Patient-reported prevalence of metamorphopsia and predictors of vision-related quality of life in vitreomacular traction: a prospective, multi-centre study

Assessment of patient-reported outcomes in vitreomacular interface disorders: A systematic literature review

Patient-reported outcome measures (PROMs) assess the impact of disease on quality of life from the patient's perspective. Our purpose was to provide an overview of current PROMs used for vitreomacular interface disorders: macular hole, epiretinal membrane, and vitreomacular traction. We review the content coverage of all identified PROMs, assess them against quality-of-life issues as identified from earlier qualitative studies, and assess their psychometric quality (measurement properties). We identified 86 studies that used a PROM and 2 qualitative studies on quality of life of patients with a vitreomacular interface disorder. Current PROMs used in vitreomacular interface disorders have a limited content coverage and unknown psychometric quality. The National Eye Institute Visual Functioning Questionnaire was used most. None of the condition-specific PROMs used patient consultation during content development, and there is only a small overlap between the content of PROMs and quality-of-life issues in qualitative studies. Reporting of psychometric quality was sparse and mostly limited to concurrent validity and responsiveness. There is a need for properly developed and validated PROMs in vitreomacular interface disorders.

New Tablet-Based Written Examination System for Metamorphopsia Quantification

Background: We aimed to develop a tablet-based written examination system (Implementing digitization in assessment for metamorphopsia: IDAM) to quantify metamorphopsia severity and monitor changes after treatment in patients with epiretinal membrane (ERM) and central serous chorioretinopathy (CSC). Methods: This prospective study included 33 eyes from 31 patients with ERM or CSC. Patients used a tablet and stylus to illustrate perceived line distortions with IDAM. IDAM displayed a grid at a size of 20° × 20° (771 × 771 pixels), and patients depicted any distortions that they perceived in the presented lines. Metamorphopsia scores were calculated by summing the line deviation distances. Scores and distortion areas were compared before and three months after treatment. Results: Thirty eyes had baseline metamorphopsia on IDAM. The average pretreatment IDAM scores were 196,598 pixels (ERM) and 98,414 pixels (CSC). IDAM and M-charts scores were correlated (r = 0.38, p = 0.03). IDAM scores improved post-treatment in both groups (both p < 0.001). Distortion areas decreased from 6.6 to 4.2 (p = 0.0049). Conclusions: IDAM allowed quantitative metamorphopsia evaluation and detected treatment responses. This tablet-based system could facilitate at-home monitoring in macular disorders.

Macular Pigment Changes and Visual Recovery Following Successful Full-Thickness Macular Hole Closure Using the Inverted Flap Technique

Objectives: This study aimed to assess the role of macular pigment optical density (MPOD) in patients with a full-thickness macular hole (FTMH) compared to healthy controls, evaluating postoperative changes in MPOD and exploring potential correlations with visual outcomes. Methods: This prospective, cross-sectional, comparative study included 16 eyes from FTMH patients who achieved anatomical hole closure following pars plana vitrectomy with the inverted ILM flap technique. Each eye underwent a comprehensive ophthalmologic examination, including BCVA and intraocular pressure measurements, anterior segment evaluation, fundus examination, and macular assessment with Enhanced Depth Imaging Optical Coherence Tomography (EDI-OCT, Spectralis, Heidelberg Engineering Inc., Heidelberg, Germany). Macular pigment optical density (MPOD) was measured using one-wavelength reflectometry (Visucam 200, Zeiss Meditec, Jena, Germany). These evaluations were conducted preoperatively and at 1, 3, and 6 months postoperatively to assess changes over time and correlate MPOD with visual outcomes. Results: Significant baseline differences were observed between FTMH patients and controls for BCVA, mean MPOD, maximum MPOD, and MPOD volume (p < 0.05). Postoperative BCVA improved significantly (p = 0.0011), with a notable increase in MPOD volume at 6 months (p = 0.01). A positive correlation was found between BCVA improvement and MPOD volume increase (r = 0.739; p = 0.002). Conclusions: In conclusion, MPOD measurement may serve as a valuable addition to the follow-up of FTMH surgery, providing insights into photoreceptor function and macular metabolic activity, potentially correlating with visual recovery. Further longitudinal studies are needed to clarify its relationship with clinical variables, such as metamorphopsia and OCT microstructural findings.

