ANATOMICAL AND VISUAL OUTCOMES OF IDIOPATHIC MACULAR HOLE SURGERY WITH INTERNAL LIMITING MEMBRANE REMOVAL USING LOW-CONCENTRATION INDOCYANINE GREEN

Effect of autologous whole blood in surgery for full-thickness macular hole: a propensity score matching analysis

BACKGROUND

Idiopathic full-thickness macular hole (FTMH) is a vision-threatening disease treated by the "gold standard" pars planar vitrectomy followed by internal limiting membrane peeling. This conventional surgical approach, while yielding a promising 90% closure rate, has a low success rate in large macular holes. Autologous blood has been proven to significantly enhance the healing process and has been introduced into ophthalmic surgeries. The aim of this study is to compare visual and anatomical outcomes of full-thickness macular holes with and without the use of autologous whole blood.

METHODS

This retrospective study included 150 patients (150 eyes) diagnosed with FTMH and underwent primary surgery during 2020-2022. Patients with a minimum of 12 months follow-up were divided into whole blood (WB) group (n = 22) and control group (n = 128). An 1:3 propensity score matching (PSM) was performed based on sex, age, cataract history, diabetes, hypertension, injury, minimum linear diameter (MLD), basal diameter (BD) and preoperative best-corrected visual acuity (BCVA). Postoperative BCVA and optical coherence tomography (OCT) findings were collected for postoperative analysis.

RESULTS

After 1:3 PSM, 22 patients in WB group were matched to 66 patients in control group. The demographic characteristics showed no significant difference except for the MLD in WB group being significantly larger than control group: 762.50 ± 353.11 μm compared to 505.91 ± 193.52 μm (p = 0.003). Despite this unfavorable condition, all MHs were closed in the WB group, while in the control group 14 MHs (21.21%) remained open (p < 0.017). The WB group showed significantly better postoperative mean BCVA than control group (p = 0.016). Also, significantly more patients had improvement in BCVA by 0.2 logMAR or more after surgery in the WB group than in the control group (p = 0.05). After surgery with WB, a rugged retinal surface was observed in MHs larger than 1000 μm via OCT imaging.

CONCLUSIONS

The incorporation of PSM can greatly reduce the bias incurred by confounders in this retrospective study. The adjuvant use of WB significantly improves the functional and anatomical outcomes after MH surgery. Especially in patients with large MHs, WB can precipitate the proliferation and migration of Müller cells which ensures foveal structure restoration.

Critical analysis of macular hole repair techniques: a comprehensive systematic review and meta-analysis comparing internal limiting membrane flap and internal limiting membrane peeling for any size of macular hole

BACKGROUND

Macular holes (MHs) are a leading cause of visual impairment and blindness worldwide defined as a partial or full thickness anatomical defect in the fovea of the retina. ILM peeling is an effective surgical procedure to repair the defect. However, this approach lacks efficacy for larger macular holes. ILM flap is a novel technique with demonstrated efficacy for repair of larger defects.

OBJECTIVE

This systematic review and meta-analysis aims to compare the effectiveness of these two techniques in treating any size and type of MH.

METHODS

A comprehensive literature search was conducted in the PubMed, Medline, and Cochrane Library databases to identify the relevant articles. The primary outcome measures were MH closure rate and postoperative VA. The statistical power was ensured by performing heterogeneity, publication bias, sensitivity analysis, and subgroup analysis. Pooled odds ratios (ORs), mean differences (MD), and 95% confidence intervals (CIs) were calculated. All statistical analyses were performed using R Statistical Software and meta package v4.17-0.

RESULTS

A total of thirty-two studies, comprising nine RCTs and twenty three retrospective studies were included in this meta-analysis, which involved 1220 eyes in the ILM flap group and 1277 eyes in the ILM peeling group. The overall MH closure rate significantly favored ILM flap technique (OR = 2.47, CI = 1.58 to 3.87; P < 0.001; I²= 30%). The overall pooled result for postoperative VA, no significant difference was observed between the two surgical methods. However, it favored ILM flap technique on subgroup analysis based on study type and MH size specifically in the RCTS with macular hole size > 400 μm (MD = -0.13, 95% CI = -0.17 to -0.08, p < 0.01; I2 = 13%), as well as on subgrouping based on follow-up duration (MD = -0.11, 95% CI = -0.14 to -0.08, p < 0.01; I2 = 25%).

CONCLUSION

ILM flap technique resulted in significantly better closure rate with all sizes of MHs, coupled with improved visual acuity in larger MHs and with follow-up duration.

Morphologic Stages of Full-Thickness Macular Hole on Spectral-Domain OCT

OBJECTIVE

To describe the sequential morphological changes of the outer retina after full-thickness macular hole (FTMH) formation utilizing a novel, objective staging system based on OCT, and to determine its association with baseline visual acuity, duration of symptoms, and postoperative visual acuity at 3 months.

DESIGN

Retrospective, observational, multicenter study.

PARTICIPANTS

Patients with idiopathic FTMH presenting to St. Michael's Hospital, Toronto, Canada, and Retina Consultants of Texas, Houston, Texas from 2009 to 2022.

METHODS

The medical charts of 1000 patients with FTMH were reviewed, and those with ≥2 preoperative spectral-domain OCTs (SD-OCTs) were analyzed. A staging system was developed by assessing outer retinal morphology on successive SD-OCT central foveal scans.

MAIN OUTCOME MEASURES

Sequential outer retinal morphological changes with SD-OCT over time and their association with baseline visual acuity, duration of symptoms, and postoperative functional outcomes.

RESULTS

Fifty-two eyes of 52 patients with a mean age of 65.4 ± 8.4 years were included. Sequential outer retinal morphologic changes at the FTMH borders occurred in 4 distinct and reproducible stages: stage A, separation of the neurosensory retina from the retinal pigment epithelium with the well-defined external limiting membrane (ELM), ellipsoid zone (EZ), and interdigitation zone (4/52, 7.7%); stage B, thickening of the EZ (27/52, 52.0%); stage C, patchy (moth-eaten) photoreceptor loss (16/52, 30.7%); and stage D, severe or complete loss of inner and outer segments and bare ELM (5/52, 9.6%). When assessing the preoperative OCT scans closest to the time of surgery, over a mean follow-up period of 288.9 ± 350.4 days (range, 5-1841), 28.85% (15/52) of eyes were in stage B, 28.85% (15/52) were in stage C, and 42.3% (22/52) were in stage D. There was a statistically significant association between increasing stage at baseline and longer duration of macular hole symptoms (P = 0.032) and worse visual acuity at baseline (P < 0.001). Additionally, patients presenting with stages B and C at the time point closest to surgery had better visual acuity outcomes 3 months postoperatively than those with stage D (P = 0.04).

CONCLUSIONS

This SD-OCT staging system describes the sequential in vivo morphologic changes after FTMH formation, providing a novel imaging biomarker.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Factors influencing the reliability of measurements in eyes with full-thickness macular holes: are we measuring incorrectly?

PURPOSE

The calliper function is used for manual measurements of full thickness macular holes (FTMHs). We aimed to investigate whether a reproducible difference could be detected beyond interobserver variability between two commonly used manufacturers in their manual calliper facility in spectral domain optical coherence tomography (OCT) for metrics related to FTMH.

