was thinner in the eyes of Group A than Group B (P < 0.001). The restorations of the ellipsoid zone and the external limiting membrane were observed in both groups, but the interdigitation zone was less frequently restored in Group A (P < 0.001).

CONCLUSIONS

Vitrectomy with the removal of the epiretinal membrane is effective in attaining a good BCVA even in the myopic eyes with long AL.

Long-Term Outcome of Vitrectomy with Suitable Internal Limiting Membrane Peeling and Air Tamponade for Highly Myopic Foveoschisis-Associated Lamellar Macular Hole

Purpose

To investigate the outcome of pars plana vitrectomy (PPV) with suitable internal limiting membrane peeling (ILM) and air tamponade for patients with highly myopic foveoschisis-associated lamellar macular hole (MH).

Methods

This retrospective interventional case series included 11 patients with highly myopic foveoschisis-associated lamellar MH who underwent PPV and indocyanine green-aided ILM peeling up to the temporal vascular arcades. Following air tamponade after surgery, all patients were instructed to maintain a face-down position. The patients were followed up for over 1 year and evaluated for MH closure and the best-corrected visual acuity before and after surgery.

Results

The mean ± standard deviation values of patient age, axial length, and follow-up duration were 67.82 ± 6.54 years, 29.21 ± 1.95 mm, and 24.27 ± 8.11 months, respectively. After surgery, the lamellar MH closed in all eyes, and 10 eyes showed vision improvement at the 1-month, 3-month, and final follow-up evaluations. One patient showed decreased vision at 2 years after surgery, with patchy chorioretinal atrophy in the macular region. Myopic foveoschisis showed resolution in three eyes and alleviation in eight. Ten patients underwent cataract surgery during PPV.

Conclusion

Extension of ILM peeling up to the temporal vascular arcades and air tamponade after PPV may improve the visual function and rate of MH closure for patients with highly myopic foveoschisis-associated lamellar MH.

SURGICAL OUTCOMES IN EYES WITH EXTREMELY HIGH MYOPIA FOR MACULAR HOLE WITHOUT RETINAL DETACHMENT

PURPOSE

The authors evaluated surgical outcomes in eyes with extremely high myopia for macular hole (MH) without retinal detachment.

METHODS

In this retrospective study, 14 eyes with axial lengths of ≥30.0 mm underwent vitrectomy and internal limiting membrane (ILM) peeling with or without inverted ILM flap insertion for MH without retinal detachment (October 2009-June 2016). Outcome measures were MH closure confirmed by optical coherence tomography, best-corrected visual acuity, and complications.

RESULTS

The mean axial length was 30.69 ± 0.76 mm. The overall final closure rate was 85.7% (12/14 eyes); the mean follow-up was 17.29 (±20.20) months. Primary anatomical MH closure after 1 operation was achieved in three of eight eyes (37.5%) without an inverted ILM flap and was achieved in six of six eyes (100%) with inverted ILM flap insertion (P = 0.031). There was no reopening of MH during follow-up. Mean visual acuity improved significantly from 1.10 ± 0.43 logarithm of the minimum angle of resolution (Snellen equivalent, 20/254) to 0.84 ± 0.50 logarithm of the minimum angle of resolution (Snellen equivalent, 20/138) (P = 0.046; 2-tailed, paired t-test). Only 1 eye developed an MH-associated retinal detachment 4.5 years after previously failed MH surgery; reattachment was achieved after a second operation.

CONCLUSION

Patients with extremely high myopia obtained anatomical and functional improvements from MH surgery; inverted ILM flap insertion achieved significantly higher primary success rates in MH closure.

INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE FOR MACULAR HOLES IN HIGH MYOPIA WITH AXIAL LENGTH ≥30 mm

PURPOSE

To evaluate the closure rate of macular holes in highly myopic eyes treated with the inverted internal limiting membrane flap technique.

METHODS

Retrospective study in 33 consecutive patients (33 eyes) with a myopic macular hole (axial length ≥30 mm) and no associated macular retinoschisis, undergoing 23-gauge pars plana vitrectomy combined with the inverted internal limiting membrane flap technique.