THE IMAGE WARPING TEST: A Novel Method to Quantify and Qualify Metamorphopsia

PURPOSE

To determine the validity, accuracy, and acceptability of the image warping test (IWT), a novel test for the measurement of visual distortion in the central visual field.

METHODS

Twenty-five volunteers with metamorphopsia secondary to vitreoretinal pathologic condition were recruited at a tertiary referral center. All subjects underwent ophthalmologic examination and measurement of metamorphopsia using Amsler grid, Morphision, M-CHARTS, and the IWT. Construct validity was determined through assessment of the association between symptoms, pathologic condition, visual acuity, established metamorphopsia test results, and IWT results.

RESULTS

There was close association between subjective estimation of metamorphopsia severity and IWT score ( P = 0.005), between Morphision result and IWT score ( P = 0.015), and between the nature of vitreoretinal pathologic condition and IWT score ( P = 0.007). There was no statistically significant correlation between best-corrected distance visual acuity and IWT score, and between M-CHARTS score and IWT score.

CONCLUSION

The IWT allows the creation of a digital map of subjective metamorphopsia that effectively measures its severity and nature, and opens the possibility to its noninvasive correction in the future through inverse mapping of the distortion map onto live images.

VALIDATION OF M-CHARTS FOR QUANTITATIVE ASSESSMENT OF METAMORPHOPSIA FOLLOWING RHEGMATOGENOUS RETINAL DETACHMENT REPAIR

PURPOSE

To validate the quantitative assessment of metamorphopsia in rhegmatogenous retinal detachment (RRD) using M-CHARTS by determining its correlation with subjective reporting of metamorphopsia with a validated metamorphopsia questionnaire (modified MeMoQ).

METHODS

The Research Ethics Board approved a prospective observational study carried out at St. Michael's Hospital, Toronto, Canada. Patients with primary, unilateral RRD and healthy controls were included. Metamorphopsia at 3 months was assessed with modified MeMoQ and M-CHARTS.

RESULTS

One hundred patients (50 with RRD, 50 controls) were included. Seventy percent (35/50) of the RRD group had metamorphopsia with M-CHARTS and 80% (40/50) with MeMoQ. The modified MeMoQ and total M-CHARTS scores were significantly higher in patients with RRD compared with controls ( P < 0.0001). Cronbach's alpha reliability coefficient was 0.934 in the RRD group. Horizontal, vertical, and total M-CHARTS scores were significantly correlated with MeMoQ scores (r s  = 0.465, P = 0.0007; r s  = 0.405, P = 0.004; r s  = 0.475, P = 0.0005, respectively). M-CHARTS was 72.7% sensitive and 94.6% specific for detection of metamorphopsia (positive score ≥ 0.2), with an area under the receiver operating characteristic curve = 0.801. A stronger correlation was found in patients who scored ≥0.2 on the M-CHARTS and reported metamorphopsia with the MeMoQ (r s  = 0.454, P = 0.001).

CONCLUSION

The authors have validated M-CHARTS as a tool to quantitatively assess metamorphopsia in patients with RRD, which is significantly correlated with patient-reported outcomes using the MeMoQ. A total score of ≥0.2 with M-CHARTS was more strongly correlated with MeMoQ.

Quantifying the Relationship Between Unilateral Induced Metamorphopsia and Stereopsis Impairment

Purpose

To investigate the relationship between unilateral metamorphopsia, characterized by visual distortions in one eye, and impaired stereopsis.

Methods

Utilizing both near and distance measurements through advanced testing systems, including 4K smartphones and an active shutter three-dimensional system, we simulated varying degrees of unilateral metamorphopsia in 30 healthy young adults aged between 21 and 29 years. Two types of contour-based stereotest symbols, lines and squares, were developed. Distortions were classified into six distinct patterns, each further divided into eight grades of severity. Participants were tasked with identifying visual targets, and their stereothresholds were determined under different conditions of induced distortion. Stereopsis was measured within a range of 2.9 to 1.0 log arcsec, at 0.2 log arcsec intervals. Stereopsis changes under different distortion scenarios were analyzed using the generalized estimating equations, with a sequential Bonferroni adjustment applied for pairwise comparisons.