METHODS

This is a non-interventional, retrospective, observational study. Two independent observers examined 8 eyes (16 OCT) scans and 128 measurements (minimal linear diameter (MLD), basal diameter and hole height on both sides) of FTMHs, taken on Heidelberg Spectralis and Topcon Triton (OCT machines). The interobserver agreement and OCT machine agreement of measurements were analysed by Bland-Altman plots and intraclass correlation coefficient (ICC) analysis. Spectralis and Triton had 125 µm and 50 µm horizontal b-scan spacing, respectively.

RESULTS

Overall, we report high absolute agreement in interobserver (ICC 0.991 (95% CI 0.985 to 0.995, p<0.001)) and OCT machine (ICC 0.993 (95% CI 0.987 to 0.996, p<0.001)) variability. Lower horizontal resolution in Triton compared with Spectralis leads to interobserver variability, in smaller horizontal measurements. Lower horizontal scanning density in Spectralis lead to relatively large interobserver variation if different reference scans were chosen, and consistently smaller MLD measurements than Triton. Vertical measurements without 1:1 scaling lead to inaccurate exaggerated oblique vertical measurements. Calliper function appears otherwise identically calibrated.

CONCLUSIONS

We report excellent interobserver and OCT machine agreement in measurements. However, the paper shows several factors that could influence the reliability of measurements acquired in eyes with FTMHs, such as the dimension of the hole as well as different image resolution, density scanning protocols or vertical scaling of the OCT machines viewing platform.

Short-term results of surgical treatment in large idiopathic macular hole cases

PURPOSE

To evaluate results of the surgical treatment for large stage (Stage 3 and 4) idiopathic macular hole cases with and without ILM flap technique.

METHODS

Sixty eyes of 60 patients diagnosed with idiopathic macular hole (MH) were included in the study. Complete ophthalmologic examination and SD-OCT examination were performed in all eyes. MH stages, MH base diameter, height and closest distance were measured quantitatively. Postoperative and 3 months visits were evaluated.

RESULTS

The mean age of the cases was 65.0 ± 8.0 (range 30-84) years, there were 31 (51.7%) female and 29 (48.3%) male patients with a mean follow-up period of 18.1 ± 16.7 (range 3-63) months. The mean best corrected visual acuity recorded at preoperative and third month control visits were 0.89 ± 0.40(preoperative) logMAR, 0.82 ± 0.60(3 month) logMAR (p < 0.05). The mean MH index was 0.48 ± 0.16, the closest hole distance was 517.86 ± 210.89 µm and mean basal diameter of holes was 947.78 ± 361.90 µm and the average height was 448.93 ± 79.80 microns. There was no statistically significant difference between anatomic results of macular hole surgery with (n = 22) and without (n = 38) flap in terms of hole closure (86.4% vs. 92.1% p > 0.05). In 90% (54 cases) of the cases, closure was observed after the first surgery. Two eyes that failed macular hole surgery were reoperated. In one of these eyes, anatomical success was obtained with macular hole massage and mechanical cytumulation. However, anatomical success could not be achieved in the other eye. CONCLUSıON: In the treatment of large macular holes, pars plana vitrectomy, internal limiting membrane peeling with/without flap and gas tamponade demonstrated high anatomical and functional success.

Impact of inverted internal limiting membrane-flap technique on functional outcome and structural restoration of small and medium size macular holes

Purpose

To evaluate the impact of the inverted internal limiting membrane (ILM)-flap technique on the visual outcome and anatomical recovery for small (<250 μ), medium (<400 μ), and large (>400 μ) macular holes (MHs).

Methods

Retrospective study included consecutive idiopathic MH cases operated on using the inverted ILM-flap technique. Clinical data were retrieved from electronic medical records (EMRs), surgical videos, and optical coherence tomography (OCT) machines. Eyes with axial length >25 mm, coexisting macular diseases, and follow-up <6 weeks were excluded. Data included the presence or absence of ILM flap and restoration of External Limiting Membrane (ELM), Ellipsoid Zone (EZ) lines. Mean visual improvement and structural recovery were compared between eyes showing ILM flap and those showing no flap in three MH size groups.

Results

Forty eyes of 38 patients with a mean age of 62.7 ± 10.1 years and a mean MH diameter of 348 ± 152 μm were included. The mean follow-up was 527 ± 478 days with anatomical closure observed in all eyes. Mean best-corrected visual acuity (BCVA) improved significantly from 0.87 ± 0.38 to 0.35 ± 0.26. ILM flap was visible in 29 (72.5%) all MHs, 7 (53.8%) small MHs (n = 13), 8 (61.5%) medium MHs (n = 13), and 14 (100%) large MHs (n = 14). The mean BCVA change was 0.47 ± 0.34, 0.53 ± 0.48, and 0.56 ± 0.20 in large, medium, and small MHs, respectively, and the difference between eyes showing ILM flap versus no flap in each MH size group was not statistically significant (P > 0.05). However, for medium MHs, it was higher in the ILM flap (0.66 ± 0.52) group compared to the no flap (0.32 ± 0.37) group. One eye with small MH developed significant gliosis resulting in reduced BCVA. ELM was restored in all eyes with small and medium MHs.

Conclusion

We observed that the ILM flap did not adversely affect anatomical and visual outcomes for MHs <400 μm. Restoration of ELM suggests minimal interference in structural recovery by an ILM flap.

Trends and Hotspots Concerning Macular Hole between 2002 and 2021: A 20-Year Bibliometric Study

BACKGROUND

Macular hole (MH) can severely impair central vision. Although it can be treated with vitrectomy surgery, avoiding recurrence and improving visual acuity are still priorities to be addressed. This study aims to reveal the trends and hotspots about MH.

METHODS

The Web of Science Core Collection (WOSCC) was used to perform a bibliometric analysis investigating trends of MH research from 2002 to 2021. We evaluated the details of associated regions, institutions, authors, and journals. To construct and overlay network visualizations, VOSviewer software was used.

RESULTS

In total, 1518 publications were collected. Our analysis showed that MH research is becoming increasingly relevant, with Japan achieving the largest number of publications (291), largest number of citations (7745 in total), and highest h-index value (48). Retina published the most publications on this topic, totaling more than the next two journals combined. An analysis of keyword co-occurrence was evaluated, highlighting several novel keywords of interest, such as flap technique, transplantation, epiretinal proliferation (EP), foveal microstructure, and retinal sensitivity.

CONCLUSIONS

Details on MH research were uncovered by comprehensively analyzing the global trends and hotspots over the past two decades, presenting valuable information for future MH research. Japan, the USA, and China hold leading positions in research on this topic. Amendable surgical methods are a potential focus for improving prognosis.

Modified inverted internal limiting membrane flap technique for macular hole closure

PURPOSE

To investigate the efficacy of modified internal limiting membrane (ILM) flap technique combined with vitreous surgery for treating macular holes and examine the outcomes in visual function and anatomic macular hole closure.

STUDY DESIGN

Retrospective, observational.

METHODS

Between July 1, 2015, and October 1, 2019, the modified inverted ILM flap technique combined with vitreous surgery was used to treat idiopathic macular holes, postoperative progression was then followed for at least 6 months in 96 participants (98 eyes). We modified the method by removing the lower half of the ILM while peeling and inverting the upper half. The mean age of the participants was 65.9 ± 11.9 years (41 men (42.7%) and 55 women (57.3%)). Retrospective evaluations of macular hole diameter, corrected visual acuity, and macular hole closure rates were performed using data from medical records.

RESULTS

The mean macular hole diameter was 623.6 ± 207.4 μm. The mean corrected visual acuity (logMAR) was 0.79 ± 0.27 before surgery and 0.46 ± 0.35 at 1, 0.35 ± 0.39 at 3, and 0.31 ± 0.36 at 6 months Post surgery, showing significant differences before and after surgery (p = 2.30 × 10^- 2). The macular hole closure rate was 98%.