RESULTS

Mean initial logarithm of the minimum angle of resolution best-corrected visual acuity was 0.59 (range, 0.22-1.8) (Snellen fraction, 20/80). At the 1-month postoperative control visit, the macular hole was closed in all patients. Reopening of the hole occurred in 2 patients. Visual acuity improved in 13 patients (39.4%): final mean ETDRS (Early Treatment Diabetic Retinopathy Study) improvement was +80 letters, and logarithm of the minimum angle of resolution was 0.4 (20/50). Staphyloma with macular involvement was present in all patients. Dissociated optic nerve fiber layer was observed in 25 patients (75.7%) and was absent in 2 (6.1%); in the remaining 6 patients, the layer could not be assessed. Gliosis was found in 14 patients (42.4%).

CONCLUSION

Vitrectomy plus the inverted internal limiting membrane flap technique was effective for treating macular holes in eyes with axial length ≥30 mm and no associated retinoschisis.

Effectiveness of combined macular buckle under direct vision and vitrectomy with ILM peeling in refractory macular hole retinal detachment with extreme high axial myopia: a 24-month comparative study

Purpose

To evaluate the efficacy of a combined macular buckle under direct vision and 23-gauge pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling in refractory macular hole retinal detachment (MHRD) with extreme high axial myopia.

Design

Prospective, randomised controlled study.

Participants

The study included 98 eyes of 98 patients of MHRD with extreme high axial (>30 mm) myopia.

Intervention

Patients were randomly assigned to undergo PPV with ILM peeling (group 1, n=52) or PPV with ILM peeling combined with macular buckle under direct vision (group 2, n=46).

Main outcome measures

Complete ocular examination included best-corrected visual acuity (BCVA) (LogMAR), applanation tonometry, optical biometry, slit-lamp biomicroscopy, colour fundus photography, ultrasound examination and optical coherence tomography at baseline and every follow-up visit.

Results

Initial retinal reattachment rate was significantly higher in group 2 than in group 1 at 12-month postoperatively (χ² test, p=0.020). Macular hole closure rate in group 2 was significantly higher than that in group 1 at 3, 12, 18 and 24 months postoperatively (Fisher's exact test, p<0.05). In initial retinal reattachment cases, the mean BCVA decreased significantly in group 2 than in group 1 at 3 months postoperatively (Wilcoxon matched pairs signed rank test, p=0.036), and had increased significantly in group 2 than in group 1 since 6 months postoperatively (Wilcoxon matched pairs signed rank test, p<0.05). Mean axial lengths in group 2 were significantly shorter than that of group 1 at each follow-up time point (Wilcoxon matched pairs signed rank test, p<0.05).

Conclusions

Combined macular buckle under direct vision and PPV with ILM peeling is more effective in treatment of MHRD with extreme high axial (>30 mm) myopia.

VITRECTOMY FOR REFRACTORY MACULAR HOLE

PURPOSE

To report two cases of the treatment of refractory macular hole.

METHODS

A retrospective case report of two patients who underwent vitrectomy for refractory macular hole.

RESULTS

Two patients underwent pars plana vitrectomy for refractory macular holes. However, the surgical methods differed in the two patients depending on whether the internal limiting membrane (ILM) remained or not. In the patient with the remnant ILM, pars plana vitrectomy, inversion of the remaining ILM flap, air-fluid exchange, and 5% C3F8 gas tamponade were performed. In the other case with no remaining ILM, pars plana vitrectomy, inversion and release of the margin of the macula hole, combined with autologous platelet concentrate, air-fluid exchange, and 5% C3F8 gas tamponade were performed. In both cases, good anatomical outcomes were achieved postoperatively.

CONCLUSION

Depending on whether the ILM remains or not, one of these two new surgical procedures can be selected. This protocol can yield positive surgical results.

Vitrectomy with internal limiting membrane peeling vs no peeling for Macular Hole-induced Retinal Detachment (MHRD): a meta-analysis

BACKGROUND

we conducted our meta-analysis of published studies to assess existing evidence about the efficacy and safety of vitrectomy with ILM peeling vs. that of vitrectomy with no ILM peeling for Macular hole-induced retinal detachment.

METHODS

Databases, including Pubmed, Cochrane Library, Ovid, Web of Science, Wanfang and CNKI, were searched to identify studies comparing outcomes following vitrectomy with ILM peeling and that with no ILM peeling for macular hole-induced retinal detachment. The meta-analysis was performed by RevMan 5.1.

