Vitrectomy for chronic macular holes

Successful anatomical closure of a photographically documented 30-year-old idiopathic full-thickness macular hole following surgery for concurrent repair of an acute macula-on rhematogenous retinal detachment

A 62-year-old man with a 30-year-old photographically documented idiopathic full-thickness macular hole and visual acuity of 6/45 developed an acute macula-on rhegmatogenous retinal detachment in his left eye. A pars plana vitrectomy, internal limiting membrane peeling around the macular hole, fluid-air exchange, endolaser retinopexy around the peripheral retinal break and perfluoropropane (C3F8) internal tamponade were performed to repair the detached retina and macular hole. One month postoperatively, the patient developed a large peripheral circumferential retinal tear with shallow retinal detachment which necessitated scleral buckling, repeat vitrectomy, endolaser photocoagulation and C3F8 tamponade. The retina was successfully re-attached and the macula hole was closed. Three years post-vitrectomy, the repaired 30-year-old macular hole remained closed although the visual acuity remained unchanged at 6/45. In summary, we describe the successful anatomical closure of a 30-year-old idiopathic full-thickness macular hole which we believe to be the longest duration photographically documented macular hole closed following surgery.

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.

PARS PLANA VITRECTOMY WITH OR WITHOUT INTERNAL LIMITING MEMBRANE PEEL FOR MACULAR HOLE: A Systematic Review and Meta-Analysis

PURPOSE

To compare the efficacy and safety of pars plana vitrectomy with and without internal limiting membrane (ILM) peeling for macular hole (MH).

METHODS

A systematic literature search on Ovid MEDLINE, Embase, Cochrane Library, and Google Scholar was performed from January 2000 to 2023. The primary outcome was the final best-corrected visual acuity (BCVA). Secondary outcomes included MH closure rates and the need for repeat surgery. The authors performed a random-effects meta-analysis on Review Manager 5.4.

RESULTS

Fourteen studies on 880 eyes were included. Pars plana vitrectomy with and without ILM peel achieved a similar final BCVA ( P = 0.66). However, pars plana vitrectomy without ILM peeling achieved a significantly better final BCVA in eyes with closed MHs (WMD = 0.05 logMAR, 95% CI, 0.01-0.10, P = 0.02). Pars plana vitrectomy with ILM peeling achieved a significantly higher primary MH closure rate (RR = 1.21, 95% CI, 1.04-1.42, P = 0.02) and lower incidence of MH reoperation (RR = 0.19, 95% CI, 0.11-0.33, P < 0.001). The final MH closure rate ( P = 0.12) and incidence of MH recurrence ( P = 0.25) were similar between groups.

CONCLUSION

Pars plana vitrectomy with and without ILM peel achieved a similar final BCVA. However, pars plana vitrectomy without ILM peeling achieved a better final BCVA in eyes with closed MHs. ILM peeling achieved a greater primary MH closure rate and reduced need for reoperation.

Quantitative evaluation of dissociated optic nerve fibre layer (DONFL) following idiopathic macular hole surgery

OBJECTIVES

To quantitatively evaluate concentric macular dark spots (CMDS) on spectral-domain optical coherence tomography (SD-OCT) to determine the morphological characteristics of dissociated optic nerve fibre layer (DONFL) following the performance of internal limiting membrane (ILM) peeling in patients with full-thickness idiopathic macular hole (IMH) closure.

METHODS

Retrospective study on patients who underwent a vitrectomy with ILM peeling procedure. BCVA, cross-sectional OCT scans, and three-dimensional reconstructions of en face OCT scans were analysed preoperatively, at 2, 6, 12 months post-operatively. A novel image analysis technique was used to automatically measure DONFL logical properties through the radius, area, the nerve fibre layer dissociation index (NFLDI), and depth of the CMDS.

RESULTS

53 eyes of 51 patients were included, and the mean follow-up was 11.53 ± 6.26 months. CMDS was found in 46 (86.79%) eyes within 2 months after ILM peeling and 50 (94.34%) eyes within 6 months after ILM peeling. CMDS concentrated on the temporal side of the macula in all 50 eyes (100%) at first detection. The area, NFLDI, and depth of CMDS in four quadrants developed significantly during the postoperative 6 months (p < 0.05), and then these changes slowed down and remained unchanged 12 months post-operatively. The morphological changes in the temporal quadrant were significantly greater than those in other quadrants at 2, 6, 12 months (all p < 0.05) post-operatively.

CONCLUSIONS

CMDS mostly appeared and concentrated on the temporal side of the macula in IMHs within two months after ILM peeling and progressed within 6 months and remained unchanged after 12 months.

Non-Invasive Retinal Imaging Modalities for the Identification of Prognostic Factors in Vitreoretinal Surgery for Full-Thickness Macular Holes

In this review, we will focus on different non-invasive retinal imaging techniques that can be used to evaluate morphological and functional features in full-thickness macular holes with a prognostic purpose. Technological innovations and developments in recent years have increased the knowledge of vitreoretinal interface pathologies by identifying potential biomarkers useful for surgical outcomes prediction. Despite a successful surgery of full-thickness macular holes, the visual outcomes are often puzzling, so the study and the identification of prognostic factors is a current topic of interest. Our review aims to provide an overview of the current knowledge on prognostic biomarkers identified in full-thickness macular holes by means of different retinal imaging tools, such as optical coherence tomography, optical coherence tomography angiography, microperimetry, fundus autofluorescence, and adaptive optics.

Impact of Race and Ethnicity on Presentation and Surgical Outcomes of Idiopathic Macular Holes

There is limited data on the presentation and surgical outcomes of idiopathic macular holes (IMH) for different ethnic and racial groups. Recognition of distinct, clinically-relevant patient subgroups may provide opportunities to identify specific unmet needs including possible barriers to optimal healthcare delivery. Medical records of patients who underwent surgery for IMH (between 2016 and 2022) at a large, urban retina practice were reviewed and self-reported ethnicity (Hispanic and non-Hispanic) and race (Asian, Black, White, and Other) were captured. The primary variables included (1) mean minimum linear diameter (MLD) at presentation and (2) surgical outcome (IMH closure status). Overall, mean MLD for all study eyes (515) was 366.1 μm, and surgical success was achieved in 489 (95.0%) eyes. Hispanic eyes presented with larger mean MLD (p = 0.002) compared to non-Hispanic eyes. Asian, Black, and Other eyes presented with larger mean MLD (p = 0.033, p < 0.001, p < 0.001) when compared to White eyes. The presentation of IMH varied in severity among different ethnic and racial groups. Hispanic patients were found to have worse preoperative visual acuity (VA), longer time to surgery, and larger mean MLD and BD compared to non-Hispanic participants. Black and Other patients were found to have worse VA, time to surgery, and larger mean MLD and BD when compared to White participants.