CONCLUSION

The modified inverted ILM flap technique combined with vitreous surgery was an effective method for treating macular holes, resulting in improvement in closure and visual acuity.

Spotlight on the Internal Limiting Membrane Technique for Macular Holes: Current Perspectives

Pars plana vitrectomy has become the standard procedure for primary macular holes (MHs) repair, including the removal of the posterior cortical vitreous, the stripping of eventual epiretinal membranes, and finally an intraocular gas tamponade. During this procedure, peeling the internal limiting membrane (ILM) has been proven to increase closure rates and avoid postoperative reopening in several researches. In fact, even in large MHs more than 400 µm, the advantage of peeling off the ILM was highlighted by better anatomical closure rates. Nevertheless, some authors suggested that ILM peeling is not always essential, because it generates various side effects in retinal structure and function. Furthermore, the ideal amount of ILM peeling and the most effective strategies for removing the ILM are still subject of research. Different surgical modifications have been reported as alternatives to traditional peeling in certain clinical settings, including ILM flaps, ILM scraping, and foveal sparing ILM peeling. As regards large MHs, the introduction of ILM inverted flap appeared as a game changer, offering a significantly higher >90% closure rate when compared to traditional ILM peeling. Modifications to inverted ILM flap procedures have been claimed in recent years, in order to define the best area and direction of ILM peeling and its correlation with functional outcomes. Moreover, several innovations saw the light in the setting of recurrent MHs, such as ILM free flap transposition, inverted ILM flap combined autologous blood clot technique, neurosensory retinal flap, and human amniotic membrane (HAM) plug, claiming higher anatomical success rate also in those complex settings. In conclusion, the aim of this review is to report how the success rate of contemporary macular surgery has grown since the turn of the century, especially for big and chronic MHs, analyzing in which way ILM management became a crucial point of this kind of surgery.

Characteristics of macular microvasculature before and after idiopathic macular hole surgery

AIM

To evaluate the macular microvasculature before and after surgery for idiopathic macular hole (MH) and the association of preoperative vascular parameters with postoperative recovery of visual acuity and configuration.

METHODS

Twenty eyes from 20 patients with idiopathic MH were enrolled. Optical coherence tomography angiography (OCTA) images were obtained before, 2wk, 1, and 3mo after vitrectomy with internal limiting membrane peeling. Preoperative foveal avascular zone (FAZ) area and perimeter and regional vessel density (VD) in both layers were compared according to the 3-month best-corrected visual acuity (BCVA).

RESULTS

The BCVA improved from 0.98±0.59 (logMAR, Snellen 20/200) preoperatively to 0.30±0.25 (Snellen 20/40) at 3mo postoperatively. The preoperative deep VD was smaller and the FAZ perimeter was larger in the 3-month BCVA<20/32 group (all P<0.05). A significant reduction was observed in FAZ parameters and all VDs 2wk postoperatively. Except for deep perifoveal VD, all VDs recovered only to their preoperative values. The postoperative FAZ parameters were lower during follow-up. Decreases in preoperative deep VDs were correlated with worse postoperative BCVA (Pearson's r=-0.667 and -0.619, respectively). A larger FAZ perimeter (Spearman's r=-0.524) and a lower deep perifoveal VD preoperatively (Pearson's r=0.486) were associated with lower healing stage.

CONCLUSION

The status of the deep vasculature may be an indicator of visual acuity in patients with a closed MH. Except for the deep perifoveal region, VD recovers only to preoperative levels.

Efficacy and safety of primary posterior capsulotomy during phaco-vitrectomy for epiretinal membrane

Purpose

To evaluate the necessity and safety of primary posterior capsulotomy during phaco-vitrectomy for idiopathic epiretinal membrane (ERM).

Setting

Seoul National University Bundang Hospital, Seongnam, Korea.

Design

Retrospective consecutive cohort analysis.

Methods

This study enrolled 219 patients (228 eyes) who underwent combined 25-gauge phaco-vitrectomy for idiopathic ERM and cataract, divided into capsulotomy (−) group (152 eyes, 144 patients) and capsulotomy (+) group (76 eyes, 75 patients). The main outcomes were rate of posterior capsular opacity (PCO) occurrence and postoperative complications. Ophthalmic examinations were performed at baseline, 1, 3, 6, and 12 months postoperatively.

Results

PCO only occurred in capsulotomy (−) group (20 eyes, 13.2%), with mean onset of 10.59 months. Visually-significant PCO that needed Nd:YAG posterior capsulotomy was present in 9 eyes (45.0% of PCO eyes). The rate of cystoid macular edema (CME) was higher in capsulotomy (+) group (6.6% vs. 15.8%, p = 0.026) with longer duration (1.50 vs. 3.36 months, p = 0.019). Female sex and posterior capsulotomy were significant risk factors for CME occurrence (p < 0.05).

Conclusion

Primary posterior capsulotomy during phaco-vitrectomy for idiopathic ERM obviated the need for Nd:YAG posterior capsulotomy, but visually-significant PCO that needed Nd:YAG laser was not common. Considering the low rate of visually-significant PCO and high rate of postoperative CME, routine posterior capsulotomy during phaco-vitrectomy may not be necessary for preventing PCO in ERM.

Epiretinal Membrane from Uncontrolled Gliosis After Inverted ILM Flap Technique for Idiopathic Macular Hole

We describe two cases with epiretinal membrane (ERM) from uncontrolled gliosis seen after multilayered inverted internal limiting membrane (ILM) flap technique for full thickness macular hole (FTMH). Two patients with FTMH who had undergone surgery with inverted ILM flap technique were examined by serial optical coherence tomography scans to evaluate the course of multilayered ILM flaps seen as foveal hyperreflective lesions postoperatively. We observed excessive uncontrolled gliosis over these hyperreflective ILM flaps with ERM formation, along with worsening metamorphopsia and best-corrected visual acuity. Case 1 underwent a repeat surgery for ERM. We report excessive uncontrolled gliosis as a rare complication of multilayered inverted ILM flap technique for FTMH. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:663-665.].

Macular microvasculature differences in patients with macular hole after vitrectomy with internal limiting membrane removal or single-layered temporal inverted flap technique

PURPOSE

To compare the macular microvasculature differences in cases with idiopathic macular hole (MH) after vitrectomy when using internal limiting membrane (ILM) removal or temporal inverted ILM flap technique (IFT).

METHOD

A total of 34 patients were included, of whom 20 were treated vitrectomy with ILM removal (group 1), and 14 were treated with IFT (group 2). The OCTA (RTVue; Optovue, Fremont, CA) parameters, including foveal avascular zone (FAZ), vessel density (VD) ratios in superficial capillary plexus (SCP), and deep capillary plexus (DCP) were evaluated at baseline and 6 months follow-up. The VD measurements in DCP and inner retinal thickness (IRT) in temporal and nasal sectors were compared in subanalyses.

RESULTS

There was no significant difference in means of post-operative BCVA and FAZ between the two groups (p = 0.943, p = 0.760). The mean VDs of the DCP was significantly decreased at 6 months postoperatively in both groups (p < 0.001, p < 0.001). The mean post-operative temporal VDs of DCP were similar in the two groups, but the mean post-operative nasal VDs of the DCP was lower in group 1 than in group 2 (p = 0.005 and p = 0.03 for parafovea and perifovea, respectively). The mean temporal IRTs were similar in the two groups, but paranasal and perinasal IRTs were significantly thinner in group 1 than in group 2 (p < 0.001, p < 0.001). The mean post-operative VDs of parafoveal and perifoveal temporal and nasal quadrants in DCP significantly and positively correlated with the IRTs.