Results

A direct and quantifiable correlation was observed between the severity of metamorphopsia and reductions in stereopsis. As the degree of visual distortion increased, notably in both frequency and amplitude, there was a corresponding decline in stereopsis. This relationship held true in both near and distance measurements of stereopsis. Statistical analyses further reinforced these findings, highlighting a significant detrimental effect of distortion components on stereoacuity.

Conclusions

The findings highlight the clinical significance of understanding the interplay between unilateral metamorphopsia and stereopsis. Early interventions in conditions leading to metamorphopsia might be critical to maintaining optimal stereopsis.

Internal Limiting Membrane Peeling and Inverted Flap Technique in Macular Hole: Postoperative Metamorphopsia and Optical Coherence Tomography

INTRODUCTION

We compared postoperative metamorphopsia and optical coherence tomography (OCT) findings between eyes that underwent internal limiting membrane (ILM) peeling and the inverted flap (IF) technique for macular hole (MH).

METHODS

This retrospective analysis included 64 eyes of 64 patients with idiopathic MH whose MH was closed after initial surgery. Thirty-nine patients were treated with pars plana vitrectomy (PPV) with ILM peeling, and 25 patients were treated with PPV with the IF technique. Best corrected visual acuity (BCVA), severity of metamorphopsia, and OCT images were collected before and 3, 6, and 12 months postoperatively. Based on the OCT images, the status of the external limiting membrane (ELM) and ellipsoid zone and the presence of hyperreflective plugs were assessed.

RESULTS

At baseline and 3, 6, and 12 months postoperatively, BCVA and severity of metamorphopsia were not significantly different between groups. The status of the ELM was significantly worse in the IF group than in the ILM peeling group at 3 and 6 months postoperatively. Significantly more hyperreflective plugs were observed in the IF group than in the ILM peeling group at 3 and 6 months postoperatively. Stepwise multiregression analysis revealed that hyperreflective plugs were significantly associated with the severity of metamorphopsia at 12 months postoperatively.

DISCUSSION/CONCLUSION

The alterations on the OCT were fewer in the ILM peeling group than in the IF group, while no significant differences were observed in postoperative severity of metamorphopsia between groups. Metamorphopsia was worse in eyes with hyperreflective plugs.

Face-down positioning or posturing after macular hole surgery

BACKGROUND

Macular holes cause severe impairment of sight. With the aim of improving the outcome of surgery for macular holes, particularly larger macular holes (those measuring over 400 μm), a variable period of face-down positioning may be advised. This review is an update of a Cochrane Review published in 2011.

OBJECTIVES

To evaluate the effect of postoperative face-down positioning on the outcome of surgery for macular hole.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 5), which contains the Cochrane Eyes and Vision Trials Register, Ovid MEDLINE, Ovid Embase, the ISRCTN registry, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform. There were no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 25 May 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which postoperative face-down positioning was compared to no face-down positioning following surgery for macular holes. The primary outcome of interest was closure of the macular hole. Other outcomes of interest included visual outcomes, quality of life outcomes, and the occurrence of adverse events. Pairs of review authors independently selected studies for inclusion, extracted data, assessed risk of bias, and evaluated the certainty of evidence using GRADE.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We analysed dichotomous data as risk ratios (RRs), and continuous data as mean differences (MDs), with 95% confidence intervals (CI). The unit of analysis was eyes.

