Factors affecting anatomical and visual outcome after macular hole surgery: findings from a large prospective UK cohort

Human amniotic membrane graft with viscodissection and intraoperative OCT for macular hole repair

Objective

To present the human amniotic membrane (hAM) graft with the novel addition of viscodissection and usage of intraoperative OCT as a potential approach to treating challenging macular holes and to describe the outcomes.

Design

Retrospective interventional case series.

Participants

10 patients with large, chronic, or persistent macular holes were included in this study.

Methods

10 eyes of 10 patients were treated using a hAM graft with viscodissection. Intraoperative OCT was utilized to assist the placement of the graft. Outcomes were monitored through clinical examinations, retinal imaging, and OCT.

Results

Macular holes were closed in all 10 patients and remained so during the entirety of the follow-up periods. 9 out of 10 patients experienced an improvement in visual acuity. Mean best corrected visual acuity increased from 1.68 logMAR (20/1000) preoperative to 0.74 logMAR (20/100) at 6 months postoperative. No adverse events were observed for any of our patients.

Conclusions

The addition of viscodissection to the standard hAM graft surgery is a potential optimization that reduces risks of iatrogenic damage to the retina. Surgeons can consider including this approach as part of their arsenal to treat such macular holes.

Internal limiting membrane peel size and macular hole surgery outcome: a systematic review and individual participant data study of randomized controlled trials

BACKGROUND

There is no consensus regarding the optimal internal limiting membrane (ILM) peel size during vitrectomy for idiopathic full thickness macular holes (iFTMH).

METHODS

A systematic review was performed to identify randomized controlled trials (RCTs) comparing vitrectomy with ILM peeling of differing sizes in adults with iFTMH. Individual participant data was obtained including relevant baseline variables. The effect of different ILM peel sizes, divided into "small" (1-disc diameter [DD] in radius or less) and "large" (>1-DD in radius) were analysed on primary hole closure and postoperative visual acuity (VA) at 6 months. A subgroup analysis analysing for the effect of macular hole size on the same outcomes was also performed. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was used to assess the certainty of evidence.

RESULTS

Five RCTs with 370 eyes were included. Primary closure was achieved in 74.7% in small peel group compared to 84.8% in large peel group (p = 0.016). Multilevel logistic regression showed that a peel radius of >1-DD probably improved hole closure slightly with odds ratio (OR) of 1.20 (95% CI: 1.11-1.31, p < 0.001) and a number needed to treat (NNT) to benefit of 31 (95% CI: 21-53). ILM peel size likely did not affect VA. The mean difference in postoperative VA was a -0.05 logMAR gain (2-3 ETDRS letters) (95% CI: -0.13 to 0.02, p = 0.155) in vision with a large ILM peel radius. The GRADE certainty of evidence was moderate for both outcomes. A significantly higher closure rate was found in the large peel group for iFTMH >400 microns with an OR of 1.24 (95% CI: 1.11-1.38, p < 0.001) and NNT to benefit of 21 (95% CI: 17-50), but not in holes <400 microns (OR 1.05 (95% CI: 0.93-1.18, p = 0.396)).

CONCLUSIONS

Performing ILM peel of more than 1-DD in radius likely improves closure rates for iFTMH although the effect size is relatively small. The effect is greater in holes >400 microns. ILM peel size probably has no significant effect on postoperative VA.

Anatomical and functional changes after internal limiting membrane peeling

Internal limiting membrane (ILM) peeling has been an acceptable step in vitrectomy surgeries for various retinal diseases such as macular hole, chronic macular edema following epiretinal membrane (ERM), and vitreoretinal traction. Despite all the benefits, this procedure has some side effects, which may lead to structural damage and functional vision loss. Light and dye toxicity may induce reversible and irreversible retina damage, which will be observed in postoperative optical coherence tomography scans. Retinal nerve fiber layer damage is attributed to ganglion cell degeneration and axonal transport alteration and dissociated optic nerve fiber layer is due to Müller cell damage. Eccentric MHs and recurrence of previous MHs may also lead to vision loss. Iatrogenic retinal damage may cause structural retinal changes without significant vision loss or progression to choroidal neovascularization. The mechanism of persistent macular edema after membrane peeling is still unclear, but it has been related to tractional trauma and blood-retina barrier damage. The reappearance of ERM is another cause of decreased vision after ILM peeling, which might be secondary to incomplete membrane removal. In glaucoma patients, ILM peeling is associated with significantly worsening the mean deviation on the visual field test after the surgery. We discussed various causes of vision loss and structural changes following ILM peeling. These causes may be attributed to the surgical procedure itself or the associated steps, instruments, and dyes used during the ILM peeling procedure.

Retinal atrophy and eccentric macular hole after internal limiting membrane peeling: a case report

BACKGROUND

Postoperative eccentric macular hole (MH) formation is a relatively rare complication after pars plana vitrectomy (PPV) with internal limiting membrane(ILM) peeling for epiretinal membrane (ERM) or MH treatment. Herein, we report a case of eccentric MH formation following PPV with ILM peeling for MH.

CASE PRESENTATION

A 62-year-old male presented with a 3-month history of blurred vision and metamorphopsia in the left eye. Preoperative optical coherence tomography (OCT) confirmed a full-thickness MH (minimum linear diameter: 675 μm). The patient underwent 25-gauge PPV with ILM peeling using indocyanine green (ICG, 0.25%) and inverted ILM flap placement. Postoperative OCT at one week confirmed MH closure. However, subsequent follow-ups revealed progressive inner retinal disorganization, atrophy, and cavitation. At five months, a parafoveal full-thickness eccentric macular hole (EMH) developed inferiorly. No additional interventions were pursued due to stable hole size and absence of retinal detachment.

CONCLUSIONS

This case highlights rare postoperative retinal atrophy and EMH formation following ILM peeling for MH repair. Potential contributors include ICG-induced photochemical toxicity, Müller cell damage from ILM peeling, and fluid shear stress. The findings underscore the need to optimize ICG protocols (reduced concentration, shorter exposure) and prioritize safer alternatives like brilliant blue G (BBG). Long-term postoperative monitoring is critical to detect delayed complications, emphasizing the balance between surgical efficacy and minimizing iatrogenic retinal injury.

Macular hole surgery in times of the COVID-19 pandemic

To assess whether there were any differences in patient presentation, morphological and functional features as well as surgical treatment for full-thickness macular holes (FTMH) during the lockdown periods amidst the COVID-19 pandemic compared to the previous year. A retrospective analysis was conducted on all patients with FTMH who received treatment at a large tertiary center during the lockdown periods from March 16 to June 16, 2020, and December 9, 2020, to June 6, 2021 (35 eyes, mean age 66 years). Corresponding periods from the previous year were chosen as a control group (41 eyes, mean age 71 years). The patients' demographics, preoperative and postoperative best-corrected visual acuity (BCVA), symptom duration, time from presentation to surgical treatment, and surgical technique were determined. The minimal and base diameters of the FTMH were assessed using spectral-domain optical coherence tomography. During the lockdown periods in the COVID-19 pandemic, there were no significant differences in the number of patients, duration of symptoms, time from presentation to surgical treatment, surgical technique, macular hole size, base diameter, closure rate or pre- and postoperative BCVA between the two groups. However, there was a significant increase in the number of patients who presented directly at the clinic on an emergency basis without prior contact with a community-based ophthalmologist. This study suggests that the diagnosis and the provision of timely surgical treatment of FTMH were not affected by the COVID-19 pandemic. However, patients more frequently sought immediate emergency care at the hospital. This could be attributed to challenges in scheduling and obtaining appointments at outpatient clinics during the COVID-19 pandemic.

Predicting Visual Recovery in Long-Standing Macular Holes: Surgical Strategies and Role of Optical Coherence Tomography Biomarkers

BACKGROUND Macular hole (MH) duration is a prognostic indicator of posttreatment visual outcomes. The aim was to evaluate chronic (≥12 months) MH treatment using extended internal limiting membrane (ILM) peeling. MATERIAL AND METHODS Medical records of patients with chronic MH treated with pars plana vitrectomy, ILM peeling (up to vascular arcades), and 20% SF6 tamponade were reviewed. Spearman correlation coefficient (r) examined relationships between MH duration and best-corrected visual acuity (BCVA). RESULTS Fifty patients were included (72.0% women; mean age, 73 years); mean (SD) MH duration was 19.1 (8.8) months. Most (76.0%) patients had a preoperative MH diameter >400 µm (mean [SD], 569.2 [164.6] µm). The MH was closed within 1 week in 46 (92.0%) patients. A significant improvement from baseline in BCVA was observed by month 1 after treatment (mean [SD] logMAR, 0.96 [0.38] vs 0.66 [0.25]; P<0.001). A moderate positive correlation was observed between MH duration and posttreatment BCVA (logMAR; r=0.40; P<0.01). Improvements in mean logMAR values through month 24 were similar when patients were stratified by MH diameter (≤400 vs >400 µm; P>0.05; all time points). Significant differences between patients with baseline MH diameter of ≤650 µm vs >650 µm were observed for BCVA (logMAR; P≤0.03; all time points). CONCLUSIONS Twenty-four month follow-up revealed a steady increase in visual acuity, with no symptom worsening. Vitrectomy, extended ILM peeling, and gas tamponade is effective for chronic MH closure, including for holes of up to 650 µm in diameter. A MH diameter >650 µm was associated with poorer BCVA results after treatment.