CONCLUSION

Single-layered temporal IFT causes fewer VD changes when compared to complete ILM removal, especially in the DCP.

Inverted internal limiting membrane flap technique versus internal limiting membrane peeling for large macular holes: A meta-analysis of randomized controlled trials

BACKGROUND

Vitrectomy with internal limiting membrane (ILM) peeling is an effective surgical procedure for the treatment of macular holes (MHs). However, there is a possibility of poor postoperative anatomical closure with conventional ILM peeling for MHs larger than 400 μm. Therefore, a novel inverted ILM flap technique was developed for such cases.

OBJECTIVES

This meta-analysis study was performed to evaluate and compare the anatomical and visual outcomes of the inverted ILM flap technique and ILM peeling in large MHs.

METHODS

The Cochrane Library, PubMed, and Embase databases were searched to identify randomized controlled trials (RCTs). The trial eligibility and risk of bias were assessed according to Cochrane review methods. The primary outcome measures included MH closure rate and postoperative visual acuity (VA). Subgroup analysis of postoperative VA based on follow-up time was also conducted. Pooled odds ratios (ORs), weighted mean difference (WMD), and 95% confidence intervals (CIs) were calculated. Statistical analysis was performed using RevMan 5.3 software.

RESULTS

Five RCTs with a total of 155 eyes in the inverted ILM flap group and 161 eyes in the ILM peeling group were included in this meta-analysis. Statistical meta-analysis revealed that the overall MH closure rate in the inverted ILM flap group was significantly higher than that in the ILM peeling group (OR, 3.10; 95% CI, 1.25 to 7.66; P = 0.01). The postoperative VA was significantly better in the inverted ILM flap group than ILM peeling group (WMD, -0.14; 95% CI, -0.21 to -0.07; P = 0.0002). The subgroup meta-analysis indicated that the postoperative VA was significantly better in the inverted ILM flap group than ILM peeling group (WMD, -0.17; 95% CI, -0.26 to -0.08; P = 0.0004) at the 3-month follow-up. However, no significant difference was observed between the two groups at the 6-month follow-up (WMD, -0.09; 95% CI, -0.20 to 0.02; P = 0.10).

CONCLUSIONS

Vitrectomy with inverted ILM flap technique showed a higher anatomical closure rate as well as visual gain-although only in the short-term as no difference in visual recovery was found at the 6-month follow-up-than did ILM peeling in large MHs. The inverted ILM flap technique should be considered as a preferred and routine procedure for the treatment of patients with MHs larger than 400 µm.

Inverted ILM Flap Technique in Idiopathic Full-Thickness Macular Hole Surgery: Functional Outcomes and Their Correlation with Morphologic Findings

Objectives

The inverted internal limiting membrane (ILM) flap technique has been shown to increase the success rate in large full-thickness macular holes (FTMHs) and in FTMHs associated with high myopia. The aim of our study was to confirm the efficacy and safety of inverted ILM flap technique in idiopathic FTMHs independent of their dimensions and to assess functional outcomes and their correlation to morphologic findings.

Methods

Sixteen consecutive patients affected by idiopathic FTMH were enrolled in this prospective study. The preoperative mean (±SD) diameter of the FTMH was 422 (±106) µm. All patients underwent vitrectomy and ILM peeling with inverted ILM flap. At 1-, 3-, and 6-month postoperative visits, visual acuity measurement, indirect ophthalmoscopy, and microperimetry were performed, and the foveal contour and the integrity of the ellipsoid zone (EZ) and external limiting membrane (ELM) were investigated using spectral domain optical coherence tomography (SD-OCT).

Results

At six months postoperatively, 15 out of 16 (93.75%) patients obtained FTMH closure. The mean best corrected visual acuity (BCVA) improved from 1.1 LogMAR to 0.3 LogMAR, and the mean retinal sensitivity (MS) improved from 7.2 to 23.4 dB. ELM defects were evident in 1 out of 16 (6.25%) eyes, and EZ defects were detected in 2 out of 16 (12,50%) eyes. A statistically significant relationship was observed between BCVA, MS, and EZ reconstitution at each follow-up visit.

Conclusions

Results confirm that the inverted ILM flap technique is a safe and effective option for FTMH treatment and show a strong correlation between higher BCVAs and MSs and EZ reconstitution after surgery.

ASSESSING THE ABILITY OF PREOPERATIVE QUANTITATIVE SPECTRAL-DOMAIN OPTICAL COHERENCE TOMOGRAPHY CHARACTERISTICS TO PREDICT VISUAL OUTCOME IN IDIOPATHIC MACULAR HOLE SURGERY

PURPOSE

To determine which spectral domain optical coherence tomography biomarkers of idiopathic macular hole (MH) correlate with the postoperative best-corrected visual acuity (BCVA) in anatomically closed MH.

METHODS

Retrospective analysis of spectral domain optical coherence tomography scans of 44 patients presenting with MH followed for a mean of 17 months. Widths of MH aperture, base, and ellipsoid zone disruption were calculated from presenting foveal spectral domain optical coherence tomography B-scans. Macular hole base area and ellipsoid zone disruption area were calculated through the custom in-house software.

RESULTS

Poorer postoperative BCVA correlated with increased preoperative choroidal hypertransmission (r = 0.503, P = 0.0005), minimum diameter (r = 0.491, P = 0.0007), and base diameter (r = 0.319, P = 0.0348), but not with preoperative ellipsoid zone width (r = 0.199, P = 0.2001). Applying en-face analysis, the BCVA correlated weakly with preoperative ellipsoid zone loss area (r = 0.380, P = 0.013), but not with preoperative MH base area (r = 0.253, P = 0.1058).

CONCLUSION

Increased MH minimum diameter, base diameter, base area, and choroidal hypertransmission are correlated with a poorer postoperative BCVA. Ellipsoid zone loss measurements were not consistently correlated with a BCVA. Choroidal hypertransmission width may be an easy-to-visualize predictive imaging biomarker in MH surgery.

A novel video overlay guided enlargement of area of ILM peeled versus inverted flap technique: A long-term study in large macular holes

BACKGROUND/AIM

To compare the intra-operative video overlay guided enlargement of Area of ILM peeled (AIP) more than three Disc Diameter (DD) versus the inverted flap technique in large (>400 µm ) Full Thickness Macular Holes (FTMH).

METHODS

Retrospectively, 127 cases of large FTMHs divided into two groups (i) Group A (n = 62)-intra-operative video-overlay guided enlargement of AIP > 3DD performed and (ii) Group B (n = 65)-Inverted flap technique was done. Mean Best Corrected Visual Acuity (BCVA), hole closure rate and postoperative foveal anatomy were noted on Optical Coherence Tomography (OCT).

RESULTS

Mean Minimal Diameter of Macular Hole (MDMH) were 632.05 ± 146.62 µm (A) and 677.24 ± 152.08 µm (B). Hole closure rate were 93.55% (A) and 96.92% (B). Mean preoperative BCVA was 1.07 ± 0.37 Log MAR (A) and 0.94 ± 0.23 Log MAR (B). Mean postoperative BCVA at 3 months were 0.73 ± 0.22 Log MAR (A) and 0.83 ± 0.24 Log MAR (B). One-way ANOVA test showed statistically better visual improvement in Group A at 3 months (p = 0.02), 6 months (p = 0.045), 12 months (p = 0.002), and 24 months (p = 0.011). Chi square test revealed Type I pattern of hole closure was statistically more in Group B (p < 0.001). Delayed Recovery of Outer Retinal Layers was more in group B (Pearson Chi square test, p = 0.039).