MAIN RESULTS

We included eight studies allocating a total of 709 eyes (699 participants). There was heterogeneity in study design, including the control group treatment (from no positioning to strict maintenance of other 'face-forward' postures) and surgical procedures (with or without inner limiting membrane peeling, with or without cataract surgery). There were also different durations of positioning, with two studies using 3 days, two studies using 5 days, and three studies using 10 days of face-down positioning. Whilst the overall risk of bias was low, all included studies were judged to be at high or unclear risk of bias due to absence of assessment of adherence to the 'prescribed' intervention of face-down positioning or posturing. The primary outcome of successful anatomical hole closure at one to six months following surgery was reported in 95 of every 100 eyes of participants advised to position face-down for at least three days after surgery, and in 85 of every 100 eyes of participants not advised to position face-down (RR 1.05, 95% CI 0.99 to 1.12, 709 eyes, 8 studies, I² = 44%). Amongst the 327 eyes of participants with macular holes of at least 400 μm, hole closure was noted in 94 of every 100 eyes of participants advised to position face-down, and in 84 of every 100 eyes of participants not advised to position face-down (RR 1.08, 95% CI 0.93 to 1.26, 5 studies, I² = 62%). Amongst the 129 eyes of participants with macular holes of less than 400 μm, hole closure was noted in 100 of every 100 eyes of participants advised to position face-down, and in 96 of every 100 eyes of participants not advised to position face-down (RR 1.03, CI 0.97 to 1.11, 4 studies, I² = 0%). The certainty of the evidence was low, downgraded for imprecision (CIs including no effect) and study design limitations (with different durations of face-down posturing used in the absence of a dose-response gradient, and limitations in measuring the exposure). Meta-analysis of visual acuity data was challenging given the use of different definitions of postoperative visual outcome across studies. Three studies reported findings by gain in Early Treatment Diabetic Retinopathy Study (ETDRS) letters (MD 2.04, 95% CI -0.01 to 4.09, very low-certainty evidence). Meta-analyses of quality of life data were not possible because of inconsistency in outcome metrics across studies. One study reported no difference between groups in quality of life, as reported on a validated quality of life metric scale (the National Eye Institute Visual Function Questionnaire - 25 (NEI VFQ-25), between face-down positioning for five days and non-face-down positioning (median NEI VFQ-25 score was 89 (interquartile range (IQR) 76 to 94) in the face-down group versus 87 (IQR 73 to 93) in the non-face-down group (adjusted mean difference on a logistic scale 0.02, 95% CI -0.03 to 0.07, P = 0.41)). Two studies reported increased ease of positioning and less pain in non-face-down positioning groups on non-validated 0-to-10-point visual analogue scores. On an ease-of-positioning score running from 0 (very difficult) to 10 (very easy), there were consistent reports of the discomfort associated with face-down positioning: the median participant-reported ease-of-positioning score was 6 (IQR 4 to 8) in those undergoing 5 days of face-down positioning versus 9 (IQR 7 to 10) in the comparator group (P = 0.01). On a pain score with 0 being pain-free and 10 being in severe pain, mean pain score was 6.52 ± 2.48 in the face-down positioning group versus 2.53 ± 2.6 in the non-face-down positioning group. The adverse event of postoperative nerve compression occurred in less than 1 in every 100 (3 per 1000) participants advised to position face-down, and 0 in every 100 participants not advised to position face-down (699 participants, 8 studies, moderate-certainty evidence).

AUTHORS' CONCLUSIONS

We identified eight RCTs evaluating face-down positioning following surgery for macular hole. The included studies were not all directly comparable due to differences in the surgical techniques used and the durations of postoperative positioning advised. Low-certainty evidence suggests that face-down positioning may have little or no effect on macular hole closure after surgery. Face-down positioning is a low-risk intervention, with serious adverse events affecting fewer than 1 in 300 people. We suggest that any future trials focus on patients with larger macular holes, with interventions and outcome measures used in previous trials (i.e. with inner limiting membrane peeling, positioning durations of three to five days, and validated quality of life metrics) to allow future meta-analyses to determine any effect with greater precision and confidence.

Contrast sensitivity and quality of life following intravitreal ranibizumab injection for central retinal vein occlusion

SYNOPSIS/PRECIS

We investigated the relationship between contrast sensitivity (CS) and vision-related quality of life (VR-QOL) in patients with central retinal vein occlusion following ranibizumab intravitreal injection; CS showed a stronger association with VR-QOL than visual acuity.

BACKGROUND/AIMS

To investigate the relationship between CS, VR-QOL and optical coherence tomography (OCT) findings in patients with cystoid macular oedema secondary to central retinal vein occlusion (CRVO-CMO) following intravitreal injection of ranibizumab.

METHODS

This was a multicentre, open-label, single-arm, prospective study. The study included 23 patients with CRVO-CMO who were followed up for 12 months after treatment. The best-corrected visual acuity (BCVA), letter contrast sensitivity (LCS) and OCT images were obtained every month. For VR-QOL assessment, the 25-item National Eye Institute Visual Function Questionnaire (VFQ-25) was administered to the patients before treatment and at 3, 6 and 12 months following treatment.