En face OCT: Breakthroughs in understanding the pathoanatomy of retinal disease and clinical applications

En face optical coherence tomography (OCT) is a practical and informative imaging modality to noninvasively visualize distinct retinal and choroidal layers by providing coronal images using boundary-specific segmentation. Ongoing research with this method is generating breakthroughs in the illustration of new perspectives of retinal disease. The clinical value of en face OCT as an advanced retinal imaging tool is growing steadily and it has unveiled many new insights into the pathoanatomy of retinal disorders. Moreover, this modality can capture various en face OCT biomarkers that correspond to different cell or tissue subtypes, which were previously only identified through histological or electron microscopy methods, underscoring the significance of this technique in providing valuable pathoanatomical information. In this comprehensive review, we will systematically summarize the en face OCT findings across a broad spectrum of retinal diseases, including disorders of the vitreoretinal interface and retinal vascular system (e.g. paracentral acute middle maculopathy or PAMM and diabetic retinopathy), in addition to the en face OCT features of other conditions such as age-related macular degeneration, pachychoroid disease spectrum, myopic degeneration, uveitis and inflammatory disorders, inherited retinal dystrophies, and drug toxicity. We will discuss and highlight the unique clinical and pathoanatomical findings uncovered with en face OCT of each these diseases mentioned above.

Prediction of Postoperative Macular Hole Status by Automated Preoperative Retinal OCT Analysis: A Narrative Review

Optical coherence tomography (OCT) is a non-invasive imaging modality essential for macular hole (MH) management. Artificial intelligence (AI) algorithms could be applied to OCT to garner insights for MH prognosis and outcomes. The objective was to review literature assessing automated image analysis algorithms in predicting postoperative outcomes for MH patients based on OCT images. A narrative search of all available published studies in peer-reviewed journals was conducted up to June 2023 following PRISMA guidelines. Three hundred sixty-eight publications underwent screening, with 14 selected for full-text review and seven determined as relevant. In MH status prediction, AI models achieved an area under the curve (AUC) of 83.6% to 98.4%. For postoperative visual acuity prediction, algorithm performance ranged from AUCs of 57% to 85%. In conclusion, novel AI algorithms were found to be predictive for postoperative MH status and postoperative visual acuity. More research in larger populations should be conducted to gauge the value of these novel algorithms in a real-world setting. [Ophthalmic Surg Lasers Imaging Retina 2025;56:XX-XX.].

DELAYED CLOSURE OF A FULL-THICKNESS MACULAR HOLE AFTER PARS PLANA VITRECTOMY WITH INTERNAL LIMITING MEMBRANE FLAP

BACKGROUND/PURPOSE

The aim of this study is to describe a patient with delayed closure of a stage 3 full-thickness macular hole after pars plana vitrectomy.

METHODS

This is a retrospective case report. Details of the case were obtained from the electronic patient record system, Medisoft.

RESULTS

A 65-year-old man was referred with a left stage 3 full-thickness macular hole measuring 720 μ m and visual acuity of 6/36. He underwent phacovitrectomy, internal limiting membrane peel with an inverted internal limiting membrane flap, and C 3 F 8 gas tamponade. Seven weeks after surgery, the macular hole was smaller at 196 μ m but remained open. The patient was listed for repeat surgery; however, another 13 weeks later, the full-thickness macular hole demonstrated type 2 closure without further intervention.

CONCLUSION

Delayed macular hole closure after pars plana vitrectomy is rare. In cases where there has been a substantial decrease in the size of a full-thickness macular hole after surgery without full closure, a short period of observation to allow for further closure may be appropriate before reconsidering surgery.

Preoperative Optical Coherence Tomography Markers and Their Significance in the Treatment of Macular Holes Using the Inverted Internal Limiting Membrane Technique

Purpose The purpose of this study was to evaluate the short-term outcomes of pars plana vitrectomy (PPV) using the inverted flap technique for full-thickness macular hole (FTMH). Specifically, the study aimed to identify significant preoperative optical coherence tomography (OCT) parameters that can serve as predictors for postoperative distance and near best-corrected visual acuity (DBCVA and NBCVA). Methods A prospective analysis was conducted on patients diagnosed with FTMH who underwent PPV from September 2022 to November 2024 using the inverted flap technique. OCT imaging was conducted preoperatively and one month postoperatively. Parameters analyzed included base diameter (BD), height of the macular hole (HT), right arm length (RAL) of macular hole (MH), left arm length (LAL) of MH, macular hole index (MHI), diameter hole index (DHI), tractional hole index (THI), hole form factor (HFF) and central retinal subfield (CRS). Statistical analysis was conducted to calculate significant predictors for DBCVA and NBCVA short-term postoperative results after PPV, with statistical significance set at p<0.05. Results A total of 46 patients, 35 (76.1%) women and 11 (23.9%) men, aged 67.6±5.7 were included in the study. Means and standard deviation for analyzed parameters were BD=937.5±355 𝜇m, HD=424.6±188 𝜇m, HT=413.6±56.5 𝜇m, RAL=359.6±125.5 𝜇m, LAL=367.5±214 𝜇m, MHI=0.477±0.12, DHI=0.46±0.15, THI=1.2±0.71, HFF=0.79±0.17 and CRS=297.4±21.8 𝜇m. Twenty-four patients presented with large FTMH (≥400 µm), and twenty-two with small FTMH (<400 µm). All patients achieved full closure of the FTMH. The most common comorbidity was hypertension, with 13 patients (28.3%). The only statistically significant predictor of DBCVA change after surgery was MHI (p=0.01). Conclusions PPV surgery using the inverted flap technique has very high efficiency. MHI can be used in the prediction of postoperative DBCVA. Further research is needed to assess the role of THI and HFF as other predictors.

INFLUENCE OF FOVEAL GLIAL TISSUE AFTER MACULAR HOLE SURGERY ON OUTER RETINAL RESTORATION AND VISUAL ACUITY

PURPOSE

To investigate the impact of foveal glial tissue on the anatomical and functional results after macular hole (MH) surgery.

METHODS

This study included 141 consecutive eyes that underwent successful vitrectomy for full-thickness MH between January 2015 and December 2022. The best-corrected visual acuity and the length of outer retinal defects were evaluated preoperatively and at 6 months postoperatively. Macular hole with retinal detachment, recurrent MH, and traumatic MH were excluded. Multiple regression analyses were conducted on outer retinal restoration and visual acuity using foveal glial tissue size, surgical technique of internal limiting membrane peeling or inverted internal limiting membrane flap, and high myopia as explanatory variables.

RESULTS

Analyses revealed that the foveal glial tissue significantly limited the outer nuclear layer, external limiting membrane restoration, and ellipsoid zone restoration as well as best-corrected visual acuity improvement (r = -0.380, P < 0.001; r = -0.314, P = 0.035; r = -0.530, P = 0.015; r = -0.00027, P = 0.001; respectively). Meanwhile, the surgical technique and high myopia did not significantly affect the restoration of outer nuclear layer, external limiting membrane, ellipsoid zone, and best-corrected visual acuity after surgery.

CONCLUSION

Foveal glial tissue after MH surgery attenuated outer nuclear layer, external limiting membrane, and ellipsoid zone restoration as well as best-corrected visual acuity improvement.

Facedown Positioning in Macular Hole Surgery: A Systematic Review and Individual Participant Data Meta-Analysis

TOPIC

To assess the anatomic and visual effects of facedown positioning (FDP) advice in patients undergoing vitrectomy with gas tamponade for idiopathic full-thickness macular holes (FTMHs) and to explore differential treatment effects by macular hole size and FDP duration.

CLINICAL RELEVANCE

The necessity and duration of FDP for FTMH closure remain contentious, with no consensus guidelines.

METHODS

Prospectively registered systematic review and individual patient data (IPD) meta-analysis of randomized controlled trials comparing FDP with no FDP (nFDP) across the MEDLINE, Embase, and Cochrane Library databases and clinical trial registries from January 2000 to March 2023 (CRD42023395152). All adults with idiopathic FTMHs undergoing vitrectomy with gas tamponade were included. The main outcomes were primary macular hole closure and postoperative visual acuity at 6 months or nearest time point.

RESULTS

Of 8 eligible trials, 5 contributed IPD for 379 eyes and were included in our analysis. The adjusted odds ratio (OR) for primary closure with FDP versus nFDP was 2.41 (95% confidence interval [CI], 0.98-5.93, P = 0.06; low-certainty evidence), translating to a risk ratio (RR) of 1.08 (1.00-1.11) and a number needed to treat (NNT) of 15. The FDP group exhibited a mean improvement in postoperative visual acuity of -0.08 logarithm of the minimum angle of resolution (logMAR) (-0.13 to -0.02, P = 0.006; low-certainty evidence) compared with the nFDP group. Benefits were more certain in participants with larger holes of minimum linear diameter ≥ 400 μm: adjusted OR for closure ranged from 1.13 to 10.12 (P = 0.030) (NNT 12), with a mean visual acuity improvement of -0.18 to -0.01 logMAR (P = 0.022). Each additional day of FDP was associated with improved odds of anatomic success (adjusted OR, 1.02-1.41, RR, 1.00-1.02, P = 0.026) and visual acuity improvement (-0.02 logMAR, -0.03 to -0.01, P = 0.002), possibly plateauing at 3 days.