CONCLUSION

Anatomically, macular hole closure rate as well as closure pattern was better in Group B. But functional improvement was better in Group A.

Inverted ILM flap technique versus conventional ILM peeling for idiopathic large macular holes: A meta-analysis of randomized controlled trials

Purpose

To compare the anatomical and visual outcomes of inverted internal limiting membrane (ILM) flap technique with the conventional ILM peeling for idiopathic large macular holes (MHs).

Methods

A meta-analysis of randomized control trials (RCTs) using online databases including NCBI PubMed, ClinicalTrials.gov, and ISI Web of Science was performed. Anatomic success and type 1 closure rates, the mean postoperative best-corrected visual acuity (BCVA) and the mean change of BCVA from baseline were analyzed.

Results

Out of 251 articles, four described clinical trials matching the inclusion criteria and were selected. They included 276 eyes (135 eyes in the inverted ILM flap group and 141 eyes in the ILM peeling group). All the studies used gas tamponade, with two studies having a follow-up duration of 3 months, while one study had a follow-up of 6 months and one study– 12 months. The meta-analysis demonstrated that anatomic success and type 1 closure rates (presence of neurosensory retina in MH) were better in the inverted ILM flap technique (odds ratio (OR) = 4.89; 95% confidence interval (CI), 2.09–11.47; P = 0.0003 and OR = 5.23; 95% CI, 2.83–9.66; P<0.00001). Similarly, the inverted flap technique was superior in terms of postoperative logMAR BCVA and mean change of logMAR BCVA from baseline (weighted mean difference (WMD) = 0.17, 95% CI, 0.11 to 0.24, P<0.00001 and WMD = 0.08, 95% CI, 0.01 to 0.16, P = 0.03)

Conclusion

Inverted ILM flap treatment resulted in better closure rates and visual acuity when compared to the standard ILM peeling for large MHs.

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.

Pars plana vitrectomy with silicone oil tamponade for primary and secondary macular hole closure: Is it still a useful procedure?

Purpose:

To evaluate usefulness of posterior vitrectomy with silicone oil tamponade for primary and secondary macular hole closure.

Methods:

We searched for publications on the surgical treatment of full-thickness idiopathic and recurrent macular hole. We divided reports into two groups: primary macular hole repair and recurrent macular hole repair with silicone oil tamponade.

Results:

In primary macular hole treatment, different authors confirmed effectiveness of silicone oil tamponade. They suggest that the most important factor for successful outcome was completeness of vitreous cavity filling with oil. Complications after this method were comparable to those after gas tamponade. However, even if good anatomical results are achieved in secondary macular hole closure, visual acuity is sometimes less rewarding.

Conclusion:

There are reports on good efficacy of silicone oil tamponade for primary and recurrent macular hole closure. Anatomical closure and visual acuity rates in pars plana vitrectomy with silicone oil and with gas filling are comparable. Gas tamponade seems to be safer and needs no more surgery. Postoperative complications in both methods are similar, but all patients with silicone oil filling need to undergo a reoperation to have the silicone removed. There are also other surgical techniques for primary macular hole closure as well as for unsuccessful primary macular hole procedures. We think that primary macular hole closure should be performed with gas tamponade, supported with different adjuvants, as a method of choice. Silicone oil tamponade could be still an alternative in cases, when there are no more efficient techniques or possibilities to treat with success recurrent macular hole.

Intraoperative optical coherence tomography in the full-thickness macular hole surgery with internal limiting membrane inverted flap placement

PURPOSE

To describe the helpfulness of using intraoperative optical coherence tomography (OCT) during surgery for full-thickness macular hole (FTMH).

OBSERVATIONS

This observational case series identifies three patients with FTMH who were treated with vitrectomy, internal limiting membrane (ILM) peel with inverted ILM flap, which was tucked into the MH, and air with 18% Sulfur Hexafluoride (SF₆) gas tamponade. Intraoperative OCT was used to confirm positioning of the ILM flap, even after complete air-fluid exchange. The patients were followed for three months after surgery and all reached a good morphological and functional outcome.

CONCLUSIONS

If confirmed by a prospective longitudinal study, the intraoperative OCT might become an important tool in assisting FTMH surgery.

Face-down or no face-down posturing following macular hole surgery: a meta-analysis

PURPOSE

To evaluate the impact of postoperative posturing with or without face-down on the anatomical and functional outcomes of macular hole surgery.

METHODS

A literature-based meta-analysis was conducted to identify studies relevant to posturing following macular hole surgery (MHS). PubMed and Web of Science databases were used to retrieve articles up to 1 June 2015. The primary measures included MH closure and ideal vision acuity improvement. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated in Review Manager.

RESULTS

Four randomized control trials (RCTs) comprising 251 cases were included in the final meta-analysis. No face-down posturing (FDP) after MHS revealed lower anatomic success rate compared to face-down posturing (OR = 0.33, 95% CI [0.13, 0.81], p = 0.02). For holes smaller than 400 μm in size, the subgroup meta-analysis indicated no significant effect of FDP on successful hole closure (OR = 0.29, 95% CI [0.01, 7.34], p = 0.45). However, when holes were larger than 400 μm, it seemed less effective on MH closure following surgery in no FDP group (OR = 0.23, 95% CI [0.07, 0.71]), and this was statistically significant (p = 0.01).

CONCLUSIONS

Our work found that no FDP was not inferior to its face-down counterpart for the success of MHS when macular holes were smaller than 400 μm in size. For macular holes larger than 400 μm, statistical analysis proved that FDP might be necessary. More well-conducted randomized control trials are needed to verify our findings.

Assessment of Foveal Microstructure and Foveal Lucencies Using Optical Coherence Tomography Radial Scans Following Macular Hole Surgery

PURPOSE

To evaluate the foveal microstructure using high-density (24-line) radial scans and their correlation with visual recovery following macular hole surgery.

DESIGN

Retrospective, consecutive, interventional case series.

METHODS

Forty-five eyes of 43 patients with ≥6 months follow-up following surgery were analyzed. Preoperative predictive measures evaluated included basal hole and minimum linear diameters. Outcome measures included best-corrected visual acuity (BCVA), postoperative foveal lucency horizontal and vertical size, external limiting membrane, and ellipsoid zone defect.

RESULTS

Mean basal hole diameter was 642 ± 330 μm and minimum linear diameter was 277 ± 161 μm. BCVA (logMAR) improved from 0.67 ± 0.23 to 0.31 ± 0.16 at 12 months (P < .001). Foveal lucency horizontal and vertical sizes (μm) improved from 97 ± 81 and 33 ± 18 at 1 month to 26 ± 33 and 19 ± 18, respectively (P < .05) at 12 months. External limiting membrane recovered in all cases at 1 month. Mean ellipsoid zone defect (μm) reduced from 136 ± 164 at 1 month to 32 ± 33 at 12 months (P < .05). Preoperative basal hole diameter correlated with horizontal foveal lucency size at all time points (P < .05). Horizontal foveal lucency size at 1 month correlated (P < .05) with BCVA at 6 and 12 months. Basal hole diameter ≥700 μm (71% sensitivity and 70% specificity) and minimum linear diameter ≥330 μm (71% sensitivity and 70% specificity) were predictive of foveal lucency development. Cataract surgery did not influence foveal lucency resolution and no holes reopened.