RESULTS

Six comparative studies comprising 180 eyes were identified. It was indicated that the rate of retinal reattachment (Odds ratio (OR) = 3.03, 95 % Confidence interval (CI):1.35 to 6.78; P = 0.007) and macular hole closure (OR = 6.74, 95 % CI:3.26 to 13.93; P < 0.001) after initial surgery was higher and the rate of recurrent retinal detachment (OR = 0.08, 95 % CI:0.02 to 0.30; P = 0.0002) was lower in the group of vitrectomy with ILM peeling than that in the group of vitrectomy with no ILM peeling. However, the improved BCVA (Weighted mean difference (WMD) = 0.14, 95 % CI: -0.20 to 0.47; P = 0.42) and the rate of postoperative complications were similar between the two groups.

CONCLUSION

Vitrectomy with internal limiting membrane peeling is an efficient and safe procedure for macular hole-induced retinal detachment.

Inverted internal limiting membrane flap technique for surgical repair of myopic macular holes

PURPOSE

To present the anatomical and functional results of vitrectomy with the "inverted internal limiting membrane flap technique" in myopic macular holes without retinal detachment.

METHODS

A prospective interventional study of 19 myopic eyes with a spherical equivalent >-6 diopters with macular holes in 18 consecutive patients. Preoperative and postoperative visual acuity and spectral domain optical coherence tomography images were evaluated. The main outcome measure was visual outcome and macular hole closure rate.

RESULTS

Mean visual acuity improved from 1.2 logMAR to 0.56 logMAR. We confirmed the closure of the macular hole with spectral domain optical coherence tomography in all cases. The closure of the macular hole began in the inner retinal layers, and the architecture gradually filled with tissue. Photoreceptor and external limiting membrane defects improved during the first 12 months after surgery.

CONCLUSION

Vitrectomy with the inverted internal limiting membrane flap technique may be an effective addition to surgical options for treating myopic macular holes. Spectral domain optical coherence tomography images confirm that the process of foveal architectural repair after this surgery continues over at least a 12-month period.

Outcomes of macular hole surgery with short-duration positioning in highly myopic eyes: a case-control study

PURPOSE

To evaluate the outcomes of macular hole (MH) surgery with 3-day prone positioning in highly myopic eyes and to compare them with those from non-highly myopic eyes.

DESIGN

Retrospective nested case-control study from a cohort of 496 consecutive patients (496 eyes) who underwent surgery for MH.

PARTICIPANTS

Forty-seven highly myopic eyes (with axial length >26 mm) were included in the study group and were matched for MH size and duration of symptoms with 47 non-highly myopic control eyes selected from the same cohort.

METHODS

All patients underwent pars plana vitrectomy, internal limiting membrane peeling, and 17% hexafluoroethane gas filling. Patients then were advised to maintain strict face-down positioning for 3 days only and to avoid the supine position during the night for a minimum of 1 week.

MAIN OUTCOME MEASURES

The MH closure rate, the relationship between axial length and closure rate, the best-corrected visual acuity (BCVA), and the surgical complications were analyzed.

RESULTS

The mean axial length was 28.5±2.2 mm in highly myopic eyes and 23.3±1.1 mm in controls (P < 0.001). Closure of the MH was achieved in 39 of 47 eyes (83%) in the study group and in 45 of 47 eyes (95.7%) in the control group (P = 0.045). Anatomic outcomes tended to decrease when axial length increased (P = 0.066). Mean BCVA improved in both groups (0.41±0.39 logarithm of the minimal angle of resolution [logMAR] vs. 0.68±0.34 logMAR) but was significantly lower in highly myopic eyes (P < 0.001). Retinal detachment occurred in 8.5% of highly myopic patients versus 2.1% of controls, but the difference was not significant.

CONCLUSIONS

Macular hole surgery with 3-day postoperative positioning in highly myopic eyes resulted in satisfactory anatomic and functional outcomes. However, the MH closure rate and mean improvement of visual acuity were less favorable than those in control eyes. Longer axial length may increase the risk of anatomic failure.

Macular hole after laser in situ keratomileusis in a 26-year-old patient

The purpose of this study is to describe the 26-year-old patient with developed macular hole after bilateral laser in situ keratomileusis (LASIK). A macular hole with sharp margins and irregular surface of surrounding retina appeared in the left eye of the female 26-year-old patient two months after LASIK for correction of myopia (followup of 6 months). Although the best corrected visual acuity (BCVA) after LASIK was 1.0, after the macular hole has developed BCVA became 0.5. After surgery, the final visual acuity recovered to 0.7. Macular hole may develop after LASIK for myopia correction due to unknown changes of vitreoretinal interface. Complete informed consent must be obtained from patients with high myopic eyes before LASIK.