Ocular Manifestations and Potential Treatments of Alport Syndrome: A Systematic Review

Objectives. Alport syndrome (AS) is a severe, rare hereditary disorder that can lead to end-stage renal disease, auditory degeneration, and ocular abnormalities. Despite extensive research on AS in relation to auditory and renal disorders, more research is needed on the ocular presentations of AS. This systematic review aims to summarize the common ocular abnormalities in patients with AS and to explore the potential treatment options for these irregularities. Methods. The PubMed, MEDLINE, and EMBASE databases were systematically searched from January 1977 to April 2022. Only papers that were published in the English language and explored the ocular abnormalities in AS patients were selected. We manually searched reference lists of included papers for additional studies. Results. A total of 23 articles involving 195 patients were included in this review. The common ocular manifestations in AS patients are lenticonus, macular holes, fleck retinopathy, and thinning of the macula. Although published literature has described the use of cataract surgeries and vitrectomies as standard surgical techniques to alleviate ocular abnormalities in non-AS patients, it must be noted that surgical techniques have not been evaluated in a large research study as a solution for AS abnormalities. Another prospective treatment for AS is gene therapy through the reversion of causative COL4 variants to wild type or exon-skipping therapy for X-linked AS with COL4A5 truncating mutations. Gene therapy, however, remains unable to treat alterations that occur in the fetal and early development phase of the disease. Conclusions. The review found no definitive conclusions regarding the efficacy and safety of surgical techniques and gene therapy in AS patients. Recognition of ocular abnormalities through an ophthalmic examination with an optical coherence tomography (OCT) and slit-lamp examination is critical to the medical field, as ophthalmologists can aid nephrologists and other physicians in diagnosing AS. Early diagnosis and care can minimize the risk of detrimental ocular outcomes, such as blindness and retinal detachment.

Intraocular Tamponade Choice with Vitrectomy and Internal Limiting Membrane Peeling for Idiopathic Macular Hole: A Systematic Review and Meta-analysis

TOPIC

A variety of different tamponade agents are used with vitrectomy combined with internal limiting membrane (ILM) peeling for the treatment of idiopathic macular holes. These agents include air, gas (sulfur hexafluoride [SF₆], hexafluoroethane [C₂F₆], and perfluoropropane [C₃F₈]), and silicone oil. The optimal tamponade agent is uncertain, and we aimed to review the effect of tamponade choice on hole closure and visual outcomes.

CLINICAL RELEVANCE

Although most surgeons initially chose to use long-acting gas (C₃F₈), there has been a gradual change in practice to the increasing use of the medium- (C₂F₆) and short-acting gases (SF₆) or even air. However, there is no consensus regarding their relative efficacies.

METHODS

Systematic review and meta-analysis of randomized controlled trials (RCTs) and prospective and retrospective comparative cohort studies comparing different tamponade agents in patients undergoing vitrectomy and ILM peeling for primary idiopathic macular holes. For RCTs, the risk of bias was assessed using the Cochrane Risk of Bias tool for RCTs, whereas for nonrandomized studies, the Risk of Bias in Nonrandomized Studies of Interventions tool was used.

RESULTS

Thirteen publications, including 2 RCTs, were identified. Overall, there was no significant difference in the anatomic closure rates between studies using SF₆ compared with either C₃F₈ or C₂F₆ (odds ratio [OR] = 0.74; 95% confidence interval [CI] = 0.51-1.08). A subgroup analysis showed a significantly higher closure rate using SF₆ (OR = 0.49; 95% CI = 0.30-0.79) in patients without postoperative posturing but not in those who were advised to posture facedown. The visual outcomes and adverse events were not significantly different. The comparisons of anatomic closure rates of patients treated with gas tamponade vs. silicone oil and with air vs. SF₆ showed no significant differences. The included studies had a number of methodological limitations and heterogeneities, making conclusions imprecise, with low or very low certainty by the Grades of Recommendation, Assessment, Development and Evaluation approach.

CONCLUSION

The current evidence base for tamponade selection with vitrectomy and ILM peeling for full-thickness macular hole has several major limitations. Further appropriately designed studies are needed to guide tamponade selection.

Prognostic Factors for Visual Outcomes in Closed Idiopathic Macular Holes after Vitrectomy: Outcomes at 4 Years in a Monocentric Study

Purpose

To identify predictive factors of visual outcomes in the eyes after successful macular hole (MH) surgery.

Methods

It is a retrospective monocentric study of the eyes that underwent successful vitrectomy for full-thickness MH in an academic, tertiary care center (CHU de Québec–Université Laval, Québec, Canada) between 2014 and 2018. We included a single eye per patient and excluded the eyes with ocular comorbidities. Clinical and anatomical features of patients were collected, including demographics, MH duration, baseline MH size, baseline visual acuity (VA), and final VA. Multiple logistic regressions were performed to determine predictive factors of VA ≥70 ETDRS letters (Snellen equivalent: 20/40) and VA gain ≥15 ETDRS letters at final follow-up. Areas under the receiver operating characteristic curve (AUC) were used to determine the performance of each model and identify the Youden index maximizing performance at a given threshold.

Results

A total of 460 eyes were included in this study; 274/460 eyes (60%) achieved final VA ≥70 ETDRS letters and 304/460 eyes (66%) had a VA gain ≥15 ETDRS letters at 24 months follow-up. Multiple logistic regression analyses showed that the main predictive factors for final VA ≥70 ETDRS letters (model AUC = 0.716) were baseline VA (OR = 1.064; p < 0.001), MH duration (OR = 0.950; p=0.005), and age (OR = 0.954; p=0.004). Predictors of VA gain ≥15 ETDRS letters at final follow-up (model AUC = 0.615) were baseline VA (OR = 0.878; p < 0.001), MH duration (OR = 0.940; p < 0.001), and MH size (OR = 0.998; p=0.036). Thresholds for the final VA ≥70 ETDRS letters model and the VA gain ≥15 ETDRS letters model were VA ≥55.5 ETDRS letters (Snellen equivalent: 6/30) and MH size of 237 μm, respectively.

Conclusion

The eyes with shorter MH duration, smaller MH size, and higher preoperative VA achieved better visual outcomes after successful MH surgery.