CONCLUSION

Using radial scans, 71% of eyes demonstrated a foveal lucency at 1 month, whose size correlated with visual recovery. Preoperative basal hole diameter was predictive of foveal lucency development and size.

Rates of Reoperation and Retinal Detachment after Macular Hole Surgery

PURPOSE

To evaluate rates of reoperation and retinal detachment (RD) after macular hole surgery.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Patients in the insurance claim-based MarketScan databases from 2007 through 2013 with a record of macular hole surgery.

METHODS

Patients with macular hole surgery were identified. Cases of definite (the same eye was coded both times) and presumed (the eye laterality was not coded) macular hole reoperations within 2, 3, and 12 months were queried. In addition, cases of postoperative RD within 2, 3, and 12 months were captured.

MAIN OUTCOME MEASURES

Rates of macular hole reoperation and postoperative RD, including subgroup analysis based on presence or absence of internal limiting membrane (ILM) peeling.

RESULTS

Records of 23465 macular hole surgeries among 20 764 patients were analyzed. Among presumed reoperations, the rates of reoperation were 4.3% (4.1% after ILM peeling and 5.0% after no ILM peeling; P = 0.01) within 2 months of surgery, 5.5% (5.3% after ILM peeling and 6.2% after no ILM peeling; P = 0.03) within 3 months of surgery, and 9.5% (9.0% after ILM peeling and 11.0% after no ILM peeling; P = 0.01) within 12 months of surgery. The rates for definite reoperations were 1.3% (1.2% after ILM peeling and 1.8% after no ILM peeling; P = 0.04) at 2 months, 1.7% (1.6% after ILM peeling and 2.5% after no ILM peeling; P = 0.004) at 3 months, and 4.1% (3.3% after ILM peeling and 7.5% after no ILM peeling; P < 0.001) at 12 months. The cumulative rate of postoperative RD was 1.81±0.09% to 2.18±0.5% after 2 months, 2.27±0.10% to 3.18±0.67% after 3 months, and 3.92±0.16% to 5.70±1.1% after 12 months. Internal limiting membrane peeling was associated negatively with postoperative RD at 2 months (2.3% vs. 1.7%; P = 0.007), 3 months (2.8% vs. 2.1%; P = 0.004), and 12 months (4.7% vs. 3.3%; P < 0.001).

CONCLUSIONS

In this sample, reoperations for macular hole were performed at low rates. Internal limiting membrane peeling was associated with lower rates of reoperation and RD.

Re-accumulation of macular pigment after successful macular hole surgery

AIMS

To investigate macular pigment optical density (MPOD) during follow-up of sealed macular holes and to study correlations of MPOD with progressive changes in spectral-domain optical coherence tomography (SD-OCT) and functional results.

METHODS

Consecutive patients (n=18) who had undergone successful vitrectomies for idiopathic macular holes were evaluated postoperatively at 1, 3, 6 and 9 months. At each follow-up visit, MPOD was measured with a modified confocal scanning laser ophthalmoscope and the outer retina evaluated by SD-OCT. The changes of MPOD postoperatively and the relationship of MPOD and SD-OCT findings to best corrected visual acuity were examined.

RESULTS

MPOD did not change significantly throughout follow-up, from 0.49±0.22 (mean±SD) at month 1 to 0.42±0.18 at month 9. There was a tendency towards a significant association between amount of MPOD and recovery of external limiting membrane during follow-up (p=0.068). Best corrected visual acuity increased significantly from 0.24±0.12 before surgery to 0.65±0.25 at month 9. Recovery of the ellipsoid zone determined most of visual acuity improvement (p=0.024). MPOD was not associated with visual acuity changes (p=0.394).

CONCLUSIONS

Revisualisation of macular pigment after successful macular hole surgery is not associated with improved visual acuity and may merely be an accompanying sign of the reapposition of the edges of the hole.

A new method to predict anatomical outcome after idiopathic macular hole surgery

PURPOSE

To investigate whether a new macular hole closure index (MHCI) could predict anatomic outcome of macular hole surgery.

METHODS

A vitrectomy with internal limiting membrane peeling, air-fluid exchange, and gas tamponade were performed on all patients. The postoperative anatomic status of the macular hole was defined by spectral-domain OCT. MHCI was calculated as (M+N)/BASE based on the preoperative OCT status. M and N were the curve lengths of the detached photoreceptor arms, and BASE was the length of the retinal pigment epithelial layer (RPE layer) detaching from the photoreceptors. Postoperative anatomical outcomes were divided into three grades: A (bridge-like closure), B (good closure), and C (poor closure or no closure). Correlation analysis was performed between anatomical outcomes and MHCI. Receiver operating characteristic (ROC) curves were derived for MHCI, indicating good model discrimination. ROC curves were also assessed by the area under the curve, and cut-offs were calculated. Other predictive parameters reported previously, which included the MH minimum, the MH height, the macular hole index (MHI), the diameter hole index (DHI), and the tractional hole index (THI) had been compared as well.

RESULTS

MHCI correlated significantly with postoperative anatomical outcomes (r = 0.543, p = 0.000), but other predictive parameters did not. The areas under the curves indicated that MHCI could be used as an effective predictor of anatomical outcome. Cut-off values of 0.7 and 1.0 were obtained for MHCI from ROC curve analysis. MHCI demonstrated a better predictive effect than other parameters, both in the correlation analysis and ROC analysis.

CONCLUSIONS

MHCI could be an easily measured and accurate predictive index for postoperative anatomical outcomes.

Correlation Between the Dynamic Postoperative Visual Outcome and the Restoration of Foveal Microstructures After Macular Hole Surgery

PURPOSE

To analyze the long-term dynamic healing process of outer retinal changes for 1 year in patients who underwent a standard vitrectomy procedure for idiopathic macular hole (MH) repair.

DESIGN

Retrospective, consecutive, observational case series.

METHODS

Data were collected on 60 eyes of 56 patients (30 women, 26 men) that underwent successful pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peeling for idiopathic MH from January 2011 to December 2012. The age distribution ranged from 56 to 85 years (mean: 64 years). Forty eyes underwent combined phacoemulsification, PPV, ILM peeling, and intraocular lens implantation; 20 preoperative pseudophakic eyes underwent PPV and ILM peeling only. The main outcome measures included logMAR best-corrected visual acuity (BCVA) and macular microstructures determined by spectral-domain optical coherence tomography performed pre- and postoperatively during follow-up visits at 1, 3, 6, 9, and 12 months.

RESULTS

One month after surgery, 24 eyes (40%) showed normal external limiting membrane (ELM), 36 eyes (60%) showed normal ELM at 3 months, and 54 eyes (90%) showed normal ELM 12 months after surgery. Six eyes (10%) revealed a continuous ellipsoid zone (EZ) at 1 month, 18 eyes (30%) at 3 months, and 48 eyes (80%) at 12 months postoperatively. There were no eyes with a disrupted ELM in the presence of an intact EZ line. The eyes with intact ELM and/or intact EZ line showed better BCVA than eyes with defects in ELM or EZ line. On the contrary, glial cell presentation is significantly associated with worse postoperative BCVA. However, the presence of foveal cystoid change is not significantly associated with postoperative BCVA.

CONCLUSIONS

The ELM and EZ line at the fovea recovered and the presence of glial cells and cystoid space resolved gradually after surgery. The postoperative visual acuity was correlated with resolved glial cells and a restored ELM and EZ line.