CONCLUSIONS

This study provides low-certainty evidence that FDP improves the anatomic and visual outcomes of macular hole surgery modestly and indicates that the effect may be more substantial for macular holes exceeding 400 μm. The findings support recommending FDP for patients with macular holes exceeding 400 μm pending further investigation.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Supervised machine learning statistical models for visual outcome prediction in macular hole surgery: a single-surgeon, standardized surgery study

PURPOSE

To evaluate the predictive accuracy of various machine learning (ML) statistical models in forecasting postoperative visual acuity (VA) outcomes following macular hole (MH) surgery using preoperative optical coherence tomography (OCT) parameters.

METHODS

This retrospective study included 158 eyes (151 patients) with full-thickness MHs treated between 2017 and 2023 by the same surgeon and using the same intraoperative surgical technique. Data from electronic medical records and OCT scans were extracted, with OCT-derived qualitative and quantitative MH characteristics recorded. Six supervised ML models-ANCOVA, Random Forest (RF) regression, K-Nearest Neighbor, Support Vector Machine, Extreme Gradient Boosting, and Lasso regression-were trained using an 80:20 training-to-testing split. Model performance was evaluated on an independent testing dataset using the XLSTAT software. In total, the ML statistical models were trained and tested on 14,652 OCT data points from 1332 OCT images.

RESULTS

Overall, 91% achieved MH closure post-surgery, with a median VA gain of -0.3 logMAR units. The RF regression model outperformed other ML models, achieving the lowest mean square error (MSE = 0.038) on internal validation. The most significant predictors of VA were postoperative MH closure status (variable importance = 43.078) and MH area index (21.328). The model accurately predicted the post-operative VA within 0.1, 0.2 and 0.3 logMAR units in 61%, 78%, and 87% of OCT images, respectively.

CONCLUSION

The RF regression model demonstrated superior predictive accuracy for forecasting postoperative VA, suggesting ML-driven approaches may improve surgical planning and patient counselling by providing reliable insights into expected visual outcomes based on pre-operative OCT features.

CLINICAL TRIAL REGISTRATION NUMBER

Not applicable.

Uncertainty-aware regression model to predict post-operative visual acuity in patients with macular holes

Full-thickness macular holes are a relatively common and visually disabling condition with a prevalence of approximately 0.5% in the over-40-year-old age group. If left untreated, the hole typically enlarges, reducing visual acuity (VA) below the definition of blindness in the eye affected. They are now routinely treated with surgery, which can close the hole and improve vision in most cases. The extent of improvement, however, is variable and dependent on the size of the hole and other features which can be discerned in spectral-domain optical coherence tomography imaging, which is now routinely available in eye clinics globally. Artificial intelligence (AI) models have been developed to enable surgical decision-making and have achieved relatively high predictive performance. However, their black-box behavior is opaque to users and uncertainty associated with their predictions is not typically stated, leading to a lack of trust among clinicians and patients. In this paper, we describe an uncertainty-aware regression model (U-ARM) for predicting VA for people undergoing macular hole surgery using preoperative spectral-domain optical coherence tomography images, achieving an MAE of 6.07, RMSE of 9.11 and R2 of 0.47 in internal tests, and an MAE of 6.49, RMSE of 9.49, and R2 of 0.42 in external tests. In addition to predicting VA following surgery, U-ARM displays its associated uncertainty, a p-value of <0.005 in internal and external tests, showing the predictions are not due to random chance. We then qualitatively evaluated the performance of U-ARM. Lastly, we demonstrate out-of-sample data performance, generalizing well to data outside the training distribution, low-quality images, and unseen instances not encountered during training. The results show that U-ARM outperforms commonly used methods in terms of prediction and reliability. U-ARM is thus a promising approach for clinical settings and can improve the reliability of AI models in predicting VA.

Surgeon's perceptions and preferences in the management of idiopathic macular hole

PURPOSE

The management of idiopathic macular holes (iMH) has evolved over time with various modifications in surgical approach. The study aimed to survey the surgeons' preferences in the management of iMH in current times.

DESIGN

Cross-sectional descriptive survey.

METHODS

A 12-item questionnaire addressing the key aspects of iMH management was sent, between October 2022 to November 2022, by personal correspondence to 104 vitreoretinal specialists, actively practicing and performing iMH surgeries at various institutes in India. The responses were gathered till January 2023 and analyzed as per appropriate statistical methods.

RESULTS

Ninety-one retina specialists responded to the survey (response rate of 87.5%) with a median annual surgical load of 30 cases (range: 5-150). Most respondents had similar views on patient selection, combined phaco-vitrectomy, internal limiting membrane (ILM) staining, ILM peel initiation and propagation, tamponade, postoperative positioning, and prognostic factors. The preferred approach for peel initiation was "pinch and peel," but "scrape and peel" was equally recommended for beginners. Most respondents considered iMH >600 microns in size as large and used additional surgical maneuvers for large and failed cases such as ILM flap, large flap, macular detachment, platelet-rich plasma application, and amniotic membrane graft. The three most important visual prognostic factors were duration, preoperative vision, and MH size.

CONCLUSIONS

The practice of surveyed surgeons performing iMH surgery was uniform in several aspects. There is a need to create consensus on the preferred ILM peel technique among trainee surgeons, revisit the iMH size classification, and standardize the surgical approach as per hole size and characteristics.

Macular holes with minimal diameter greater than 650 µm close in 85% of cases after vitrectomy and ILM peeling with visual benefit

PURPOSE

To describe the postoperative outcomes of eyes with primary full-thickness macular holes (MH) greater than 650 μm.

DESIGN

Retrospective, monocentric, consecutive case series.

PARTICIPANTS

Patients with primary MH operated at Lariboisière Hospital, Paris, France.

METHODS

Records of patients with MH with a minimum horizontal diameter greater than 650 μm that underwent primary surgery with internal limiting membrane (ILM) peeling (complete or with inverted ILM flap) between January 2010 and January 2022 were reviewed.

MAIN OUTCOME MEASURES

Postoperative MH closure rate and visual acuity.

RESULTS

74 eyes of 73 patients met the inclusion criteria. The mean minimum horizontal diameter was 777 ± 108 µm (650-1114). It ranged between 650 and 800 µm in 40 eyes (54%) and was ≧ 800 µm in 34 eyes (46%). The closure rate was 77% (57/74) after primary surgery and was significantly higher in MH between 650 and 800 µm, than in MH ≧ 800 µm (87.5% versus 64.7%, p = 0.02). In the 58/74 eyes in which conventional ILM peeling was performed, closure rate was 74.1% (43/58), significantly higher in MH ranging between 650 and 800 µm than in MH ≧ 800 µm (84.8% versus 60.0%, p = 0.03). In closed MH, 50/64 (78%) eyes achieved a VA gain ≥0.2 logMAR (3 lines), and 14 (21.9%) eyes a final BCVA ≥ 0.3 logMAR.

CONCLUSION

MH surgery with conventional ILM peeling allowed closed MH ≧ 650 μm and < 800 μm with a success rate close to 85% that decreased in larger MH. A significant visual improvement was achieved after MH closure, even in MH ≧ 800 μm.

[Current treatment strategies for vitreomacular traction and macular holes: a survey of retinal specialists in Germany]

BACKGROUND

To evaluate the different treatment strategies for eyes with vitreomacular traction (VMT) and macular holes (MF) regarding the indications and initiation of treatment.

OBJECTIVE

The aim of this study is to facilitate clinical decision making by presenting the opinions of experienced retinal specialists in the context of the current literature and the changed approval situation for ocriplasmin.

MATERIAL AND METHODS

Members of the German Retina Society (RG) were questioned in an online survey. Based on a literature review a 100-question questionnaire was created and sent to all members of the RG via an electronic link to the online platform "LimeSurvey". Voluntary participation was possible from 15 October 2021 to 15 November 2021. Data collection and statistical analysis were anonymized.

RESULTS

The responses of the 115 participants were congruent with the presentation of the new S1 guidelines on this topic. The indications for active treatment of focal VMT without MF were postponed in favor of watchful waiting, with the individual symptoms of the patient playing a major role in the proposed temporal management. The results on the indications for vitrectomy are consistent and convincingly confirm the opinions on the efficacy and risk assessment of this therapeutic procedure.

CONCLUSION

The results presented provide an overview of the consensus and controversies in the current treatment options for VMT and MF. With the help of a homogeneous and experienced group of retinal experts, it was possible to develop individual treatment strategies.

SPARING VERSUS REMOVAL OF EPIRETINAL PROLIFERATION IN THE SURGICAL REPAIR OF FULL-THICKNESS MACULAR HOLES

PURPOSE

To evaluate the efficacy of vitrectomy with epiretinal proliferation (EP) sparing for full-thickness macular hole accompanied by EP.

METHODS

A multicenter, retrospective study. Eyes were divided into two groups: the sparing group (Group S) included eyes in which the EP around the hole was peeled and preserved, whereas the removal group (Group R) included eyes in which the EP was partially or completely removed. The internal limiting membrane was peeling in all eyes.