Modified internal limiting membrane flap technique for large chronic macular hole: Two case reports

RATIONALE

Internal limiting membrane (ILM) peeling and gas tamponade are the standardized treatments for macular holes (MHs). However, the close rate is low, and postoperative vision is unsatisfactory in large, chronic MHs. Currently, various modifications of the ILM flap techniques are being gradually applied for large MHs in the hope of obtaining better postoperative effects. This study described 2 successful cases achieved by "Sandwich-type" modified ILM flap covering technique in patients with large, chronic MHs.

PATIENT CONCERNS

A 62-year-old woman presented with decreased vision and visual distortion of the left eye for 18 months. Optical coherence tomography (OCT) showed the absence of full-thickness neuroepithelial tissue in the central fovea, with a minimum MH diameter of 742 μm and a base diameter of 1630 μm. A 57-year-old man experienced decreased visual acuity for 8 months. OCT showed the absence of full-thickness neuroepithelial tissue in the central fovea, with a minimum MH diameter of 713 μm and a basal diameter of 939 μm.

DIAGNOSES

Two patients were diagnosed with large, chronic MH based on the OCT results and duration of the hole.

INTERVENTIONS

The 2 patients were treated with the "sandwich-type" modified ILM flap covering technique.

OUTCOMES

Large, chronic MH closure was observed using SD-OCT, and the BCVA improved. The patients were very satisfied with the postoperative results.

LESSONS

"Sandwich-type" modified ILM flap covering technique may be a safe, effective way for large, chronic MH.

Inverted Internal Limiting Membrane Flap vs Complete Internal Limiting Membrane Peeling for Large Macular Holes in Nonposturing Surgery

Purpose:

This study compared anatomical and functional outcomes of the inverted internal limiting membrane flap (ILMF) technique with complete ILM peeling (ILMP) in nonposturing surgery for large, full-thickness macular holes (MHs).

Methods:

This was a retrospective, comparative, single-surgeon study. Eyes with idiopathic large full-thickness MHs (minimum diameter > 400 μm) were included. A total of 46 patients including 22 ILMF cases and 24 ILMP cases were analyzed. No positioning instructions were advised postoperatively.

Results:

Primary hole closure was achieved in all patients (100%) in both groups. Mean logMAR visual acuity (VA) improved significantly in both groups compared with the preoperative values (ILMF: 0.60 [SD, 0.26] postoperatively, vs 0.93 [SD, 0.3] preoperatively, P = .032; ILMP: 0.43 [SD, 0.22] postoperatively vs 0.83 [SD, 0.16] preoperatively, P < .01). However, ILMP showed a statistically significant improvement in VA compared with ILMF ( P = .02).

Conclusions:

All MHs in both groups closed after surgery (100%). There was a statistically significant improvement of VA in the ILMP group compared with the ILMF group ( P = .02). Not posturing after surgery did not compromise surgical success in both groups.

Factors predicting normal visual acuity following anatomically successful macular hole surgery

PURPOSE

To assess the incidence of normal vision following anatomically successful macular hole surgery and associated clinical variables.

METHODS

Multicentre, retrospective chart review. Preoperative, intraoperative and postoperative clinical data were extracted from electronic medical records from seven European vitreoretinal units. Inclusion criteria were as follows: eyes undergoing primary vitrectomy for idiopathic full-thickness macular hole from January 2015 to January 2018; postoperative macular hole closure confirmed by spectral domain optical coherence tomography (OCT); preoperative pseudophakia or phakic eyes receiving combined cataract surgery; one-year follow-up. The primary outcome was 'normal vision' defined as a final best-corrected visual acuity (BCVA) ≥ 20/25. Univariate, multivariate and decision-tree analyses were conducted to evaluate the clinical variables associated with 'normal vision'. Odds ratios (OR) and confidence intervals (CIs) were calculated.

RESULTS

Of 327 eligible cases, 91 (27.8%) achieved 'normal vision' at 1 year. Multivariate analysis identified variables significantly associated with 'normal vision': shorter symptom duration (odds ratio [OR]=1.05; 95% confidence interval [CI]:1.02-1.09; p = 0.002), smaller preoperative OCT minimum linear diameter (OR per 100-micron increase = 1.65; 95%CI:1.31-2.08; p < 0.001) and better mean preoperative BCVA (OR = 15.13; 95%CI: 3.59-63.65; p < 0.001). The decision-tree analysis found that the most significant variable associated with 'normal vision' was symptom duration. 'Normal vision' was achieved in 70.6% of eyes operated within one week from symptom onset and in 45% of eyes with symptom duration between 1 and 3 weeks.

CONCLUSIONS

These findings suggested urgent surgery is justified for small macular holes of short duration.

OCT-A in the Management of Vitreoretinal Diseases and Surgery

ABSTRACT

Optical coherence tomography angiography is a relatively new noninvasive technique that is changing our approach in the management of several retinal diseases such as neovascular age-related macular degeneration, occlusive retinal diseases, or diabetic retinopathy, but it could also be useful in nonprimary vascular retinal pathologies such as vitreoretinal interface surgical disorders.In idiopathic vitreoretinal interface disorders and surgical retinal diseases, the study of vascular involvement, not commonly assessed by invasive methods, could be useful to reveal specific vascular abnormalities. Such information may be useful for a more detailed phenotyping of each clinical picture before and after surgical treatment, providing potential new prognostic biomarkers.The review discusses the current and potential utility of optical coherence tomography angiography to study vitreoretinal pathologies of surgical interest.

Surgical technique for approaching chronic or persistent macular holes: Two case reports

Purpose

To report the anatomic and functional outcomes of an innovative surgical technique for either chronic or persistent macular holes (MHs).

Observations

A consecutive retrospective interventional case series of 2 patients with chronic macular hole in one case and persistent macular hole in the other case were included. Surgical technique involves pars plana vitrectomy, use of triamcinolone acetonide for posterior hyaloid staining followed by internal limiting membrane peeling in case number 1, macula area is detached by means of subretinal injection of balanced salt solution (BSS) trough 3 puncture retinotomies strategically placed. Fluid–air exchange is done and gas tamponed is injected. Face-down position is required. Preoperative, and postoperative best corrected visual acuity was recorded. Spectral-domain optical coherence tomography (SD-OCT) scans were registered and compared. Case number 1 did not achieve a complete closure of the macular hole during a 6-month follow-up period. Case number 2 had successful hole closure after the procedure and was maintained for 12 months of follow up. No worsening in visual acuity was reported in neither eye, and improvement in visual acuity in case number 2 was observed from CF to 20/100 at the end of 12 months of follow up.