RESULTS

The LCS and VFQ-25 composite score improved significantly from baseline to 12 months following treatment. The multiple regression analysis revealed that the LCS of the affected eye and BCVA of the fellow eye were related to the VFQ-25 composite score following treatment. The LCS improvement showed a significant correlation with the improvement in the VFQ-25 composite score, whereas the BCVA improvement was not correlated with the improvement in the VFQ-25 composite score. Stepwise multiple regression analyses revealed that, at the time of macular oedema resolution, the distance between the external limiting membrane and retinal pigment epithelium (ELM-RPE) and average ganglion cell-inner plexiform layer (GCIPL) thickness were associated with LCS.

CONCLUSION

CS had a stronger association with VR-QOL than with BCVA in patients with CRVO-CMO. With the resolution of macular oedema, CS was associated with ELM-RPE thickness and average GCIPL thickness.

Patient-reported outcome measures in vitreoretinal surgery: a systematic review

This review article systematically reviews the use of Patient Reported Outcome Measures (PROMs) in Vitreoretinal surgery, with the aim of recommending a preferred PROM-tool for use in clinical practice. Vitreoretinal surgery lags behind other ophthalmic subspecialties in the adoption of PROMs as a core outcome measure of success post-operatively. Current outcomes rely heavily on post-operative Best Corrected Visual Acuity (BCVA) and anatomical success on imaging modalities such as Ocular Coherence Tomography (OCT), despite the link between each of these measures and patient satisfaction being uncertain. We systematically reviewed the available literature in March 2021, in accordance with PRISMA guidelines, searching six databases: MEDLINE, EMBASE, Web of Science, APA PsycINFO, SCOPUS and Cochrane Library. Critical appraisal of PROM-tools was facilitated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias checklist. We identified 14 eligible original research papers that used PROMs as a primary or secondary outcome of success post-operatively in patients having undergone vitreoretinal surgery. Eight different generic and vision-related PROM-tools were identified as being used in vitreoretinal studies, none of which were vitreoretinal-disease-specific. Our review article considers whether generic-health PROMs (e.g., EQ5D) or vision-related PROMs (e.g. NEI VFQ-25) are precise or responsive enough following vitreoretinal surgery to have a meaningful impact on clinical or research practice. We also consider the importance of standardisation of clinical outcomes in vitreoretinal clinical trials.

Calculating the individual probability of successful ocriplasmin treatment in eyes with vitreomacular traction–Validation and refinement of a multivariable prediction model

Purpose

To evaluate a multivariable model predicting the individual probability of successful intravitreal ocriplasmin (IVO) treatment in eyes with vitreomacular traction (VMT).

Methods

Data from three prospective, multicenter IVO studies (OASIS, ORBIT, and INJECT) were pooled. Patients were included if they were treated for a symptomatic VMT without a full-thickness macular hole. A prediction model for VMT resolution using the factors ‘age’ and ‘horizontal VMT diameter’ was validated by receiver operating characteristic analysis and according to grouped prediction after calibration. Multivariable regression analysis was performed to check robustness and explore further improvements.

Results

Data from 591 eyes was included. In the univariate analysis all key factors (age, gender, VMT diameter, lens status, ERM) significantly correlated to treatment success. The prediction model was robust and clinically applicable to estimate the success rate of IVO treatment (AUC of ROC: 0.70). A refinement of the model was achieved through a calibration process.

Conclusion

The developed multivariable model using ‘horizontal VMT diameter’ and ‘age’ is a valid tool for prediction of VMT resolution upon IVO treatment.

Predictors of vision-related quality of life in patients with macular oedema receiving intra-vitreal anti-VEGF treatment

PURPOSE

To determine which demographic and clinical characteristics are predictive of vision-related quality of life (VrQoL) and quality of life (QoL) in patients with macular oedema receiving intravitreal anti-vascular endothelial growth factor (VEGF) treatment.