Anatomical and Functional Outcomes of Pars Plana Vitrectomy for Lamellar Macular Defects

PURPOSE

The aim of this study is to investigate the anatomical and functional outcomes of surgical management of lamellar macular defects.

DESIGN

This study is a retrospective observational case series.

METHODS

Overall, the records of 89 eyes of 78 consecutive patients with a clinical diagnosis of either lamellar macular hole, macular pseudohole, or foveal pseudocyst were reviewed. Twenty-one (23.6%) of the 89 eyes underwent pars plana vitrectomy by a single ophthalmologist. Preoperative and postoperative visual acuities (VAs) were compared, and the anatomical outcome of vitrectomy was examined by studying the restoration of the foveal contour on optical coherence tomography (OCT) scans. Comparisons of visual acuity and OCT measurements between vitrectomized and nonvitrectomized eyes were made. Comparisons were also made between the 3 different types of lamellar macular defects.

RESULTS

Anatomical closure of the lamellar macular holes was achieved with a single surgical procedure in all vitrectomized eyes as confirmed by OCT. Visual acuity improved in 15 eyes (71%), from 0.39 ± 0.30 logMAR preoperatively to 0.26 ± 0.19 logMAR postoperatively (t20 = 2.425; P = 0.025). Macular pseudohole was associated with better presenting VA (F2,86 = 8.524; P < 0.001) and postoperative VA (F2,18 = 8.920; P = 0.002) than the other types of lamellar defects. Better postoperative VA was significantly correlated with better preoperative VA (r = 0.579; P = 0.006) and greater preoperative central foveal thickness (r = -0.535; P = 0.012).

CONCLUSIONS

Pars plana vitrectomy provided a high success rate of anatomical and functional improvement for eyes with all types of lamellar macular defects.

Comparison between subjective and objective internal limiting membrane peeling area during epiretinal membrane surgery

PURPOSE

To determine the reliability of surgeons in estimating internal limiting membrane peeling area during epiretinal membrane surgery and to evaluate their ability to remove a predetermined internal limiting membrane surface.

METHODS

One senior surgeon and two junior surgeons were asked to reach a target internal limiting membrane peeling surface (ILMPS) with an eccentricity of 1 optic disk diameter (centered on the fovea) in patients undergoing epiretinal membrane surgery. The ILMPS was measured on video recordings during epiretinal membrane surgery with no dye and then after brilliant blue G staining.

RESULTS

Thirty patients were included. Median (interquartile range) ILMPS was 9.3 mm(2) (5.7-16.3 mm(2)) and 7.4 mm(2) (3.7-16.4 mm) before and after brilliant blue G, respectively (P = 0.17). The ILMPS was significantly larger in eyes operated by the senior surgeon than in those operated by the junior surgeons (P = 0.01). The senior surgeon reached the target ILMPS more often than the junior surgeons: 87% versus 47%, respectively (P = 0.02).

CONCLUSION

Subjective estimation of the ILMPS with no dye was fair, but this area was larger for the surgeon with greater surgical expertise.

Comparative study of the effects of room air and sulfur hexafluoride gas tamponade on functional and morphological recovery after macular hole surgery: a retrospective study

BACKGROUND

To compare the effects of room air and sulfur hexafluoride (SF6) gas tamponade on functional and morphological macular recovery after vitrectomy for the treatment of idiopathic macular hole (MH).

METHODS

A total of 22 eyes of 22 patients with preoperative diameter of MH smaller than 500 µm were retrospectively studied. Pars plana vitrectomy with internal limiting membrane peeling was performed, followed by fluid-air exchange with room air or 20% SF6. Surgical outcomes were analyzed, regarding best-corrected visual acuity (BCVA) and spectral domain optical coherence tomography images.

RESULTS

The primary closure rate was 100% in both groups, while there was a statistically significant difference in the prone posturing period between the SF6 group (7.0 ± 1.6 days) and the air group (3.7 ± 0.6 days; p < 0.0001, unpaired t test). Mean BCVA at baseline, month 1 and month 3 was 0.25, 0.63 and 0.77 in decimal units in the SF6 group and 0.32, 0.60 and 0.73 in the air group, respectively.

CONCLUSIONS

This study suggests that room air tamponade may provide equally prompt functional and morphological recovery as well as a comparable rate of MH closure with even a shorter prone posturing period compared with SF6 gas tamponade, at least for MH with relatively small diameters.

Arcuate retinotomy for the repair of large macular holes

BACKGROUND AND OBJECTIVE

To present a case series to elucidate a novel technique that involves the creation of an arcuate retinotomy in the treatment of large macular holes after failed primary repair.

PATIENTS AND METHODS

retrospective chart review. Six eyes (six patients) with large macular holes, all of which had failed primary repair, underwent 25 gauge pars plana vitrectomy revision coupled with full thickness arcuate retinotomy temporal to the macular hole and fluid-gas exchange. The main outcome measure was anatomic macular hole closure based on optical coherence tomography (OCT), with visual acuity and visual field evaluation as secondary outcome measures.

RESULTS

Five of the six patients (83%) had successful hole closure with three of the six patients (50%) exhibiting improvement in visual acuity.

CONCLUSION

Arcuate retinotomy is a new approach that may aide in the repair of large macular holes not otherwise amenable to closure with traditional techniques.

Treatment of idiopathic macular hole with silicone oil tamponade

Purpose

We analyzed the anatomical and visual outcomes after surgical treatment of idiopathic macular holes with pars plana vitrectomy, internal limiting membrane (ILM) peeling using Brilliant Blue dye, and silicone oil tamponade without postoperative posturing.

Methods

This was a retrospective interventional study of 10 eyes in eight patients who underwent surgical treatment of idiopathic macular holes using pars plana vitrectomy, ILM peeling using Brilliant Blue dye, and silicone oil tamponade without postoperative posturing. The preoperative staging of macular holes and postoperative anatomic outcomes were assessed using spectral-domain optical coherence tomography.

Results

All patients were women with a mean age of 66.86 ± 4.8 years. In two patients, bilateral macular holes were present and both eyes were operated on. Stage 2 macular hole was diagnosed in three eyes, three eyes had stage 3, and four eyes had stage 4 macular holes. Anatomical success and closure of the macular hole was achieved in nine eyes (90%) after one operation. In one eye, the macular hole was closed after reoperation. The preoperative mean best-corrected visual acuity (BCVA) was 0.15 decimal units (0.8 logMAR units). Until the end of the follow-up period, BCVA was 0.25 decimal units (0.6 logMAR units). Visual acuity was improved in seven patients (70%). In two patients (20%), visual acuity remained at the same level, and in one eye (10%), visual acuity decreased. Postoperatively, all patients reported a significant reduction of metamorphopsia.

Conclusion

Initial results after 20G pars plana vitrectomy with peeling of the ILM, use of dye (Brilliant Blue), and tamponade with silicone oil without postoperative posturing gave good anatomical and functional outcome in terms of visual acuity and reduction of metamorphopsia. Taking into account the age of the patients, this method, which does not require prolonged postoperative face-down posturing, was well tolerated by the patients. Because the anatomical and visual outcome as well as the rate of postoperative complications are comparable to those when gas is used as a tamponading agent, silicone oil tamponade can also be safely used as a first option in surgery of macular holes. However, a longer period of follow-up of the operated eyes, as well as a larger group of operated eyes, will be required to identify long-term outcomes of this surgical treatment.

Techniques, rationale, and outcomes of internal limiting membrane peeling

BACKGROUND

The internal limiting membrane represents the structural interface between the retina and the vitreous and has been postulated to serve several essential functions. Recently, internal limiting membrane peeling has been used in the treatment of a variety of retinal disorders. We review the history, techniques, rationale, and outcomes of internal limiting membrane peeling.