Efficacy of inverted internal limiting membrane flap technique for the treatment of macular hole in high myopia

PURPOSE

To determine the effect of pars plana vitrectomy (PPV) with inverted internal limiting membrane (ILM) flap technique for macular hole with or without retinal detachment in highly myopic eyes.

DESIGN

Retrospective, interventional case series.

METHODS

Ten eyes of 10 patients with macular hole with (4 eyes) or without (6 eyes) retinal detachment in high myopia (axial length more than 26.5 mm) were treated by PPV with inverted ILM flap technique.

RESULTS

Macular hole closure was observed in 8 eyes (80%) following the initial surgery (in 5 eyes without retinal detachment and in 3 eyes with retinal detachment). In 4 eyes with retinal detachment caused by macular hole, retinas of 3 eyes were reattached by the initial surgery. Postoperative best-corrected visual acuity improved by more than 2 lines in 5 eyes (50%), was unchanged in 4 eyes (40%), and worsened by more than 2 lines in 1 eye (10%).

CONCLUSIONS

Inverted ILM flap technique might contribute to a high closure rate of macular hole and be a preferable adjuvant to the treatment of macular hole in high myopia with or without retinal detachment.

The effect of autologous serum on vitrectomy with internal limiting membrane peeling for idiopathic macular hole

PURPOSE

We sought to evaluate the effects of intraoperative adjunctive autologous serum in idiopathic full-thickness macular hole surgeries, and to compare the surgical outcomes with a no-serum control group.

METHODS

In this retrospective, case-control study, 38 consecutive eyes received vitrectomy with internal limiting membrane removal for idiopathic full-thickness macular holes. Two groups were created according to the use of autologous serum. Outcome measures were visual acuity (VA), closure of the macular hole confirmed by optical coherence tomography, and surgical complications.

RESULTS

Anatomical closure of the macular hole was achieved in 18 of 19 eyes (94.7%) in the vitrectomy with the autologous serum group, and in 18 of 19 eyes (94.7%) in the control group. The closure rates did not differ significantly between 2 groups (P=1.000; the Fisher's exact test). At the final follow-up, the mean logMAR VA improved significantly in both groups (SD, standard deviation) [from 1.08 (0.21) to 0.47 (0.21) in vitrectomy with the serum group and from 1.01 (0.32) to 0.44 (0.30) in the control group (both P<0.001; 2 tailed, paired t test)]. There was no significant difference between these 2 groups in terms of visual outcomes (P=0.738; 2-tailed t test). There were no surgical complications, such as retinal detachment and endophthalmitis.

CONCLUSIONS

The outcome of macular hole surgery did not differ both anatomically and functionally regardless of the use of adjuvant autologous serum. There seemed to be no additive effect with autologous serum.

Axial length and outcomes of macular hole surgery assessed by spectral-domain optical coherence tomography

PURPOSE

To use spectral-domain optical coherence tomography (SD OCT) to evaluate macular hole surgery outcomes and features predicting anatomic failure.

DESIGN

Retrospective, interventional case series.

METHODS

Fifty-two eyes of 50 consecutive patients with macular holes were examined. All eyes underwent 3-port pars plana vitrectomy with internal limiting membrane peeling. Eyes were examined after surgery by dense serial SD OCT scanning over the macula.

RESULTS

Eyes with initial anatomic failure were significantly more likely to have greater axial length and refractive error and more posterior staphyloma compared with eyes with initial anatomic success (P = .031 to .0060, < .0001). Overall initial and final anatomic success rates were 92.3% (48 of 52 eyes). In highly myopic eyes with axial lengths of 26.0 mm or more, initial and final success rates were 73.3% (11 of 15 eyes) compared with 100.0% (37 of 37 eyes) of eyes with axial lengths of less than 26.0 mm (P = .0050). In highly myopic eyes, initial and final success rates were 0% (0 of 3 eyes) of eyes with axial lengths of 30.0 mm or more compared with 91.7% (11 of 12 eyes) of eyes with axial lengths of 26.0 mm or more and of less than 30.0 mm (P < .0001). Retinoschisis-like thickening of the outer retina was seen in 3 (75.0%) of 4 eyes with initial failure compared with 3 (6.3%) of 48 eyes with initial success (P = .0030).