Conclusions and Importance

This surgical technique has previously demonstrated to provide resolution of chronic, large and persistent MH. However, in our case series we observed a complete closure of the macular hole in only one of two patients. Therefore, in spite of being a very small case series these results suggest the need to perform further studies to identify the presence of risk factors which could decrease the probability of failure with this interesting surgical technique.

NO FACE-DOWN POSITIONING SURGERY FOR THE REPAIR OF CHRONIC IDIOPATHIC MACULAR HOLES

PURPOSE

To report visual and anatomical outcomes after the repair of chronic idiopathic macular holes (MHs) with no face-down positioning.

METHODS

We conducted a retrospective review of chronic MH cases of greater than 1-year duration that were repaired through pars plana vitrectomy with broad internal limiting membrane peeling and no face-down positioning between March 2009 and December 2017. There were 18 eyes of 18 patients that met inclusion criteria. Patients with MH duration of less than 1 year and without at least 1 month of follow-up were excluded. Macular hole staging and measurements were performed with spectral domain optical coherence tomography.

RESULTS

Mean MH duration was 5.0 ± 6.9 years. Two-thirds of MHs had a basal diameter of more than 1,000 μm. Mean preoperative Snellen visual acuity was 20/302 and improved to a mean postoperative visual acuity of 20/112 (P ≤ 0.0001). Visual acuity improved in all patients who achieved successful anatomical closure, 94.4% (17/18) of eyes.

CONCLUSION AND RELEVANCE

Patients in this series with chronic MH who underwent no-face-down MH repair demonstrated a high single-surgery anatomical closure rate with a significant improvement in visual acuity.

Morpho-Functional Evaluation of Full-Thickness Macular Holes by the Integration of Optical Coherence Tomography Angiography and Microperimetry

(1) Objective: To use optical coherence tomography angiography (OCTA) and microperimetry (MP) to evaluate the correlation between retinal structure and function in patients with idiopathic, full-thickness macular holes (FTMHs) (2) Methods: This prospective, observational study included 11 eyes of 10 patients with FTMHs evaluated before surgery using OCTA and MP. MP sensitivity maps were superimposed and registered on slabs corresponding to superficial capillary plexus (SCP) and deep capillary plexus (DCP) on OCTA, and on the outer plexiform layer (OPL) and the Henle fiber layer (HFL) complex in en face OCT. On these maps, mean retinal sensitivity was calculated at 2° and 4°, all centered on the FTMH. Cystic cavity extension was assessed on the slab corresponding to the OPL + HFL complex in en face OCT and DCP in OCTA using the Image J software (Version 1.49v; National Institutes of Health, Bethesda, MD, USA); (3) Results: Absolute scotomas were observed corresponding to the FTMH. Additionally, rings of relative scotoma in the perilesional area were detected and correlated to the cystic spaces on en face OCT and OCTA. There was a significant correlation between reduced retinal sensitivity at 2° and 4° diameters around the FTMH and the extension of cystic areas (p < 0.01). There was a significant correlation between the extension of cystic cavities and BCVA (p < 0.01). (4) Conclusions: Morpho-functional analysis of FTMH using OCTA and MP, and the correlation between vascular abnormalities and impaired retinal sensitivity, may provide new, useful information. This integrated evaluation of FTMH may be useful to determine the function–structure correlation before and after vitreoretinal surgery, in order to gain a better understanding of the functional consequences induced by the morphological alterations, assessing outcomes in a more objective way, and potentially adding new surgical prognostic factors.

Incomplete fluid-air exchange technique for idiopathic macular hole surgery

AIM

To explore an improved procedure involving incomplete fluid-air exchange for idiopathic macular hole (IMH), and the closure rate, visual function, and the visual field of macular holes (MHs) were evaluated.

METHODS

This prospective randomized controlled study, included 40 eyes of 40 patients with IMH who were treated with pars plana vitrectomy and peeling of the internal limiting membrane. They were grouped by random digital table. Twenty-one eyes underwent incomplete fluid-air exchange (IFA) and 19 eyes underwent traditional complete fluid-air exchange (CFA) as the control group. Outcomes included best-corrected visual acuity (BCVA), intraocular pressure, and optical coherence tomography, light adaptive electroretinography, and visual field evaluations.

RESULTS

All MHs <400 µm were successfully closed. BCVAs before and 6mo after surgery were 0.82±0.41 logMAR and 0.28±0.17 logMAR in IFA group and 0.86±0.34 logMAR and 0.34±0.23 logMAR in CFA group, respectively. The electroretinogram analysis of patients in IFA group revealed increases in b-wave amplitudes at 1, 3, and 6mo after surgery. Additionally, patients in IFA group showed an amplitude increase of 28.6% from baseline at 6mo (P<0.05), while no obvious improvements were noted in CFA group. Although there were no statistically significant improvements in either group, the IFA group showed a slight increase in mean sensitivity (P>0.05).

CONCLUSION

IFA is a reliable method that offers comparable closure rate to CFA and facilitates improvements in visual function.

The Role of Single-Layered Flap in Temporal Inverted Internal Limiting Membrane Flap Technique for Macular Holes: Pros and Cons

Purpose

To assess the safety and effectiveness of the single-layered inverted internal limiting membrane (ILM) flap technique for treating chronic, large, or highly myopic macular holes (MHs).

Methods

The medical records of 20 eyes of 20 consecutive Japanese patients with large MHs (n=6) (minimal diameter, >400 μm), chronic MHs (n=2) (symptom duration, >24 months), MHs in high myopia (n=11) (axial length, >26 mm), and MHs in a patient unable to maintain prone positioning postoperatively (n=1) were reviewed retrospectively. All patients underwent 25-gauge pars plana vitrectomy and the temporal inverted ILM flap technique. A semicircular ILM notch was made temporally two disc diameters from the MH using a 25-gauge knife, and the ILM was peeled temporally to create a semicircular ILM flap using a 25-gauge forceps. The single-layered ILM flap was inverted in a nasal direction to cover the MH. When an epiretinal membrane (ERM) was present, it was peeled before the ILM flap was inverted.

Results

The MHs closed successfully in all (100%) eyes postoperatively. In the MHs associated with an ERM, after hole closure, gradual foveal deformation occurred in both the area from which the ILM was not peeled and the ILM flap inverted side.