RESULTS

Forty-six eyes were included. Twenty-five eyes were in Group S, and 21 eyes were in Group R, with no difference in preoperative best-corrected visual acuity (BCVA) ( P = 0.96). After primary surgery, macular holes were closed in all eyes, and there were no complications in either group. Postoperative 12-month BCVA significantly improved in both groups (both P < 0.01), while Group S had better 12-month BCVA than Group R ( P = 0.016). In the multivariable analysis, EP sparing was associated with better BCVA at 12 months ( P = 0.006) after accounting for the minimal macular hole size and preoperative BCVA.

CONCLUSION

Epiretinal proliferation sparing and removal were both safe and effective techniques, while EP sparing may provide a favorable outcome for eyes with full-thickness macular hole and EP.

OPTICAL COHERENCE TOMOGRAPHY FEATURES ASSOCIATED WITH VITREOMACULAR TRACTION RELEASE AND MACULAR HOLE SIZE PROGRESSION FOLLOWING TREATMENT WITH OCRIPLASMIN

PURPOSE

To evaluate OCT features for vitreomacular traction (VMT) release and change in macular hole (MH) size after treatment with ocriplasmin.

METHODS

Patients who had undergone treatment with ocriplasmin for VMT with or without MH ≤400 µm were included. The main outcomes were VMT release and changes in minimum linear diameter MH size at 4 weeks in MHs that persisted. OCT features evaluated were central retinal thickness, vitreomacular adhesion length, posterior vitreous cortex (PVC) insertion angles 500 µm from the insertion points, and minimum linear diameter size.

RESULTS

Sixty patients were included: 37 had isolated VMT and 23 VMT with a MH. Four weeks after ocriplasmin injection, the overall VMT release rate was 66.7% (40/60); 64.9% (24/37) in eyes with isolated VMT and 69.6% (16/23) in eyes with MH. VMT release was associated with younger age (P = 0.02). Macular hole closure was achieved in 26.1% (6/23) and was associated with a smaller ratio of the temporal to the nasal PVC angle (P < 0.01). Of the 17 persistent MHs, 76.5% (13/17) increased in minimum linear diameter size from baseline 186 (±78) to 358 (±133) µm (P < 0.001). Progression in minimum linear diameter size showed a negative linear association with the size of the nasal PVC angle (R2 = 0.39, P = 0.002) and a positive linear association with the ratio of the temporal to nasal PVC angle (R2 = 0.39, P = 0.002).

CONCLUSION

In patients with VMT-associated MHs, the risk of MH enlargement following ocriplasmin is negatively correlated with the nasal PVC angle size and is increased if the ratio of the temporal to nasal angle is >1.

COMPLEX MACULAR HOLE CLOSURE BY TEMPORAL INTERNAL LIMITING MEMBRANE FLAP WITHOUT ENDOTAMPONADE

PURPOSE

To evaluate the safety, efficacy, and imaging features of a novel surgical technique without endotamponade in repairing complex macular hole (MH).

METHODS

Retrospective review of consecutive cases with complex MH underwent pars plana vitrectomy with temporal internal limiting membrane flap, which was stabilized using perfluorocarbon liquid and viscoelastics. At the conclusion of surgery, perfluorocarbon liquid was removed, and no endotamponade agent would be used. Complex MH was defined as a basal linear diameter of ≥400 µm and/or associated with high myopia. Visual acuity, pattern of MH closure on optical coherence tomography, formation of epiretinal membrane, and operative complications were reported.

RESULTS

Twenty-four eyes were included, and the mean basal linear diameter was 988.3 µm. MH closure was achieved in 24 (100%), of which, 8 (33%) achieved type 1A closure. The mean postoperative logarithm of the minimum angle of resolution visual acuity improved from 0.93 at baseline to 0.74, 0.51, 0.55, and 0.52 at 1-month, 3-month, 6-month, and last follow-up, respectively. Foveal gliosis was observed in 3 eyes (12.5%), and 10 (41.7%) developed nasal epiretinal membrane. One eye developed vitreous hemorrhage, which resolved spontaneously.

CONCLUSION

This novel surgical technique that requires no endotamponade is effective in achieving complex MH closure. A substantial proportion of patients developed epiretinal membrane, and its clinical significance requires further investigation.

Combined Epiretinal Proliferation and Internal Limiting Membrane Inverted Flap for the Treatment of Large Macular Holes

We are presenting a new method for the treatment of large macular holes (MHs) with the use of an inverted flap consisting of both internal limiting membrane (ILM) and epiretinal proliferation (EP). A prospective interventional case series was conducted from September 2021 to January 2023. MH patients with coexistent EP visualized preoperatively in macula optical coherence tomography and with a MHs minimum linear diameter larger than 400 microns underwent standard pars plana vitrectomy with the creation of an inverted petaloid flap (consisting of both ILM and EP) and gas tamponade. Sixteen eyes were included in our case series. MHs closure was successful in all the eyes with a single procedure. The preoperative minimum linear diameter was 707.63 (±164.02 μm), and the preoperative best corrected visual acuity was 1.11 ± 0.52. The postoperative BCVA was 0.51 ± 0.20 (p = 0.01) at 6 weeks postoperatively, and the final BCVA was 0.45 ± 0.20 (p = 0.008). EP can be safely combined with ILM for the creation of an inverted, petaloid flap to cover and facilitate the closure of large MHs.

Prediction of long-term visual outcome of idiopathic full-thickness macular hole surgery using optical coherence tomography parameters that estimate potential preoperative photoreceptor damage

PURPOSE

To identify optical coherence tomography (OCT) parameters that predict postoperative best corrected visual acuity (BCVA) and are based on recent understanding of the pathomechanism of idiopathic full thickness macular hole (iFTMH) formation and closure.

METHODS

A retrospective consecutive case series of patients who had macular hole (MH) surgery at our institution between 2016 and 2022 was performed. 32 eyes of 30 patients were selected with at least 12 months of follow-up, closed MH and good quality OCT at each visit. Univariate correlation analysis, multiple logistic regression with forward stepwise selection, and Akaike's Information Criterion (AIC) were used to identify the best predictors for postoperative BCVA at 6 and 12 months (M), and final (≥ 12 M) visits, and a new OCT index was created. Abilities of best models/indices to predict < 0.30 logMAR (> 20/40) BCVA were compared to macular hole index (MHI) using the area under the receiver operating curve (AU-ROC) analysis.

RESULTS

Statistical analysis revealed base diameter (B) (6 M), preoperative BCVA and B (12 M) and smaller ELM-GCL distance (A), and B (final visit) as predictors for postoperative BCVA. AU-ROC analysis indicated greatest AUC at 6 M for MHI and B (0.797, p = 0.004 and 0.836 p = 0.001, respectively) and for the new A/B index at 12 M and final visit (0.844, p = 0.002 and 0.913, p = 0.003, respectively).

CONCLUSION

Our study suggests that MHI and B can be useful predictors of short term BCVA while the new A/B index that incorporates OCT parameters indicating potential preoperative photoreceptor damage may be a good predictor for long term postoperative BCVA. Our findings support the theory that initial hole formation mechanisms and photoreceptor damage define visual prognosis.

Meta-regression of idiopathic full-thickness macular holes diameter and anatomical closure rate: Implications to intraoperative technique

Purpose

Primary surgery failure of macular holes causes poor visual acuity outcomes. Several studies indicate that small-medium idiopathic full-thickness macular holes (iFTMH) have consistent and high anatomical closure rates after vitrectomy and internal limiting membrane (ILM) peeling, regardless of iFTMH diameters. However, there is no systematic analysis examining the relationship between iFTMH diameters and anatomical closure rates.

Methods

In this systematic review and meta-regression, we searched PubMed, Embase, and Web of Science databases on October 24th, 2022. We included studies regarding iFTMH, with ILM peeling/inverted flap technique, long-lasting gas tamponade, and face-down position after surgery. Univariable meta-regression with a restricted cubic spline model and component-plus-residual plot after covariables adjustment were used to explore non-linear association.

Results

A total of 7257 participants from 19 randomized controlled trials and 49 observational studies were included in this meta-analysis. In ILM peeling group, every 100-μm increment in diameter was associated with a 3.8 % (95 % confidence interval [CI], 1.8%-5.7 %, P < 0.001) relatively lower anatomical closure rate. Yet, among studies using the inverted flap technique, baseline iFTMH diameter was not associated with a lower anatomical closure rate (0.2 %, 95%CI, -4.2 %-4.5 %, P > 0.9). The restricted cubic spline model and component-plus-residual plot controlling for age, sex, and symptom duration prior to surgery showed no evident non-linearity in both surgical techniques.

Conclusions

The iFTMH diameter is linear and inversely associated with the anatomical closure rate after the ILM peeling technique, but not with the inverted flap technique. The present study supports the use of advanced techniques, e.g., inverted flap technique, in small-medium iFTMH to improve anatomical closure rates.

PEDICLE TRANSPOSITION FLAP, INVERTED FLAP, FREE FLAP, AND STANDARD PEEL FOR LARGE FULL-THICKNESS MACULAR HOLES: A Comparative Study

PURPOSE

To compare anatomical and functional outcomes of four different techniques for the treatment of large idiopathic full-thickness macular holes.