METHODS

Vision-related quality of life (VrQoL) and quality of life (QoL) were measured in 712 patients with retinal exudative disease receiving anti-VEGF treatment at baseline, 6 and 12 months. VrQoL was measured using an item-response theory based 47-question item bank (EyeQ), whereas QoL was measured using the EuroQol Five Dimensions (EQ-5D) questionnaire. The EQ-5D score was dichotomized into a perfect score of 1 and a suboptimal score of <1. Demographic and clinical patient characteristics were considered as possible predictors of (Vr)QoL. Prediction models for (Vr)QoL were created with linear mixed models and generalised estimating equations, using a forward selection procedure.

RESULTS

A worse VrQoL was predicted by poorer LogMAR visual acuity of the better eye, female sex, single civil status, older age, longer length of anti-VEGF treatment at baseline and the presence of non-ocular and ocular comorbidities. Suboptimal EQ-5D scores were predicted by poorer LogMAR visual acuity of the better eye, female sex, single civil status, older age, the presence of non-ocular comorbidities and a lower educational background.

CONCLUSIONS

Along with visual acuity of the better eye, which is the main factor used in clinical decision making, other patient characteristics should also be considered for the risk assessment of (Vr)QoL, such as sex, age, civil status, comorbidities and length of anti-VEGF treatment.

Surgical interventions for lamellar macular holes

BACKGROUND

Lamellar macular holes (LMHs) are small, partial-thickness defects of the macula defined by characteristic features on optical coherence tomography (OCT), including a newly recognised type of epiretinal membrane termed 'epiretinal proliferation'. There may be a rationale to recommend surgery for individuals with LMHs, particularly those with functional or anatomical deterioration, or poor baseline vision causing significant disability, to stabilise the LMH and prevent further visual deterioration; however, there is currently no evidence-based consensus.

OBJECTIVES

To assess the effect of surgical interventions on post-operative visual and anatomical outcomes in people with a confirmed LMH.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid, Embase Ovid, Scopus SciVerse, ISRCTN registry, US National Institutes of Health Ongoing Trials Register, ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). We also searched reference lists of included trials to identify other eligible trials which our search strategy may have missed. The date of the search was 20 July 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) involving participants with a confirmed LMH diagnosis which reported one or more surgical intervention(s), alone or in combination, in at least one arm of the RCT.

DATA COLLECTION AND ANALYSIS

We used standard methods as expected by Cochrane. Two study authors independently extracted data and assessed the risk of bias for included trials. Trial authors were contacted for further information and clarification.

MAIN RESULTS

A single RCT was eligible for inclusion. Thirty-six participants were randomised in a 2:1 ratio; 24 were allocated to undergo surgery (pars plana vitrectomy, peeling of the epiretial proliferation followed by fovea-sparing removal of the internal limiting membrane) and 12 (10 following two participant dropouts) to observation. Overall, the certainty of the evidence was low for all outcomes due to selection and detection bias, and the low number of participants enrolled in the study which may affect the accuracy of results and reliability of conclusions. At six-month follow-up, change in vision was better in the surgery group (-0.27 logMAR improvement) than observation (0.02 worsening) (mean difference (MD): -0.29 logMAR, 95% confidence intervals (CI): -0.33 to -0.25). Central retinal thickness increased in the surgery group over 6 months 126 μm increase) compared with observation group (decrease by 11μm) (MD: 137 μm, 95% CI: 125.87 μm to 148.13 μm). Finally, at six-month follow-up, retinal sensitivity was better in the surgery group (3.03 dB increase) compared with the observation group (0.06 dB decrease) (MD: 3.09 dB, 95% CI: 2.07 to 4.11 dB). Vision-related quality of life and metamorphopsia were not reported. No adverse outcomes or complications were reported in the study, however, authors could not provide information on whether any individuals developed deterioration in vision of 0.2 logMAR or worse.

AUTHORS' CONCLUSIONS

The included single trial demonstrated improvements in visual and anatomical outcome measures for participants with a LMH who underwent surgery compared with observation only. Therefore, we can conclude that participants who undergo surgery may achieve superior post-operative best corrected visual acuity and anatomical outcomes compared with observation only. However, the results of a single and small RCT provides limited evidence to support or refute surgery as an effective management option for LMHs. Future RCTs with a larger number of participants and with fewer methodological limitations and biases are necessary to inform future clinical practice.