Conclusions

The single-layered inverted ILM flap technique, a simple surgery to treat MHs, provides scaffolding for retinal gliosis and may facilitate bridge formation between the walls of the MH under the flap. Considering the 100% success rate of MH closure, this technique seems to be effective and safe for treating chronic, large, or highly myopic MHs and MHs in patients unable to maintain postoperative prone positioning. In the MHs associated with ERMs, gradual foveal deformation was observed after ERM peeling. Further studies are needed to minimize surgical complications and understand the mechanism of this technique. This trial is registered with UMIN000035091.

Pathogenesis and Management of Macular Hole: Review of Current Advances

Macular hole has been believed to be a disorder of vitreomacular interface, which forms as a result of abnormal vitreous traction from incomplete vitreous detachment. However, our recent studies demonstrated that dynamic forces, caused by mobile posterior cortical vitreous with fluid currents, exist already at early stages of macular hole development. Therefore, in eyes with flexible vitreous, the contributions of tractional forces due to vitreous shrinkage are unlikely. These facts indicate that in the development of idiopathic macular holes, there is a greater contribution of dynamic forces than has been previously reported. This review also evaluates the recent findings in the assessment of the idiopathic macular holes and the recent therapeutic strategies for optimal management. Inner limiting membrane is considered to improve anatomical closure rate; however, it is still questionable if peeling is necessary in holes less than 250 µm. There are plenty of publications indicating that in the management of small and medium size hole (less than 400 µm), use of long-lasting gas and face-down position is not always required; however, it may be necessary for the treatment of large holes. Ocriplasmin and expansile gas had been reported to be successful for management of small- and medium-sized holes and vitreomacular attachment.

Perspectives of Autologous Mesenchymal Stem-Cell Transplantation in Macular Hole Surgery: A Review of Current Findings

The main treatment available for idiopathic macular holes is represented by pars plana vitrectomy with internal limiting membrane peeling. However, late-stage macular holes are affected by a higher risk of surgical failure. Although adjuvant techniques can be employed, a satisfactory functional recovery is difficult to achieve in refractory macular holes. Given their neuroprotective and antiapoptotic properties, mesenchymal stem cells (MSCs) may represent an appealing approach to treat these extreme cases. The purpose of this review is to highlight the findings regarding healing mechanisms exerted by mesenchymal stem cells and preliminary application in cases of refractory macular holes. When compared with MSCs, MSC-derived exosomes may represent a feasible alternative, given their reduced risk of undesired proliferation and easiness of use.

Efficacy of the Inverted Internal Limiting Membrane Flap Technique with Perfluorocarbon Liquid-Mediated Selective Staining for Large Macular Hole Repair

PURPOSE

The aim of the present study was to evaluate the efficacy of the inverted internal limiting membrane (ILM) flap technique that involved the use of a perfluorocarbon liquid (PFCL) bubble for the selective prevention of indocyanine green (ICG) staining of the parts of the inverted flap in contact with the retinal pigment epithelium for large macular hole (MH) closure.

MATERIALS AND METHODS

This retrospective, interventional, comparative study included 26 patients with idiopathic large MHs (minimum diameter, > 400 µm) who underwent vitrectomy using the inverted ILM flap technique with conventional ILM staining with ICG (n = 14, Group 1) or PFCL-mediated selective ILM staining with ICG (n = 12, Group 2). The hole closure rate, best-corrected visual acuity (BCVA), and optical coherence tomography findings were analyzed at baseline and 1, 3, and 6 months after surgery in both groups.

RESULTS

Hole closure was achieved in all the eyes. BCVA significantly improved after surgery in both groups (p < 0.001 for both groups), although Group 2 exhibited significantly better values at 3 and 6 months after surgery (p = 0.008 and 0.001 at 3 and 6 months, respectively). The sizes of ellipsoid zone defect significantly decreased after surgery in both groups (p < 0.001 relative to the baseline width in both groups), and it was significantly smaller in Group 2 than in Group 1 at 3 (p = 0.006) and 6 (p = 0.001) months after surgery.

CONCLUSIONS

The findings of this study suggest that recovery of the photoreceptor layers and, consequently, the postoperative VA are better with the inverted ILM flap technique employing PFCL-mediated selective ILM staining with ICG than with the technique employing conventional ILM staining with ICG methods for patients with large MHs.

ANTERIOR LENS CAPSULE IN THE MANAGEMENT OF CHRONIC FULL-THICKNESS MACULAR HOLE

PURPOSE

To report the use of anterior lens capsule flap transplantation in two cases with chronic full-thickness macular hole (MH).

METHODS

Case series.

RESULTS

Two cases of chronic MH with a new treatment approach were reported. In the first case, a 66-year-old man presented with a chronic idiopathic MH in the left eye for 2 years. Presenting visual acuity was hand motion. The patient underwent phacoemulsification and vitrectomy with anterior lens capsule flap transplantation in the MH. At 5 months postoperatively, the visual acuity was 20/200 with MH closure. In the second case, a 68-year-old woman presented with decreased visual acuity for 2 years. Her visual acuity was hand motion in the right eye. The patient underwent phacoemulsification and vitrectomy with anterior lens capsule flap transplantation in the MH. Visual acuity improved to 20/400 with reduction in the MH diameter. Vision and MH diameter remained stable over 5 months postoperatively.

CONCLUSION

Lens capsular flap transplantation is useful in closing chronic MH in the short term.

Retrospective study of changes in ocular coherence tomography characteristics after failed macular hole surgery and outcomes of fluid-gas exchange for persistent macular hole

Purpose

The aim is to study the changes in ocular coherence tomography (OCT) parameters of large (≥400 μ) full-thickness macular holes (FTMHs) after a failed surgery and evaluate the outcome of fluid-gas exchange (FGE) in the treatment of persistent macular hole and role of OCT in predicting outcome after the secondary intervention.

Methods

Changes occurring in the OCT parameters of FTMH after a failed vitrectomy were evaluated. FGE was done in an operating room with three pars plana sclerostomy ports. The anatomical and functional outcomes of FGE for these persistent macular holes were also assessed. Anatomical closure was defined as the flattening of the hole with resolution of subretinal cuff of fluid. Anatomical success after FGE was defined as flattening of macular hole with the resolution of subretinal cuff of fluid and neurosensory retina completely covering the fovea. Functional success was defined as an improvement of at least one line of best-corrected visual acuity (BCVA).