METHODS

This single-center retrospective study included 129 eyes of 126 patients with large (>500 µ m) full-thickness macular holes who presented between January 2018 and October 2022. All patients underwent 23/25 G vitrectomy and gas with standard internal limiting membrane (ILM) peel, pedicle transposition, inverted, or free flap technique. Postoperative optical coherence tomography images were assessed by two independent masked graders.

RESULTS

Mean age was 73.2 years (SD 8.4) with a median F/U of 5 months (IQR 8). The overall anatomical success rate was 81%; it was significantly lower (59%) for the standard ILM peel ( P < 0.0001). The pedicle transposition flap showed superior visual recovery compared with the free flap (+27 vs. +12 ETDRS letters, P = 0.02). At 3 months, restoration of the external limiting membrane was significantly better for the pedicle transposition flap compared with free flap and standard ILM peel ( P = 0.008 and P = 0.03) and superior to all the other techniques at 6 months ( P = 0.02, P = 0.04, and P = 0.006).

CONCLUSION

Standard ILM peel alone offers inferior outcomes for the management of large full-thickness macular holes. Of the alternative ILM techniques, despite similar closure rates, foveal microstructural recovery is most complete following the pedicle transposition flap and least complete following the free flap.

The time course of spontaneous closure of idiopathic full-thickness macular holes

PURPOSE

Spontaneous closure of idiopathic full-thickness macular holes (iFTMH) has been reported regularly. However, little is known about its probability and timeline.

METHODS

In this retrospective study all consecutive patients who presented between August 2008 and August 2019 were screened for the presence of a macular hole and only iFTMHs were included. The primary outcome measure was the spontaneous closure of the iFTMH.

RESULTS

Of 1256 eyes with macular holes, 338 fulfilled the inclusion criteria. Spontaneous closure of the iFTMH was detected in 31 eyes (9.2%) with a median time of 44 days after diagnosis. Eyes exhibiting spontaneous closure demonstrated a higher baseline best-corrected visual-acuity (BCVA) and smaller iFTMH diameter (p < 0.0001 and p < 0.0001, respectively). The mean BCVA improved from 0.4 logMAR (SD ± 0.21) to 0.29 logMAR (SD ± 0.20) after spontaneous closure (p = 0.031). The iFTMH diameter was positively correlated with the time to spontaneous closure (Pearson-r = 0.37, p = 0.0377). Spontaneously closed iFTMHs reopened in 16% (n = 5) of cases, with a median of 136 days after closure. A logistic regression model showed the hole diameter was associated with spontaneous closure (odds-Ratio 0.97, 95%CI [0.96, 0.98]). The Kaplan-Meier-Curve revealed that approximately 25% of small-iFTMH (n = 124) and 55% of iFTMH with a diameter < 150µm (n = 48) closed spontaneously within two months.

CONCLUSION

The established gold-standard for the treatment of iFTMHs is macular surgery. However, the potential for spontaneous closure of small iFTMHs must be acknowledged. Therefore, if surgical treatment is delayed in individual cases, close observation is recommended.

[Predictive parameters for anatomical surgical success in full-thickness macular holes : A retrospective evaluation of 391 eyes]

BACKGROUND

Full-thickness macular hole (FTMH) is a rare disease. Not all FTMHs can be closed by primary surgical intervention.

OBJECTIVE

This work aims to characterize a large patient population with FTMHs and to detect possible predictive factors for anatomical treatment success.

MATERIALS AND METHODS

The study comprises a retrospective analysis of all consecutive idiopathic macular holes between March 2008 and June 2019 at the University Eye Hospital Cologne. Epidemiologic data, preoperative parameters (size of the FTMH), and surgical technique were examined in relation to the closure rate following primary surgery.

RESULTS

The anatomical closure rate for idiopathic FTMH after primary surgery was 83.6%. No association between age, gender, and lens status and closure rate could be shown. Regarding anatomical surgical success, the favorable prognostic factors identified were a small FTMH size, short symptom duration, performance of transconjunctival 23-gauge vitrectomy, and application of the inverted flap technique of the internal limiting membrane (ILM).

CONCLUSION

Surgical treatment represents a valuable treatment option for patients with macular holes due to good prospects of success. Prompt intervention after diagnosis using 23-gauge vitrectomy and an ILM flap with gas tamponade seems to result in the most favorable outcomes.

Etiologies and clinical characteristics of macular hole: An 8-year, single-center, retrospective study

To investigate the etiologies and clinical characteristics of full-thickness macular hole (FTMH) cases at Shanxi Eye Hospital in North China. Patients diagnosed with FTMH who underwent surgery from 2012 to 2020 were included, and the etiologies and clinical features of MH types were analyzed in an 8-year, cross-sectional, retrospective study. A total of 752 cases (776 eyes) were analyzed. The top 3 subtypes of MH were idiopathic (IMH, 64.4%), myopic (MMH, 21.1%) and traumatic (TMH, 3.7%) MH. Among these, there were significant differences in sex, age, and baseline best-corrected visual acuity (BCVA) distributions. Females predominated in the IMH and MMH groups, while males predominated in the TMH group. The IMH onset age was older than the MMH and TMH onset ages. Baseline BCVA in the IMH (Z = 8.9, P < .001) and the other group (Z = 4.0, P < .001) was significantly better than that in the MMH group. In the IMH group, females were younger, had a shorter axial length (AL), and had a worse baseline BCVA than males, while in the MMH group, there were no significant sex differences. Multivariate correlation analysis showed that a smaller hole diameter in IMH, no retinal detachment in MMH, and a younger age in TMH may result in better baseline BCVA. The most common MH etiologies were IMH, MMH and TMH, which contributed to differences in clinical features. Females predominated in the IMH and MMH groups, and the onset of MMH occurred 6.5 years earlier than the onset of IMH. Therefore, early fundus monitoring in females and high myopia patients is helpful for the early detection and treatment of MH.

Wound Healing in a Porcine Model of Retinal Holes

Purpose

To investigate retinal wound healing, we created a new porcine model of retinal hole and identified the cells involved in hole closure.

Methods

Sixteen landrace pigs underwent vitrectomy, and a subretinal bleb was created before cutting a retinal hole using a 23G vitrector. No tamponade was used. Before surgery and one, two, and four weeks after surgery, the eyes were examined by optical coherence tomography and color fundus photos. At the end of follow-up, the eyes were enucleated for histology. Tissue sections of 5 µm were prepared for hematoxylin-eosin staining and immunohistochemical analysis with antibodies to retinal glial and epithelial cells.

Results

Retinal holes below 1380 µm in diameter closed spontaneously within four weeks, whereas larger holes remained open. Hole closure was mediated by central movement of the edges of the hole and in most cases the formation of a gliotic plug. Fluorescence microscopy revealed that the plug consisted of cells positive for glial fibrillary acidic protein, indicating the presence of macroglial cell types. Specifically, the plug was positive for S100 calcium-binding protein B, mainly representing astrocytes, while it was negative for anti-glutamine syntethase, representing Müller glia. These findings suggest that astrocytes are the predominating cell type in the plug. Minimal glial reaction was seen in the retinal holes that did not close.

Conclusions

We present a new porcine model for investigating large retinal holes. The retinal holes closed by approximation of hole edges, and the remnant retinal defect was closed with an astroglial plug.

Platelet concentrates in macular hole surgery. A journey through the labyrinth of terminology, preparation, and application: a comprehensive review

The surgical management of macular holes is undergoing continuous evolution, with recent focus on the utilization of platelet concentrates as a promising adjunctive intervention. Currently, they present a valid surgical approach for achieving anatomical and functional success with a non-inferiority comparably to the alternative surgical techniques. Nonetheless, the utilization of varied platelet concentrates terminologies, coupled with the lack of standardization in their preparation methodologies, engenders both lexical confusion and challenges in comparing scientific studies published up until now. In this review, we summarized the published evidence concerning the application of platelet concentrates in macular holes surgery, aiming to clarify the terminology and methodologies employed and to establish a common consensus facilitating further development and diffusion of this promising technique.

Choroidal hypertransmission width on optical coherence tomography: a prognostic biomarker in idiopathic macular hole surgery

PURPOSE

To test the hypothesis that optical coherence tomography (OCT) choroidal hypertransmission width (CHW) is a prognostic biomarker in idiopathic macular hole (MH) surgery METHODS: Retrospective cohort study of consecutive patients undergoing successful pars plana vitrectomy for idiopathic MH. We collected demographic, clinical, and OCT variables at the preoperative and last available visits. Two investigators assessed the following OCT parameters: MH minimum diameter, base diameter, CHW, ellipsoid zone, and external limiting membrane status (absent vs. present). Delta CHW was calculated as the difference between CHW and MH minimum diameter. Linear models were used to investigate factors associated with postoperative best-corrected visual acuity (BCVA) and BCVA change.