CONCLUSIONS

Axial length of 30.0 mm or more may increase the risk of anatomic failure of macular hole surgery.

Vitreoretinal surgery for macular hole after laser assisted in situ keratomileusis for the correction of myopia

AMS: To describe the characteristics and surgical outcomes of full thickness macular hole surgery after laser assisted in situ keratomileusis (LASIK) for the correction of myopia.

METHODS

13 patients (14 eyes) who developed a macular hole after bilateral LASIK for the correction of myopia participated in the study.

RESULTS

Macular hole formed 1-83 months after LASIK (mean 13 months). 11 out of 13 (84.6%) patients were female. Mean age was 45.5 years old (25-65). All eyes were myopic (range -0.50 to -19.75 dioptres (D); mean -8.4 D). Posterior vitreous detachment (PVD) was not present before and was documented after LASIK on 42.8% of eyes. Most macular hole were unilateral, stage 4 macular hole, had no yellow deposits on the retinal pigment epithelium, had no associated epiretinal membrane, were centric, and had subretinal fluid. The mean diameter of the hole was 385.3 microm (range 200--750 microm). A vitrectomy closed the macular hole on all eyes with an improvement on final best corrected visual acuity (VA) on 13 out of 14 (92.8%) patients.

CONCLUSIONS

This study shows that vitreoretinal surgery can be successful in restoring vision for most myopic eyes with a macular hole after LASIK.

Full-Thickness Macular Hole after LASIK for the Correction of Myopia

PURPOSE

To describe 19 patients (20 eyes) who developed a macular hole (MH) after undergoing bilateral LASIK for the correction of myopia.

DESIGN

Noncomparative, interventional, retrospective, multicenter case series.

PARTICIPANTS

Nineteen patients (20 eyes) who developed an MH after bilateral LASIK for the correction of myopia at 10 institutions in Venezuela, Colombia, Puerto Rico, Spain, and the United States.

METHODS

Chart review.

MAIN OUTCOME MEASURE

Macular hole development.

RESULTS

The MH formed between 1 to 83 months after LASIK (mean, 12.1). In 60% of cases, the MH developed < or =6 months after LASIK, and in 30% of cases it developed > or =1 year after LASIK. Eighteen of 19 (94.7%) patients were female. Mean age was 46 years (range, 25-65). All eyes were myopic (range, -0.50 to -19.75 diopters [mean, -8.9]). Posterior vitreous detachment was not present before and was documented after LASIK in 55% of eyes. A vitrectomy closed the MH on the 14 eyes that underwent surgical management, with an improvement of final best-corrected visual acuity in 13 of 14 (92.8%) patients. Our 20 eyes with a full-thickness MH after LASIK reflect an incidence of approximately 0.02% (20/83938).

CONCLUSION

An MH may infrequently develop after LASIK for the correction of myopia. Our study shows that vitreoretinal surgery can be successful in restoring vision for most myopic eyes with an MH after LASIK. Vitreoretinal interface changes may play a role in MH formation after LASIK for the correction of myopia.

Morphologic analysis of stage 3 and stage 4 macular holes: implications for treatment

PURPOSE

To determine whether the observed anatomy of macular holes can be explained by a hydrodynamic model in which fluid flow through the hole is balanced by fluid pumping across the retinal pigment epithelium. We use this model to draw conclusions about the possible role of vitreomacular traction in determining the anatomy of macular holes and their resolution after vitreous surgery.

DESIGN

Cross sectional.

METHODS

Retrospective study in a clinical practice. The study included 42 eyes of 42 patients with a stage 3 or 4 macular hole (Gass classification). We measured the radius of the macular hole and the radius of the surrounding cuff of subretinal fluid from color or red-free fundus photographs and determined the relationship between these two variables.

RESULTS

The mean age of the patients was 68.0 +/- 7 years (range, 51 to 80). Twenty-five patients had stage 3 macular holes and 17 patients had stage 4 macular holes. The neurosensory detachment radius was related to the square of the macular hole radius for stage 3 and stage 4 holes, with no significant difference between the stage 3 and stage 4 linear trend lines (P = .999). There was no correlation between patient age and the area of the macular hole (r = 0.0645) or neurosensory detachment plus hole (r = 0.156) over the range of age in this study. However, the area of the doughnut-shaped cuff of subretinal fluid increased with increasing patient age (P = .0493), thus suggesting an age-dependent decline in the pumping ability of the retinal pigment epithelium.