Results

Twenty-eight eyes (28 patients) were included in the study. After the failed vitrectomy, OCT showed an increase in the base diameter, opening diameter, and height of the hole. After the secondary procedure, anatomical closure was achieved in 89.3% eyes. Mean BCVA improved from logMAR 0.88 ± 0.24 (20/152) to logMAR 0.66 ± 0.24 (20/91) (P < 0.001). Eight (28.6%) patients achieved final BCVA ≥20/60. Functional success was obtained in 19 patients (67.9%). There was no association between anatomical success after FGE and any of the pre-FGE OCT parameters or indices.

Conclusion

Unsuccessful surgery causes swelling of the outer and middle retinal layers with retraction of inner layers of the retina. Performing FGE while visualizing the retina is a good option for the treatment of large persistent macular holes as it causes complete drying of the macula, better success rates, and a reduced complication rate. Pre-FGE OCT does not help in predicting the outcome of FGE for persistent macular hole.

Comparative study of inverted internal limiting membrane (ILM) flap and ILM peeling technique in large macular holes: a randomized-control trial

Background

The anatomical success rate of macular hole surgery ranges around 93–98%. However, the prognosis of large macular holes is generally poor. The study was conducted to compare the anatomical and visual outcomes of Internal Limiting Membrane (ILM) peeling vis-a-vis inverted ILM flap for the treatment of idiopathic large Full-Thickness Macular Holes (FTMH).

Methods

This was a prospective randomized control trial. The study included patients with idiopathic FTMH, with a minimum diameter ranging from 600 to 1500 μm. The patients were randomized into Group A (ILM peeling) and Group B (inverted ILM flap). The main outcome measures were anatomical and visual outcome at the end of 6 months. Anatomical success was defined as flattening of macular hole with resolution of the subretinal cuff of fluid and neurosensory retina completely covering the fovea.

Results

There were 30 patients in each group. The mean minimum diameters in Group A and B were 759.97 ± 85.01 μm and 803.33 ± 120.65 μm respectively (p = 0.113). The mean base diameter in group A and B was 1304.50 ± 191.59 μm and 1395.17 ± 240.56 μm respectively (p = 0.112). The anatomical success rates achieved in Group A and B were 70.0 and 90.0% respectively (p = 0.125). The mean best-corrected visual acuity (BCVA) after 6 months was logMAR 0.65 ± 0.25 (Snellen equivalent, 20/89) in Group A and logMAR 0.53 ± 0.20 (Snellen equivalent, 20/68) in Group B (p = 0.060). The mean improvement in BCVA was 1.4 lines and 2.1 lines in groups A and B respectively (p = 0.353). BCVA≥20/60 was achieved by 13.3 and 20.0% in group A and B respectively (p = 0.766).

Conclusion

The anatomical and functional outcome of Inverted ILM flap technique in large FTMH is statistically similar to that seen in conventional ILM peeling.

Trial registration

Clinical Trials Registry – India (Indian Medical Research) CTRI/2017/11/010474.

Electronic supplementary material

The online version of this article (10.1186/s12886-018-0826-y) contains supplementary material, which is available to authorized users.

THE CURRENT SURGICAL MANAGEMENT OF LARGE, RECURRENT, OR PERSISTENT MACULAR HOLES

PURPOSE

To evaluate the current surgical options available for the management of large (>400 μm), recurrent, or persistent macular holes (MHs).

METHODS

A review of the literature was performed, focusing on the epidemiology, pathophysiology, diagnosis, and surgical treatments of large, recurrent, or persistent MHs. Based on this review, a comprehensive overview was provided regarding the topic of large, recurrent, or persistent MHs and focused on recent surgical management updates.

RESULTS

For large MHs, variations of the inverted internal limiting membrane flap technique demonstrated promising rates of primary hole closure and significant visual acuity improvements. For recurrent or recalcitrant MHs, early repeat vitrectomy with extension of the internal limiting membrane peel remains the most straightforward and optimal surgical technique to achieve secondary closure. Regardless of the surgical approach, the goal of each technique described is to induce or aid in stimulating gliosis within the MH to maximize closure.

CONCLUSION

Despite the high success rate of modern MH surgery, large, recurrent, or persistent MHs remain a challenge for retinal surgeons. This review provides a detailed summary on the rationality and efficacy of current surgical options.

Comparative analysis of large macular hole surgery using an internal limiting membrane insertion versus inverted flap technique

BACKGROUND

To determine whether the internal limiting membrane (ILM) insertion technique is as effective as the inverted ILM flap technique for the initial surgical treatment of eyes with large idiopathic macular holes (MHs).

METHODS

This retrospective, non-randomised, comparative clinical study included 41 eyes with large MHs (minimum diameter >500 µm) that were treated using the ILM insertion technique or the inverted ILM flap technique. The hole closure rate, postoperative best corrected visual acuity (BCVA) and swept source optical coherence tomography findings were analysed at 6 months after surgery.

RESULTS

There were 15 and 26 eyes in the insertion and inverted flap groups, respectively. Hole closure was achieved in all eyes. The mean final BCVA was better in the inverted flap group than in the insertion group (0.527 vs 0.773, p=0.006), although significant postoperative improvements were observed in both groups (p<0.001). Postoperative foveal discolouration was more common in the insertion group than in the inverted flap group (86.7% vs 7.7%, p<0.001). Complete resolution of ellipsoid zone and external limiting membrane defects was observed in 7 and 18 eyes, respectively, in the inverted flap group; in contrast, complete resolution was not observed in any of the eyes in the insertion group (p=0.035 and p<0.001, respectively).

CONCLUSION

The ILM insertion technique may be as effective as the inverted ILM flap technique for the closure of large MHs. However, the latter technique results in better recovery of photoreceptor layers and, consequently, better postoperative visual acuity.

AGE-RELATED CLINICAL OUTCOME AFTER MACULAR HOLE SURGERY

PURPOSE

To evaluate functional and anatomical retinal recovery according to patient age using spectral domain optical coherence tomography in eyes with surgically closed macular holes.

METHODS

We retrospectively studied 83 eyes with anatomically closed idiopathic macular holes after surgery confirmed by spectral domain optical coherence tomography. Patients were divided into four subgroups based on age (Group 1: ≤ 60, Group 2: 61-65, Group 3: 66-70, Group 4: > 70). Best-corrected visual acuity and reconstruction of the external limiting membrane and ellipsoid zone after surgery were documented for 12 months.