RESULTS

Thirty-six eyes (36 patients) with a median (interquartile range (IQR)) follow-up of 9 (8-11) months were included. The median BCVA (IQR) improved from 0.75 (1-0.6) logMAR preoperatively to 0.2 (0.6-0.1) logMAR at the last visit (p < 0.001). Preoperative MH minimum diameter (for a 10-μm increase, estimate (standard error (SE)): 0.009 (0.003) logMAR, p = 0.003), base diameter (for a 10-μm increase, 0.003 (0.001) logMAR, p = 0.032), CHW (for a 10-μm increase, 0.008 (0.002) logMAR, p < 0.001), and delta CHW (for a 10-μm increase, 0.013 (0.005) logMAR, p = 0.009) were significantly associated with postoperative BCVA. The proportion of variance explained was the highest for MH CHW (R2 0.35), followed by minimum MH diameter (R2 0.24), delta CHW (R2 0.19), and MH base diameter (R2 0.14). None of the study variables was associated with delta BCVA.

CONCLUSION

Preoperative CHW is associated with postoperative visual acuity in patients undergoing successful idiopathic MH surgery and may be a useful OCT prognostic biomarker.

Comparison of the use of internal limiting membrane flaps versus conventional ILM peeling on post-operative anatomical and visual outcomes in large macular holes

BACKGROUND

Idiopathic full-thickness macular hole (iFTMH) closure rates following conventional vitrectomy, gas tamponade and internal limiting membrane (ILM) peeling decrease when the minimum linear diameter (MLD) ≥ 500 microns. ILM flap creation has been proposed to improve closure in larger holes. This study evaluated the anatomical and functional impact of ILM flap introduction to routine practice in iFTMH ≥500 microns.

METHODS

Retrospective, interventional analysis of prospectively collected data of 191 eyes from consecutive surgeries for primary iFTMH ≥500 microns performed by two surgeons between June 2018 and June 2022, during which both surgeons replaced ILM peeling with ILM flap creation. Post-operative best-corrected visual acuity (BCVA) and anatomical closure were compared between Group 1 (ILM peel) and Group 2 (ILM flap) in an intention-to-treat analysis.

RESULTS

Rates of iFTMH closure were greater in the ILM flap group (77/80; 96.3%) than the ILM peel group (94/110; 85.5%) (OR = 4.37, 95% CI = 1.23-15.55, p = 0.023). A non-significant increase in post-operative BCVA improvement was observed in the ILM flap group (p = 0.084). There was no statistically significant difference in final BCVA (p = 0.83). Multivariate logistic regression found only MLD (OR = 0.993, 95% CI = 0.989-0.997, p = 0.001) and ILM flap group (OR = 5.795, 95% CI = 1.313-25.570, p = 0.020) predicted primary closure.

CONCLUSION

ILM flap creation improves closure rates in larger holes and should be considered routinely in iFTMH ≥500 microns. Whether ILM flaps affect post-operative visual function remains uncertain.

Surgery for idiopathic full-thickness macular holes within four months of symptom onset yields superior visual outcomes: Results from an Irish patient cohort

PURPOSE

To describe the anatomical, visual, and safety results of full-thickness macular hole (FTMH) repair surgery and determine factors influencing outcomes.

PATIENTS AND METHODS

A retrospective chart review was performed on all patients who underwent primary FTMH repair surgery by a single surgeon over a 3-year period. For comparisons, Snellen visual acuity (VA) was converted to logMAR equivalent. Anatomical hole closure, visual improvement, and final VA of ≤ 0.30 logMAR were the primary outcome measures.

RESULTS

Twenty eyes of 19 patients were included. Mean patient age was 69 years (range 55 to 80 years) and 74% were female. Mean minimum linear diameter (MLD) was 440 μm (range 170 μm to 1200 μm). Mean duration of symptoms before surgery was 16 weeks (range 3 to 39 weeks). 100% of eyes achieved successful anatomical FTMH closure. Mean VA improved from 1.03 ± 0.43 logMAR (Snellen 6/60) preoperatively to 0.35 ± 0.22 logMAR (Snellen 6/15) postoperatively (p = 0.0001). Patients with worse preoperative VA gained more vision than those with better preoperative VA (p = 0.01). Eyes operated on within 4 months of symptom onset were more than twice as likely to achieve a postoperative VA of ≤ 0.30 logMAR (Snellen 6/12 or better) compared to eyes with a longer duration of symptoms (p = 0.03).

CONCLUSION

FTMH repair surgery was safe and effective, with outcomes comparing favourably with published international studies. All patients benefited from surgery regardless of symptom duration, presenting VA or FTMH size. However, surgery performed within 4 months of symptom-onset was particularly beneficial, highlighting the need for prompt referral and surgery.

[Macular hole: Differential diagnosis, treatment options and new guideline recommendations]

Full-thickness macular holes (FTMH) usually result in a pronounced reduction of visual acuity and represent one of the most frequent indications for retinal surgery. If diagnosed and treatment is initiated at an early stage, surgery has a high success rate with respect to both hole closure and improvement of visual acuity. Optical coherence tomography (OCT)-based staging and sizing enables an estimation of the surgical outcome. The differential diagnostic distinction from clinically similar disorders, such as lamellar macular holes, macular pseudoholes, and foveoschisis is clinically relevant as the pathogenesis, prognosis and treatment are significantly different. While vitrectomy with peeling of the inner limiting membrane (ILM) and gas tamponade is established as the standard treatment for FTMH, some aspects of treatment are handled differently between surgeons, such as the timing of surgery, the choice of endotamponade and the type and duration of postoperative positioning. For FTMH associated with vitreomacular traction, alternative treatment options in addition to vitrectomy include intravitreal ocriplasmin injection and pneumatic vitreolysis. The current clinical guidelines of the German ophthalmological societies summarize the evidence-based recommendations for diagnosis and treatment of FTMH.

A COMPARATIVE STUDY OF MEDIUM-SIZED MACULAR HOLE SURGERY WITH INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE VERSUS CONVENTIONAL PEELING

PURPOSE

To investigate surgical results for medium-sized (251-400 µ m) macular holes (MHs).

METHODS

This retrospective observational study involved 266 eyes of 262 consecutive patients who underwent internal limiting membrane (ILM) peeling (147 eyes in the ILM peeling group) or inverted ILM flap cover technique (119 eyes in the inverted flap group) for primary medium-sized full-thickness MHs. Macular hole associated with retinal detachment, recurrent MH, and traumatic MH were excluded.

RESULTS

The primary closure rate for overall medium-sized MHs was 100% (119 of 119 eyes) in the inverted flap group, which was significantly higher than that (94.6% [139/147 eyes]; P = 0.010) in the ILM peeling group. Notably, even after adjusting for the minimum MH diameter, presence of high myopia, or preexisting posterior vitreous detachment, the primary closure rate was significantly better in the inverted flap group than in the ILM peeling group (Cochran-Mantel-Haenszel test, overall adjusted P = 0.006, 0.009, 0.005, respectively). The preoperative and postoperative restoration of the outer retinal layers and visual acuity were comparable between the inverted ILM flap and ILM peeling techniques.

CONCLUSION

Primary closure for medium-sized MHs was significantly superior in the inverted flap group than in the ILM peeling group.

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

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

Influence of the dilution method on the intraocular duration of C3F8 in vitrectomy for macular hole: a randomized clinical trial

PURPOSE

To compare the injection of small amounts of undiluted C3F8 with the traditional gas injection in vitrectomy for macular hole treatment.

METHODS

This clinical trial included 26 individuals divided into two groups. Group 1 received an intravitreal injection of 0.9-1.0 mL of 100% C3F8, and Group 2 received 15-20 mL of 20% C3F8.

RESULTS

The median intraocular gas duration was 31 days in Group 1 and 34 in Group 2. The median letter gains in corrected distance visual acuity for the 26th postoperative week were 20 letters in Group 1 and 12.5 in Group 2. The median intraocular pressure was normal in both groups. Primary anatomical success was 11/13 in both groups.

CONCLUSIONS

The use of C3F8 gas in a small undiluted volume is an alternative that slightly reduces the duration of the gas without negatively affecting the anatomical and visual response.

Outcomes of 25-Gauge Pars Plana Vitrectomy in the Treatment of Idiopathic Macular Hole

AIM

The main aim of this study is to evaluate the anatomical and functional results of pars plana vitrectomy (PPV) with peeling of the internal limiting membrane (ILM), membrane blue staining and subsequent expansile gas tamponade (perfluoropropane) in the treatment of idiopathic macular hole (IMH).

MATERIAL AND METHODS

The retrospective analysis consisted of 100 eyes of a total of 100 patients (61 women and 39 men) with IMH, operated on at the Department of Ophthalmology of the Slovak Medical University and University Hospital Bratislava from 1 January 2021 to 1 January 2024, using 25-gauge PPV with ILM peeling and perfluoropropane tamponade (C3F8) of 15% concentration. After surgery, the patients were required to remain in a face-down position for at least one week. Best corrected visual acuity (BCVA), minimal linear diameter (MLD) on optic coherence tomography, macular hole closure type and occurrence of complications were evaluated. The obtained results were expressed with the use of arithmetic averages and displayed in graphs.

RESULTS

Primary closure of macular hole was achieved in 93 patients (93%). The most frequently occurring type of closure was 1A. After surgery, the BCVA of all patients improved, from an average value of 0.101 preoperatively to 0.300 one year after surgery. In all groups of patients (regardless of the size of the macular hole before surgery), during the one-year follow-up period there was a gradual increase in BCVA with its stabilization by 6 months. The main factors that influenced postoperative BCVA were the preoperative values of MLD and BCVA.