CONCLUSIONS

Our data are consistent with a hydrodynamic model in which macular hole anatomy is determined by a balance between fluid flow through the hole and fluid outflow across the retinal pigment epithelium. Because stage 3 and stage 4 macular holes exhibit a similar relationship between the size of the macular hole and the size of the cuff of subretinal fluid around the hole, simple relief of vitreomacular traction would not lead to resolution of the subretinal fluid cuff unless it is accompanied by a reduction in hole diameter due to approximation of wound edges.

Effect of Internal Limiting Membrane Removal in Treatment of Retinal Detachment Caused by Myopic Macular Hole

The purpose of this study was to evaluate the anatomical outcomes of vitrectomy with internal limiting membrane removal in highly myopic eyes with retinal detachment caused by a macular hole. Nineteen, consecutive, highly myopic eyes with full thickness macular hole with retinal detachment were treated by vitrectomy with internal limiting membrane removal, endolaser photocoagulation on the center of the hole and fluid gas exchange. In five eyes with other peripheral breaks, scleral buckling (3 cases), encircling (1 case) and barrier laser (1 case) were combined. In 15 eyes (79.0%) the macular hole was closed after the initial surgery. In 4 eyes (21%) the macular hole was reopened, but these were successfully treated with fluid gas exchange (1 case) or macular buckling (3 cases). The visual acuity was improved in 15 eyes (79.0%). In conclusion, these results suggest that the removal of the perifoveal internal limiting membrane may be an important adjuvant in the treatment of the myopic macular hole with retinal detachment.

Types of macular hole closure and their clinical implications

AIMS

To evaluate the clinical significance of macular hole closure types assessed by optical coherence tomography (OCT).

METHODS

This study involved 34 eyes of 32 patients who had undergone anatomically successful idiopathic macular hole surgery. The closed macular holes were categorised into two patterns based on OCT; type 1 closure (closed without foveal neurosensory retinal defect) and type 2 closure (closed with foveal neurosensory retinal defect). Association between visual prognosis, type of hole closure, and possible prognostic factors were analysed.

RESULTS

19 eyes (61.3%) were classified into the type 1 closure and 12 eyes (38.7%) into the type 2 closure. The extent of postoperative visual improvement of type 1 closure group was larger than that of type 2 closure group (p=0.002). The preoperative macular hole size of type 2 closure group was significantly larger than that of type 1 closure group (p=0.006). The duration of symptoms was positively correlated with the preoperative macular hole size (p=0.01). Recurrence of macular hole occurred only in the type 2 closure group.

CONCLUSION

The type of macular hole closure, which was influenced by the preoperative hole diameter, was associated with postoperative visual prognosis. Early detection and intervention in macular hole should be emphasised.

Internal limiting membrane removal in macular hole surgery for severely myopic eyes: a case-control study

AIMS

To determine the surgical outcome of indocyanine green (ICG) assisted retinal internal limiting membrane (ILM) peeling in macular hole surgery for severely myopic eyes and compare the visual and anatomical outcomes with an emmetropic control group.

METHODS

10 severely myopic eyes (-6.0 D or greater) of 10 patients with macular holes without retinal detachment were recruited prospectively. All eyes received ICG assisted ILM removal of 3-4 disc diameters around the macular holes. Cases were matched with a prospective control group of 10 emmetropic macular hole patients who underwent identical ICG assisted ILM peeling surgery in the same period.

RESULTS

The mean refractive error in the myopic and control group was -11.8 D and +0.3 D, respectively (two tailed t test, p < 0.001). The mean follow up duration for the myopic and control group was 12.1 and 13.3 months, respectively (two tailed t test, p = 0.63). The primary anatomical closure rate in both groups was 90% (Fisher's exact test, p = 1.0). For both the myopic and control groups, there were significant improvement in the mean log MAR visual acuity after the surgery with improvements from 0.86 to 0.57 for the myopic group (two tailed t test, p = 0.015) and 0.89 to 0.44 for the control group (two tailed t test, p = 0.002). The mean preoperative and postoperative visual acuity, rates of final visual acuity of 20/50 or better, and improvement of two or more lines were not statistically different between the two groups.

CONCLUSION

ICG assisted ILM peeling in macular hole surgery for severely myopic eyes without retinal detachment gives promising anatomical and visual outcomes, which are comparable to that of non-severely myopic eyes.