RESULTS

Mean patient age was 64.5 ± 9.8 years (range 44-81). Mean visual improvement in logMAR units (ETDRS letter score) at 12 months was worse in older age subgroups (Group 1: 0.4 ± 0.3 [20], Group 2: 0.4 ± 0.3 [20], Group 3: 0.2 ± 0.3 [10], Group 4: 0.1 ± 0.3 [5], P = 0.001). When age was more than 65 years, total number of eyes with restored retinal microstructure after surgery was lower (22 eyes, 53.7%; 32 eyes, 76.2%; P = 0.018) and time (months) to structural recovery was longer (10.2, 7.1, P < 0.001) than age under 65 years. Visual improvement corresponded to recovery of the outer retinal layers. In multivariate analysis, patients of older age (odds ratio, 0.91; 95% CI, 0.89-0.93) had less visual improvement at month 12.

CONCLUSION

Poor visual outcomes and delayed microstructural recovery occurred in older subjects after anatomically closed macular hole surgery. Older age may be indicative of poor clinical outcome in repaired macular holes.

Outcomes of chronic macular hole surgical repair

PURPOSE

To report visual and anatomic outcomes of chronic macular hole surgery, with analysis of pre-operative OCT-based hole size and post-operative closure type.

SETTINGS AND DESIGN

An IRB-approved, retrospective case series of 26 eyes of 24 patients who underwent surgery for stage 3 or 4 idiopathic chronic macular holes at a tertiary care referral center.

STATISTICAL ANALYSIS

Student's t-test.

RESULTS

Nineteen of 26 eyes (73%) had visual improvement after surgery on most recent exam. Twenty-one of 26 eyes (81%) achieved anatomic closure; 16 of 26 eyes (62%) achieved type 1, and five of 26 eyes (19%) achieved type 2 closure. Post-operative LogMAR VA for type 1 closure holes (0.49) was significantly greater than for type 2 closure and open holes (1.26, P < 0.003 and 1.10, P < 0.005, respectively), despite similar pre-operative VA (P = 0.51 and 0.68, respectively). Mean pre-operative hole diameter for eyes with type 1 closure, type 2 closure, and holes that remained open were 554, 929, and 1205 microns, respectively. Mean pre-operative hole diameter was significantly larger in eyes that remained open as compared to eyes with type 1 closure (P = 0.015).

CONCLUSION

Vitrectomy to repair chronic macular holes can improve vision and achieve long-term closure. Holes of greater than 3.4 years duration were associated with a greater incidence of remaining open and type 2 closure. Larger holes (mean diameter of 1205 microns) were more likely to remain open after repair.

Optimal management of idiopathic macular holes

This review evaluates the current surgical options for the management of idiopathic macular holes (IMHs), including vitrectomy, ocriplasmin (OCP), and expansile gas use, and discusses key background information to inform the choice of treatment. An evidence-based approach to selecting the best treatment option for the individual patient based on IMH characteristics and patient-specific factors is suggested. For holes without vitreomacular attachment (VMA), vitrectomy is the only option with three key surgical variables: whether to peel the inner limiting membrane (ILM), the type of tamponade agent to be used, and the requirement for postoperative face-down posturing. There is a general consensus that ILM peeling improves primary anatomical hole closure rate; however, in small holes (<250 µm), it is uncertain whether peeling is always required. It has been increasingly recognized that long-acting gas and face-down positioning are not always necessary in patients with small- and medium-sized holes, but large (>400 µm) and chronic holes (>1-year history) are usually treated with long-acting gas and posturing. Several studies on posturing and gas choice were carried out in combination with ILM peeling, which may also influence the gas and posturing requirement. Combined phacovitrectomy appears to offer more rapid visual recovery without affecting the long-term outcomes of vitrectomy for IMH. OCP is licensed for use in patients with small- or medium-sized holes and VMA. A greater success rate in using OCP has been reported in smaller holes, but further predictive factors for its success are needed to refine its use. It is important to counsel patients realistically regarding the rates of success with intravitreal OCP and its potential complications. Expansile gas can be considered as a further option in small holes with VMA; however, larger studies are required to provide guidance on its use.

Microperimetric Biofeedback Training Improved Visual Acuity after Successful Macular Hole Surgery

Purpose. To evaluate the efficacy of setting a preferred retinal locus relocation target (PRT) and performing Macular Integrity Assessment (MAIA) biofeedback training in patients showing insufficient recovery of best corrected visual acuity (BCVA) despite successful closure of an idiopathic macular hole (MH). Methods. Retrospective interventional case series. Nine eyes of 9 consecutive patients with the decimal BCVA of less than 0.6 at more than 3 months after successful MH surgery were included. A PRT was chosen based on MAIA microperimetry and the patients underwent MAIA biofeedback training. BCVA, reading speed, fixation stability, and 63% bivariate contour ellipse area (BCEA) were evaluated before and after the training. Statistical analysis was carried out using paired Student's t-test. Results. PRT was chosen on the nasal side of the closed MH fovea in 8 patients. After the MAIA training, BCVA improved in all patients. The mean logMAR value of BCVA significantly improved from 0.33 to 0.12 (p = 0.007). Reading speed improved in all patients (p = 0.29), fixation stability improved in 5 patients (p = 0.70), and 63% BCEA improved in 7 patients (p = 0.21), although these improvements were not statistically significant. Conclusion. MAIA biofeedback training improved visual acuity in patients with insufficient recovery of BCVA after successful MH surgery.

Autologous Internal Limiting Membrane Fragment Transplantation for Large, Chronic, and Refractory Macular Holes

OBJECTIVE

To evaluate a technique of autologous internal limiting membrane (ILM) fragment transplantation for the treatment of large, chronic, and/or refractory macular holes (MH).

DESIGN

This was a 6-month prospective interventional case series.

METHOD

Ten eyes of 10 patients with MH underwent pars plana vitretomy (PPV) and ILM peeling followed by transplantation of an autologous ILM fragment to the MH. Six patients had primary MH with an internal diameter greater than 500 µm and a duration of more than 18 months, including 1 patient with nonproliferative diabetic retinopathy previously treated with panretinal photocoagulation. Four eyes with MH had previously been submitted to PPV (i.e. 1 for retinal detachment and 3 to attempt to close large MH). One of the latter also displayed juxtapapillary choroidal neovascularization due to age-related macular degeneration. The primary and secondary outcomes were MH closure and improvement of the best corrected visual acuity (BCVA), respectively.

RESULTS

Complete MH closure was achieved in all cases. A statistically significant improvement in the average BCVA was observed after 6 months of follow-up (p = 0.018; paired t test). The BCVA improved in 8 eyes (80%), and in 6 of those eyes it improved by ≥ 15 letters. In 1 patient, the BCVA remained unchanged after the surgery, but the visual field reportedly improved. One patient experienced a slight worsening (0.16 logMAR). Two cases developed atrophy of the retinal pigment epithelium despite MH closure and BCVA improvement.