CONCLUSION

PPV with ILM peeling and perfluoropropane tamponade is an effective treatment for idiopathic macular holes with a success rate of more than 90%. This surgical procedure, associated with a relatively low number of complications, brings patients a definite improvement of BCVA.

Unexpected Vision Loss following Six Intravitreal Injections for Neovascular Age-Related Macular Degeneration

Introduction

We present a case of a patient with preceding vitreomacular traction (VMT) who developed a full-thickness macular hole (FTMH) following his sixth intravitreal aflibercept injection for the treatment of age-related macular degeneration and review the literature on risk factors and pathogenesis of this adverse event.

Case Presentation

FTMH can occur after an extended number of repeat intravitreal injections in the setting of worsening vitreomacular adhesion or VMT. This patient's FTMH was successfully treated surgically in a timely manner, and additional injections were resumed safely.

Conclusions

Patients with an unexpected decrease in vision after intravitreal injections should be reevaluated with optical coherence tomography to rule out alternative pathology including vitreomacular interface abnormalities. FTMH, if present, should be treated promptly to allow for resumption of therapy as needed and visual optimization.

VERTICAL AND HORIZONTAL METAMORPHOPSIA ONE YEAR AFTER SURGERY FOR MACULAR HOLES ≤ 500 µ m WITH AND WITHOUT INVERTED INTERNAL LIMITING MEMBRANE FLAP

PURPOSE

To investigate the effect of an inverted internal limiting membrane flap (IF) and other factors on metamorphopsia after macular hole surgery.

METHODS

Prospective case series of patients undergoing pars plana vitrectomy with gas tamponade, with either conventional internal limiting membrane peeling (CP) or an IF, for primary idiopathic macular holes ≤ 500 µ m. Vertical and horizontal metamorphopsia were measured as M-scores (degrees) using M-charts preoperatively and at 2, 6, and 12 months postoperatively.

RESULTS

Fifty-three eyes of 53 patients were included of whom 27 underwent CP and 26 were treated with an IF. After macular hole surgery, all patients were pseudophakic. Vertical and horizontal metamorphopsia improved from 1.08 (±0.51) and 0.98 (±0.70) preoperatively to 0.58 (±0.37) and 0.45 (±0.36) at 2 months ( P < 0.01), with no further significant improvement at 6 months (0.39 [±0.31], P = 0.07 and 0.31 [±0.28], P = 0.18) or at 12 months (0.37 [±0.30], P = 0.72 and 0.28 [±0.28], P = 0.99). There was no significant difference in the mean vertical and horizontal metamorphopsia between patients with CP and with an IF at 2 months ( P = 0.063, P = 0.10), 6 months ( P = 0.25, P = 0.16), or 12 months ( P = 0.62, P = 0.22). Preoperative vertical M-score improved at 12 months after macular hole surgery by 61% and 64% in the CP and IF groups, respectively ( P = 0.84), and the horizontal M-score by 65% and 71%, respectively ( P = 0.98).

CONCLUSION

The use of an IF has no evident bearing on the degree of postoperative metamorphopsia 12 months after surgical repair of macular holes ≤ 500 µ m.

[Multimodal topographically oriented approach to the study of full-thickness macular holes]

PURPOSE

This article studies the relationship between structural changes according to the findings of optical coherence tomography (OCT) and OCT angiography (OCTA), microperimetry (MP), multifocal electroretinography (mfERG) parameters in topographically corresponding areas of the macular region in idiopathic full-thickness macular holes (FTMH).

MATERIAL AND METHODS

OCT, OCTA, MP and mfERG were performed in 14 eyes with FTMH stages I-IV according to Gass. In 13 points at a distance of 0-2.5°, 2.5-5.0°, and 5.0-10.0° from the fixation point, the light sensitivity (LS), amplitude and latency of the P1 component were compared with the size of the hole, the area of cystic changes (CC) at the level of the inner nuclear layer (INL) and the outer plexiform layer and Henle fiber layer complex (OPL+HFL), vessel density in the superficial and deep capillary plexus (SCP and DCP).

RESULTS

LS and P1 component amplitude were significantly reduced at a distance of up to 5.0° from the fixation point. LS correlates with the apical and basal diameter of the hole (R> -0.53), the area of CC in the INL (R> -0.62) and the OPL+HFL complex (R> -0.55), the density of vessels in the SCP at a distance of up to 2.5° from the fixation point (R>0.51) and in the DCP at a distance of up to 5° from the fixation point (R>0.49). The P1 amplitude correlates with the basal diameter of the hole (R= -0.38), the area of CC in the INL and the OPL+HFL complex (R> -0.33) and vessel density in the SCP (R=0.37) at a distance of up to 2.5° from the fixation point, as well as vessel density in the DCP at a distance of up to 5° from the fixation point (R=0.47). Vessel density in the DCP is significantly lower in the presence of CC in the retina (p<0.001).

CONCLUSION

In FTMH, there is a relationship between bioelectrical activity and LS, and structural disorders, capillary perfusion in different layers of the retina. A multimodal topographically oriented approach allows studying the relationship between structural and functional parameters in individual points of the retina and can be used in monitoring of FTMH after surgical treatment.

Treatment of Failure of Macular Hole Closure due to Post-Vitrectomy Macular Edema Using Sub-Tenon Triamcinolone Acetonide Injection: A Case Report

Introduction

Post-vitrectomy cystoid macular edema (CME) can lead to failure of macular hole (MH) closure. We report 2 cases of failure of MH closure due to post-vitrectomy CME, which were successfully treated using sub-Tenon triamcinolone acetonide (STTA) injection.

Case Presentations

Case 1 involved a 72-year-old male patient with a Gass Stage 3 MH in the right eye. He underwent pars plana vitrectomy (PPV), internal limiting membrane translocation, and sulfur hexafluoride (SF6) gas injection with cataract surgery in his right eye. The MH did not close postoperatively; further, CME developed at the edge of the MH. Accordingly, the patient underwent an STTA injection. Approximately 2 weeks after the STTA injection, the CME disappeared and the MH closed, which has remained closed 1 year after PPV. Case 2 involved a 78-year-old female patient with Gass Stage 3 MH in the left eye. The patient underwent the same surgical procedure as that performed in case 1. Further, she presented with failure of MH closure caused by CME; therefore, an STTA injection was performed. Approximately 6 weeks after STTA injection, the CME disappeared and the MH closed; further, there was maintained improvement of best-corrected visual acuity for 6 months.

Conclusions

STTA injection could be considered before reoperation in cases involving failure of MH closure due to postoperative CME.

A Modification of the Inverted Internal Limiting Membrane Flap Technique without Heavy Liquids and Prone Posturing

Primary closure of large macular holes remains challenging, and variations of inverted inner limiting membrane (ILM) flap surgery have been described. In the present retrospective, interventional, single-centre case series, we propose a superior flap design with minimal posturing. Eight eyes of eight patients (four women and four men) in the period between July 2020 and March 2022 underwent 23 G three-port vitrectomy with a superior inverted ILM flap and 20% SF6 endotamponade for a full thickness macular hole (MH) by the same experienced surgeon (F. M. H.). Seven MHs were classified as large (> 400 µm) and one as medium (250 - 400 µm). The mean MLD was 638.0 ± 166.4 µm (range: 353 - 851 µm). MH closure was achieved in all (8/8, 100%) patients with a single surgery. The median best-corrected visual acuity (BCVA) improved from 6/120 (Snellen) (range: finger counting [FC] to 6/19) preoperatively to 6/19 (range: FC to 6/9.5) after surgery, without any intra- or postoperative complications. The superior inverted ILM flap technique seems to be a safe and successful approach for the primary closure of large MHs. Further studies should investigate our proposed surgical technique on a larger population, potentially without air or gas endotamponade.

Twenty-seven-gauge vitrectomy: a consecutive, single-centre case series with exclusive use over a 4-year period

BACKGROUND

To assess the safety and effectiveness of the exclusive use of 27-gauge instruments for all vitreoretinal diseases requiring vitrectomy.

METHODS

In this retrospective study, 1020 consecutive surgeries were performed on 958 eyes of 848 patients using 27-gauge instruments from March 2017 to June 2021. Patients with a minimum follow-up of 3 months were included. Surgical case-mix, best-corrected visual acuity (BCVA), intraocular pressure (IOP), intra- and post-operative complications, and surgery times were recorded.

RESULTS

The study patients were followed up for averagely 11 months. Of the 1020 vitrectomies, 958 were primary procedures. Of the 148 retinal detachment (RD) cases, 138 (93%) required a single vitrectomy. Primary macular hole closure was achieved in 143 of 145 (99%) cases. The average surgical times were 55 and 38 min for RD surgeries and for all other indications, respectively. BCVA improved significantly at the final visit (20/49) compared with the pre-operative visit (20/78) (p < 0.01). IOP was similar at the pre-operative (14.8mmHg) and final (14.3mmHg) visits. Complications recorded include transient hypotony in 39 eyes, iatrogenic retinal breaks in 2 eyes, and a vitreous bleed in 1 other eye.