Vitreomacular Traction Surgery from the DISCOVER Study: Intraoperative OCT Utility, Ellipsoid Zone Dynamics, and Outcomes

BACKGROUND AND OBJECTIVES

To characterize the clinical and ellipsoid zone (EZ) integrity outcomes in surgical intervention for symptomatic vitreomacular traction (VMT), and to evaluate the utility of intraoperative optical coherence tomography (OCT) during VMT surgery.

PATIENTS AND METHODS

This was a post-hoc analysis of eyes in the DISCOVER study undergoing pars plana vitrectomy (PPV) with intraoperative OCT for VMT-related macular disease. Data were collected prospectively on feasibility and utility of intraoperative OCT, with follow-up lasting 12 months.

RESULTS

Forty-three eyes of 41 patients were included and mean visual acuity improved from 20/96 to 20/45 (P < .001). Intraoperative OCT provided information that impacted surgical decision-making in eight patients (18.6%). EZ integrity metrics significantly improved from baseline to 12 months and directly correlated with functional outcomes (P < .001).

CONCLUSIONS

Retinal function and morphology improved significantly following PPV for VMT. Intraoperative OCT provided surgeon-perceived valuable information in select cases. Further research is needed to determine whether this information impacts overall surgical outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:544-550.].

Clinical Update on Metamorphopsia: Epidemiology, Diagnosis and Imaging

Purpose: To discuss the pathophysiology of metamorphopsia, its characterisation using retinal imaging and methods of assessment of patient symptoms and visual function.Methods: A literature search of electronic databases was performedResults: Metamorphopsia has commonly been associated with vitreomacular interface disorders (such as epiretinal membrane) and has also regularly been noted in diseases of the retina and choroid, particularly age-related macular degeneration and central serous chorioretinopathy. Developments in optical coherence tomography retinal imaging have enabled improved imaging of the foveal microstructure and have led to the localisation of the pathophysiology of metamorphopsia within the retinal layers of the macula. Alteration of alignment of inner and outer retinal layers at various retinal loci has been identified using multimodal imaging in patients with metamorphopsia in a range of conditions. Although the Amsler Grid assessment of metamorphopsia is a useful clinical indicator, new emerging methods of metamorphopsia assessment with psychophysical tests such as M-CHARTS and preferential hyperacuity perimetry, have been developed.Conclusions: It appears that there is a complex relationship between visual acuity and metamorphopsia symptoms that vary between retinal conditions. Although metamorphopsia has traditionally been challenging to measure in the clinic, advances in technology promise more robust, easy-to-use tests. It is possible that home assessment of metamorphopsia, particularly in conditions such as age-related macular degeneration, may help to guide the need for further clinic evaluation and consideration of treatment.

Patient-reported outcomes of ocriplasmin for the treatment of vitreomacular traction: a systematic review and synthesis of the literature

Purpose

Vitreomacular traction (VMT) is a disease in which the vitreous exerts abnormally strong traction on the macula, the area of the eye responsible for detailed central vision. If this traction significantly distorts the macula then VMT can lead to troublesome distorted vision (metamorphopsia), sometimes occurring despite relatively preserved visual acuity. Ocriplasmin, administered as a single intravitreal injection, aims to release VMT and improve vision. While the effect of ocriplasmin on traction release and visual acuity is well characterized, the effect of symptoms like metamorphopsia is not.

Methods

A systematic review and synthesis of the literature on patient reported outcomes (PRO) in relation to the use of ocriplasmin for the treatment of VMT was undertaken using MED-LINE and Embase databases, and the Cochrane central register of controlled trials (CENTRAL).

Results

The review identified PRO data from 870 patients across three randomized controlled trials. The most commonly reported PROs were the 25-item National Eye Institute Visual Function Questionnaire (VFQ-25), a broad measure of vision-related quality of life, and Visual Function Response (VFR), an outcome combining quality of life and visual acuity outcomes. Treatment with ocriplasmin produced significant patient benefit vs control (sham or placebo-injection). Ocriplasmin was associated with a higher proportion of patients experiencing a clinically meaningful improvement in visual functioning with a difference of 11.8% for VFQ-25 and 23.2% for VFR responder analyses, respectively.

Conclusion

Patients with VMT have material impairment in visual functioning and quality of life, relative to their reduction in visual acuity. Ocriplasmin results in a significant improvement in visual functioning. Future research could include the development of new PROs specific to VMT.