CONCLUSION

Treatment with autologous ILM fragment transplantation seems to be an efficient alternative for large, chronic, and refractory MH.

Predicting visual outcome following surgery for idiopathic macular holes

Since Kelly and Wendel [Arch Ophthalmol 1991;109:654-659] first reported successfully treating macular holes (MHs) using pars plana vitrectomy in 1991, MH surgery has been constantly improved. For example, introducing the removal of the internal limiting membrane considerably increased the closure rate of MHs, and the advent of microincision vitrectomy surgery reduced surgical trauma and decreased patient discomfort after surgery. As modern MH surgery can achieve a higher anatomical success rate and alleviate patients' postoperative distress, postoperative visual outcomes have lately become the primary concern. Informing patients of the expected visual acuity and visual improvement before surgery is ideal, but predicting postoperative visual outcomes is difficult because a large number of factors are associated with them. In this paper, we review previous studies and provide accumulating evidence for the relationship between individual prognostic factors and visual outcomes after MH surgery.

Idiopathic macular hole: analysis of visual outcomes and the use of indocyanine green or brilliant blue for internal limiting membrane peel

BACKGROUND

Our aim was to analyze outcomes of idiopathic macular hole surgeries in relation to staging and the use of indocyanine green (ICG) or brilliant blue (BB) for internal limiting membrane (ILM) peel.

METHODS

Baseline, surgical, and outcome data for 351 consecutive primary macular hole surgeries was prospectively collected using electronic medical record software between 2001 and 2011. The outcomes for these cases were analysed in relation to staging and the use of ICG (0.5 mg/ml) or BB for ILM peel.

RESULTS

Mean age was 68.9 years (range 39-87) with 66.4 % females and 54.1 % right eyes. Follow-up duration was median 0.55 years. Vision was significantly improved from logMAR 0.97 (SD 0.45) (Snellen equivalent 20/185) preoperatively to 0.65 (SD 0.51) (20/90) at final follow-up. One hundred and eighteen patients had stage 2 macular holes, 185 stage 3, and 48 stage 4. Mean duration of symptoms varied with stage of hole: stage 2 0.53 years (SD 0.43), stage 3 0.79 years (SD 0.68), and stage 4 1.20 years (SD 1.26), p = 0.0002. Closure rates of the holes were significantly different, with stage 2 closing in 95.8 %, stage 3 in 73.0 %, and stage 4 in 56.3 %, p < 0.0001. At final follow-up, mean visual acuity (VA) was 0.42 (SD 0.33) (20/50) for stage 2, 0.75 (SD 0.53) (20/110) for stage 3, and 0.87 (SD 0.60) (20/145) for stage 4 holes, p < 0.0001. Postoperative VA was 0.71 (SD 0.53) (20/100) for patients in whom ICG was used, and 0.52 (SD 0.43) (20/70) for BB, p = 0.003. The proportion of patients who achieved a closed hole was less for ICG (73.2 %) than BB (89.9 %), p = 0.0005. For those patients with stage 2 hole who achieved hole closure, mean improvement in VA was significantly better for BB (0.47, SD 0.36) than for ICG (0.30, SD 0.31), p = 0.01.

CONCLUSIONS

Macular hole stage is a useful measure to help predict the chance of postoperative hole closure and visual outcome. The relationship between duration of symptoms and increasing stage suggests macula hole patients require prompt referral for consideration of early surgery. Better visual outcomes were achieved with BB for ILM peel than with ICG.

Morphologic characteristics of chronic macular hole on optical coherence tomography

PURPOSE

To investigate the morphologic characteristics of chronic macular holes (MHs) using optical coherence tomography.

METHODS

We retrospectively reviewed optical coherence tomographic images of consecutive patients who had been diagnosed with MH. Chronic MH was defined as MH that was observed without being surgically treated for at least 1 year. Optical coherence tomographic parameters were compared between chronic and acute MH.

RESULTS

Thirteen eyes of 13 patients were classified as chronic MH, and 67 eyes of 67 patients were classified as controls. While the basal hole diameter of chronic MH was not different from that of controls (P = 0.146), the minimum hole diameter (781.8 μm) of chronic MH was larger than that of controls (448.4 μm; P < 0.001). The hole height and MH index were smaller in the chronic MH group (380.6 μm; 0.31) than in control group (469.9 μm, 0.53; P = 0.033, P = 0.003). Intraretinal fluid was less frequently observed in chronic MH than in controls (P < 0.001). Retinal pigment epithelial atrophy was only observed in chronic MH.

CONCLUSION

Chronic MH has features distinct from those of acute symptomatic MH on optical coherence tomography. These findings provide useful insight for the differentiation of chronic MH from acute MH.

Re-operation of idiopathic full-thickness macular holes after initial surgery with internal limiting membrane peel

BACKGROUND/AIMS

A retrospective consecutive case series to evaluate the efficacy of re-operation in patients with persistent or recurrent idiopathic full-thickness macular hole after initial surgery with internal limiting membrane peel (ILM).

METHODS

491 patients underwent surgery for full-thickness macular hole from January 2004 to November 2007. Fifty-five patients either did not close or reopened during the follow-up period. Thirty patients with initial ILM peel underwent repeat surgery involving vitrectomy, enlargement of ILM rhexis and gas tamponade.

RESULTS

Anatomical closure rate was 88.8% for primary surgery and 46.7% (14/30) for re-operation. There was a statistically significant improvement in overall best corrected visual acuity (BCVA) from re-operation baseline BCVA (p=0.02) within 1 year. For holes that did not close after the second surgery, visual acuity did not worsen.

CONCLUSION

Re-operation has a reduced success rate of anatomical closure. However, BCVA is statistically significantly improved from re-operation baseline, so even though we cannot return vision to pre-pathological baseline, re-operation can improve on this new baseline.

[Macular holes that should not be operated]

The prognosis for macular holes has greatly improved since the advent of vitrectomy. Most improve both anatomically and functionally with effective treatment. However, some situations challenge the indication for surgery: old holes, large holes, and holes associated with retinal pathology.

Relationship between macular hole size and the potential benefit of internal limiting membrane peeling

Macular hole size is a predictor for anatomical closure. Holes >400 μm in aperture size on an OCT scan are more likely to close when ILM is peeled