CONCLUSION

This study revealed that 27-gauge vitrectomy instruments can be used for a wide range of indications, with exclusive use in certain settings. The outcomes were similar to other gauges, including for rhegmatogenous retinal detachment, with minimal complications.

Inter- and intra-observer agreement in the measurement of macular holes by optical coherence tomography

BACKGROUND AND OBJECTIVE

A full-thickness macular hole ("FTMH") is a foveal lesion caused by a defect in the full thickness of the neurosensory retina. Its diagnosis and the indication for surgical treatment take into account the measurement of the hole according to the tool provided by the OCT. This measurement can be performed by several ophthalmologists during the follow-up of a patient. The aim of this study is to find out whether there is intra-individual and inter-individual variability in these measurements.

MATERIAL AND METHODS

Retrospective review of OCT b-scan images with a diagnosis of FTMH. Measurements of the minimum diameter of the FTMH were performed using the hand-held tool available on the DRI-Triton (Topcon, Japan) at 1:1 and 1:2 scales, on different days, by 2 retina specialists and 2 residents. These measurements were compared to assess inter-observer and intra-observer correspondence.

RESULTS

Thirty-four images were analysed. For intra-observer variability, a correlation index higher than 0.98 was obtained in all cases. For inter-observer variability, the intra-class correlation coefficient was 0.94 (95% CI: 0.91-0.97) for the 1:1 scale, and 0.94 (95% CI: 0.91-0.97) for the 1:2 scale.

CONCLUSIONS

OCT-measured AMEC size values are reproducible between ophthalmic specialists and residents and are independent of the imaging scale at which the measurement is made.

THERAPEUTIC EFFECT OF USING AUTOLOGOUS PLATELET CONCENTRATE IN VITRECTOMY FOR MACULAR HOLE: A Systematic Review and Meta-Analysis

PURPOSE

To summarize the current evidence regarding the therapeutic effect of using autologous platelet concentrate (APC) in vitrectomy for macular hole (MH).

METHODS

The PubMed, Web of Science, and Embase databases were searched according to the PROSPERO protocol (CRD42022366202). Controlled trials comparing whether APC was used in the vitrectomy of MH were included. The primary outcome was the closure rate of MH and postoperative best-corrected visual acuity, and the secondary outcome was the incidence of different types of complications.

RESULTS

Seven studies that included 634 eyes were eligible. For the primary outcome, the usage of APC significantly improved the closure rate of MH in vitrectomy (odds ratio [OR] = 5.34, 95% confidence interval, 2.83-10.07, P < 0.001). Postoperative visual acuity did not significantly differ between the APC group and similar baseline controls (SMD = -0.07, 95% confidence interval, -0.35 to 0.22, P = 0.644). For the secondary outcome, using APC did not result in additional complications regarding postoperative retinal detachment or the recurrence of MH.

CONCLUSION

The use of APC in vitrectomy was associated with a superior closure rate of the hole and no additional complications; therefore, it is effective and safe in MH surgery.

The Evolution and Visual Prognosis of Glial Proliferation with Different Grades after Macular Hole Surgery: An Optical Coherence Tomography-Based Study

INTRODUCTION

The glial proliferation after macular hole (MH) surgery was divided into two types previously: those replacing the entire intraretinal layer and those involving only the inner foveal layers. The evolution and prognosis of the former type were elaborated on in previous studies, but the latter one has received limited attention. Therefore, this study aims to investigate the evolution of glial proliferation with varying grades after MH surgery and its effects on foveal microstructure and best-corrected visual acuity (BCVA).

METHODS

In this retrospective research, we reviewed 202 eyes from 196 consecutive patients who underwent a successful idiopathic MHs repair. Based on optical coherence tomography images, glial proliferation was classified into three types: A-type, which replaced the entire intraretinal layer; B-type, located at the level of and above the external limiting membrane (ELM); and C-type, situated above the ELM.

RESULTS

Of the 67 eyes that attended the 1-, 4-, and 10-month follow-up, A-type, B-type, C-type, and no glial proliferation were identified in 27 (40.3%), 17 (25.4%), 20 (29.8%), and 3 eyes (4.5%), respectively, at 1 month. Within 10 months, the prevalence of A-type glial proliferation significantly decreased (p < 0.001), but the changes in B-type (p = 0.261), C-type (p = 0.151), and no glial proliferation (p = 0.492) were not significant. In 32 of the 67 eyes, the grade of glial proliferation gradually improved, with A-type transforming into B- or C-type in 19 of 27 eyes (70.4%), B-type into C-type or no glial proliferation in 11 out of 17 eyes (64.7%), and C-type gradually disappearing in 2 out of 20 eyes (10.0%). Among the eyes that attended at least one follow-up (1 M, 202 eyes; 4 M, 161 eyes; 10 M, 97 eyes), those with A-type glial proliferation showed the most defective outer retinal layers, worst BCVA, and thinnest central fovea compared with the other two types at all follow-up time points (p < 0.001). Eyes with C-type glial proliferation exhibited significantly better photoreceptor layer status and BCVA compared with those with B-type glial proliferation. A-type glial proliferation at 1 month, which showed significant association with BCVA at 10 months, could be accurately predicted by the minimum linear diameter with a cut-off >547.5 μm (p < 0.001).

CONCLUSION

Within 10 months, A-type glial proliferation substantially resolves but the prevalence of B- and C-type remains unchanged. B-type glial proliferation hinders the restoration of photoreceptors and impairs visual recovery despite being located within the inner retina.

Macular hole repair: the effect of size and nonsupine posture on postoperative outcomes

Background

Postoperative face-down positioning (FDP) for up to 2 weeks is believed to be necessary for successful closure of macular holes. FDP, however, can be disabling and uncomfortable and is a major burden for elderly patients. The aim of this study was to investigate how nonsupine posturing and macular hole size affect anatomical and functional success of macular hole closure.

Methods

The medical records of patients with idiopathic macular holes who were treated surgically between 2016 and 2019 were reviewed retrospectively. Exclusion criteria included vitreomacular traction, previous retinal detachment, or chronic macular hole.

Results

A total of 115 eyes of 115 patients were included. Average age was 69.2 ± 8.2 years; 63 patients (55%) were female. Anatomical success was achieved in 108 patients (94%) with a single operation. In small holes (<400 μm), closure was seen in 98% of cases (95% CI, 94%-100%); in large holes (≥400 μm), 90% of cases (95% CI, 76%-94%). Visual acuity remained stable or improved in 108 patients (92%). Average preoperative best-corrected visual acuity was 1.02 ± 0.45, with an overall improvement of 5 lines postoperatively. Small holes and large holes improved, with an average of 3 versus 7 lines gained, respectively.

Conclusions

In this study cohort, favorable anatomical and functional outcomes were achieved without postoperative FDP. These outcomes are comparable to the traditional FDP approach.

Relaxing Retinotomy in Recurrent and Refractory Full-Thickness Macular Holes: The State of the Art

The prevailing standard of care for primary repair of full-thickness macular holes (FTMHs) is pars plana vitrectomy with internal limiting membrane (ILM) peeling and gas tamponade, as it gives a high closure rate of roughly 90%. On the other hand, the surgical management of recurrent and refractory FTMHs represents, so far, a demanding and debated subject in vitreoretinal surgery since various approaches have been proposed, with no consensus concerning both adequate selection criteria and the best surgical approach. In addition, the existence of multiple case series/interventional studies showing comparable results and the lack of studies with a direct comparison of multiple surgical techniques may lead to uncertainty. We present an organized overview of relaxing retinotomy technique, a surgical approach available nowadays for the secondary repair of recurrent and refractory FTMHs. Besides the history and the description of the various techniques to perform relaxing retinotomies, we underline the results and the evidence available to promote the use of this surgical approach.

Vitrectomy with sulfur hexafluoride versus air tamponade for idiopathic macular hole: a retrospective study

BACKGROUND

To evaluate the effect of room air and sulfur hexafluoride (SF6) gas in idiopathic macular hole(MH)surgery.

METHODS

Retrospective, interventional, and comparative study. 238 eyes with the idiopathic macular hole that underwent pars plana vitrectomy, internal limiting membrane peeling, fluid-air exchange, and 20% SF6 (SF6 group:125 eyes) or room air tamponade (air group: 113 eyes) were reviewed. The primary outcome measure was the closure rate of primary surgery.

RESULTS

The baseline characteristics of the SF6 group and air group were comparable except for the hole size (479.90 ± 204.48 vs. 429.38 ± 174.63 μm, P = 0.043). The anatomical closure rate was 92.8% (116 / 125) with the SF6 group and 76.1% (86 / 113) with the air group (P < 0.001). A cut-off value of MH size to predict primary anatomical closure was 520 μm, which is based on the lower limit of 95% confidential interval of the MH size among the unclosed patients in the air group. There was no significant difference in anatomical closure rates between SF6 and air group (98.7% vs. 91.9%, P = 0.051) for MH ≤ 520 μm, whereas a significantly lower anatomical closure rate was shown in the air group than SF6 group (46.2% vs. 84.0%, P < 0.001) for MH > 520 μm.

CONCLUSION

SF6 exhibited more effectiveness than air to achieve a good anatomical outcome for its longer tamponade when MH > 520 μm.