METHODS

A review of the literature.

RESULTS

Internal limiting membrane peeling has been used to successfully treat a variety of retinal disorders including macular hole, epiretinal membrane, diabetic macular edema, retinal vein occlusion, and others.

CONCLUSION

Internal limiting membrane peeling may serve as an important component in the armamentarium of retinal surgery.

The significance of the external limiting membrane in the recovery of photoreceptor layer after successful macular hole closure: a study by spectral domain optical coherence tomography

PURPOSE

To evaluate the external limiting membrane (ELM) by spectral domain optical coherence tomography (SDOCT) and its correlation with the inner segment/outer segment (IS/OS) line in patients with successful macular hole surgery.

PROCEDURES

Forty-five eyes were divided into 3 groups according to the interval between surgery and first examination. In the first group the interval was between 6 and 12 months, in group 2 it was >12 months and ≤ 24 months, and in group 3 it was >24 months. The IS/OS and ELM of participants' eyes were postoperatively assessed using SDOCT in 2008 and 12 months later.

RESULTS

A statistically significant association between the integrity of the ELM and the IS/OS junction line was observed in postoperative examinations in all 3 groups. Eyes with a complete IS/OS junction line had an intact ELM. Between the first and the second examinations, a significant improvement in best-corrected visual acuity (BCVA) was noted only in group 1. A positive statistical association was also observed in group 1 between restoration of the IS/OS junction line and improvement in BCVA over follow-up.

CONCLUSIONS

The restoration of the IS/OS junction line is directly related to the integrity of the ELM.

Central photoreceptor viability and prediction of visual outcome in patients with idiopathic macular holes

Purpose

To identify the correlation between preoperative optical coherence tomography (OCT) features and postoperative visual outcomes in eyes with idiopathic macular holes (MHs).

Methods

Data from 55 eyes with idiopathic MHs which had been sealed by vitrectomy were retrospectively reviewed. Correlation analysis was conducted between postoperative visual acuity (V_postop, logarithm of the minimum angle of resolution [logMAR]) and preoperative factors, including four OCT parameters: the anticipated length (A) devoid of photoreceptors after hole closure, MH height (B), MH size (C), and the grading (D) of the viability of detached photoreceptors. Additionally, the formula for the prediction of visual outcome was deduced.

Results

V_postop was determined to be significantly correlated with the preoperative visual acuity (V_preop) and OCT parameters A, C, and D (p<0.001). Based on the correlation, the formula for the prediction of V_postop was derived from the most accurate regression analysis: V_postop=0.248×V_preop+1.1×10^-6×A²-0.121×D+0.19.

Conclusions

The length and viability of detached photoreceptors are significant preoperative OCT features for predicting visual prognosis. This suggests that, regardless of the MH size and symptom duration, active surgical intervention should be encouraged, particularly if the MH exhibits good viability in the detached photoreceptor layer.

Management of macular holes: a comparison of 1-year outcomes of 3 surgical techniques

PURPOSE

To evaluate the contribution of internal limiting membrane (ILM) peeling with and without indocyanine green (ICG) to hole closure and functional results in patients with idiopathic macular hole.

METHODS

Two hundred sixty-four patients with macular hole underwent pars plana vitrectomy. Of the 264, 240 patients completed 1-year follow-up and were divided into three groups: no ILM peeling (84 patients), ILM peeling without ICG (66 patients), and ICG-assisted ILM peeling (90 patients).

RESULTS

Macular holes were closed in 87% of the "no peeling" group, in 75% of the ILM peeling without ICG group, and in 92.3% of the ICG-assisted ILM peeling group. Visual acuity improved 2 Snellen lines in all groups (71%, 68%, and 78%, respectively) after successful surgery. In all 3 groups, 20% gained 4 Snellen lines and 14% reached 20/20 vision. There was no statistically significant difference in outcomes among the three groups. Cataract progression was noted more frequently in the ILM peeling groups. No cases of ICG toxicity were recognized.

CONCLUSION

ICG-assisted peeling of the ILM increased macular hole closure rate but was not statistically superior to vitrectomy without membrane peeling. The patients who had ILM peeling without ICG had the least favorable results both anatomically and functionally. The visual gain that was recorded for the majority of the patients after successful macular hole surgery was two Snellen lines.

Equivalent tamponade by room air as compared with SF(6) after macular hole surgery

BACKGROUND

To evaluate the effect of tamponade by room air after vitrectomy for the treatment of idiopathic macular hole (MH).

METHODS

There were 156 eyes of 151 patients studied. The patients' ages ranged from 35 to 88 years old (mean: 65.1 years). After conventional pars plana vitrectomy with internal limiting membrane peeling, fluid air exchange was performed using 20% SF(6) (Gas group: 91 eyes) or room air (Air group: 65 eyes). Surgical outcomes were retrospectively analyzed.

RESULTS

Mean preoperative hole diameter was 352 microm in the Gas group and 370 microm in the Air group (P = 0.558). The closure rate of all cases was 91.0% after first surgery and 98.7% at last follow-up. The primary closure rate was 90.1% in the Gas group after 7.44 +/- 1.66 (mean +/- SD) days prone positioning period, and 92.3% in the Air group after 3.83 +/- 0.97 days of prone positioning. There was significant difference in prone positioning period (P < 0.0001), but not in the first closure rate (P = 0.132).

CONCLUSION

This study suggests that room air may have an equivalent tamponade effect, in spite of the shorter prone positioning period, than SF(6) after MH surgery.

Restored photoreceptor outer segment and visual recovery after macular hole closure

PURPOSE

To evaluate restoration of the photoreceptor outer segment and visual outcomes in closed macular holes.

DESIGN

Retrospective case series.

METHODS

We retrospectively observed the reparative process of macular holes in 28 eyes one, three, and six months postoperatively using spectral-domain optical coherence tomography. We evaluated the reflective line at the junction between the photoreceptor inner and outer segment (IS/OS) and the best-corrected visual acuity (BCVA).

RESULTS

The outer photoreceptor layer showed a foveal detachment, a disrupted IS/OS line, or both one month postoperatively. No eye had a continuous IS/OS line. These abnormalities were gradually restored at various levels. At six months, nine eyes had a normal outer photoreceptor layer, four eyes outer foveal defects with a continuous IS/OS line, 12 eyes a disrupted IS/OS line, and three eyes outer foveal defects with a disrupted IS/OS line. The mean BCVAs were significantly (P = .017) lower in groups with a disrupted IS/OS line compared to groups with a continuous IS/OS line with or without outer foveal defects.

CONCLUSIONS

Macular hole closure is attained by bridge formation (foveal detachment) and the IS/OS line heals in varying degrees. The visual outcomes were significantly better in eyes with a continuous IS/OS line than in those with a disrupted IS/OS line.

Should Indocyanine green should be used to facilitate removal of the internal limiting membrane in macular hole surgery

Indocyanine green (ICG) is one of several vital dyes that are used in vitreoretinal surgery to aid visualization of diaphanous collagenous tissues in what has been called chromovitrectomy. As shown herein, much has been written about the use and rather narrow safety profile of ICG. The discussion surrounding its applications would have ended long ago were it not for the occasional patient who keeps returning to the office with permanent central scotomas after ICG-assisted macular hole surgery. The purpose of this Viewpoint is to reemphasize potential methods of proper use and clarify safety issues of this particular vital dye that enhances surgical technique but not necessarily visual outcome.