Full-Thickness Macular Hole Progressing from Lamellar Macular Hole with Epiretinal Proliferation

Case of Spontaneous Closure and Recurrence of Macular Hole in Vitrectomized Eye

Rationale

Development and spontaneous closure of a macular hole (MH) in a vitrectomized eye is relatively rare. We report our findings in a case in which vitrectomy was performed successfully to treat a vitreous hemorrhage (VH), but a MH developed eight months later. The MH spontaneously closed 2 weeks later, but then reopened. A second vitrectomy was performed with insertion of the internal limiting membrane flap into the MH which led to the successful closure of the MH. The purpose of this article is to present an explanation of how MH developed in this eye without vitreous traction.

Patient

A 64-year-old woman visited an eye clinic with vision reduction in her right eye of 3 days duration. A VH was detected in the right eye and pars plana vitrectomy (PPV) was performed. A retinal tear was detected which was the origin of the VH. The vision was restored to a decimal visual acuity of 1.2. Eight months later, the patient noticed that her vision was distorted and was referred to our hospital.

Diagnosis

Optical coherence tomographic (OCT) images showed a thin epiretinal membrane on the macula, cystoid changes in the macular area, and a full-thickness MH.

Interventions

The MH closed spontaneously in two weeks, however a lamellar MH with an epiretinal proliferation (EP) developed 11 months later. Two months later, OCT showed cyst-like changes in the retina and a full-thickness MH. A second PPV was performed with the insertion of the ILM flap and EP into the MH to close the MH. Her visual acuity improved, and distorted vision was not present.

Lessons

Clinicians should be aware that a MH can develop in a vitrectomized eye without vitreous traction but can close spontaneously. We conclude that careful follow-up examinations are necessary even in vitrectomized eyes.

Long-Term Results of Adjunct Autologous Platelet-Rich Plasma in Lamellar Macular Hole Surgery Showing Lasting Restoration of Foveal Anatomy

The aim of this study was to evaluate the long-time results of highly concentrated autologous platelet-rich plasma (PRP) used as an adjunct in lamellar macular hole (LMH) surgery. Nineteen eyes of nineteen patients with progressive LMH were enrolled in this interventional case series, on which 23/25-gauge pars plana vitrectomy was performed and 0.1 mL of highly concentrated autologous platelet-rich plasma was applied under air tamponade. Posterior vitreous detachment was induced, and the peeling of tractive epiretinal membranes, whenever present, was performed. In cases of phakic lens status, combined surgery was carried out. Postoperatively, all patients were instructed to remain in a supine position for the first two postoperative hours. Best-corrected visual acuity (BCVA) testing, microperimetry, and spectral domain optical coherence tomography (SD-OCT) were carried out preoperatively and at minimum 6 months (in median 12 months) postoperatively. Foveal configuration was postoperatively restored in 19 of 19 patients. Two patients who had not undergone ILM peeling showed a recurring defect at 6-month follow-up. Best-corrected visual acuity improved significantly from 0.29 ± 0.08 to 0.14 ± 0.13 logMAR (p = 0.028, Wilcoxon signed-rank test). Microperimetry remained unchanged (23.38 ± 2.53 preoperatively; 23.0 ± 2.49 dB postoperatively; p = 0.67). No patients experienced vision loss after surgery, and no significant intra- or postoperative complications were observed. Using PRP as an adjunct in macular hole surgery significantly improves morphological and functional outcomes. Additionally, it might be an effective prophylaxis to further progression and also the formation of a secondary full-thickness macular hole. The results of this study might contribute to a paradigm shift in macular hole surgery towards early intervention.

Epiretinal proliferation embedding combined with internal limiting membrane flap inversion for secondary macular hole: Two case reports

Purpose

We describe the cases of two patients for whom we performed an epiretinal proliferation (EP) embedding technique combined with internal limiting membrane (ILM) flap inversion for a full-thickness macular hole (FTMH) with EP.

Observations

Patient 1 was a 69-year-old Japanese man with decreased vision in his left eye (20/40). He underwent pars plana vitrectomy (PPV) twice for rhegmatogenous retinal detachment and intraocular lens (IOL) dislocation in his left eye. B-scan optical coherence tomography (OCT) imaging revealed FTMH and EP on the surface of a macular hole (MH). We performed a vitrectomy, EP embedding, and ILM inversion (fill). Patient 2 was a 73-year-old Japanese man with decreased vision in his right eye (20/32). He underwent PPV for vitreous hemorrhage and proliferative diabetic retinopathy in his right eye. B-scan OCT imaging revealed FTMH and EP on the surface of an MH. We performed a vitrectomy, EP embedding, and ILM inversion (cover). Six months post-surgery, the FTMH in both patients had closed completely, and each patient's foveal contour and visual acuity (20/20) had improved.

Conclusions and importance

EP embedding combined with ILM flap inversion may be effective for treating secondary MHs with EP.

Formation and evolution of idiopathic lamellar macular hole-a pilot study

Background

The developmental pathways and subsequent evolutional processes of idiopathic lamellar macular hole (LMH) were studied with spectrum domain optical coherence tomography (SD-OCT).

Methods

Twenty-seven eyes of 26 patients of idiopathic LMH with pre-LMH SD-OCT available were retrospectively reviewed. Relevant OCT parameters and best-corrected visual acuity (BCVA) were collected and analyzed.

Results

Four types of developmental pathways of idiopathic LMH were noted. Type 1 (5 cases), involved disruption of a foveal cyst from vitreomacular traction. Type 2 (10 cases), demonstrated rupture of parafoveal cysts or schisis mainly from epiretinal membrane (ERM). In type 3 pathway (5 cases), a central intraretinal cyst formed under tight ERM with subsequent cyst roof dehiscence. Type 4 (7 cases), showed gradual loss of foveal tissue without cystic lesions from ERM traction. There was no statistically significant change in BCVA during LMH formations or subsequent evolutional processes in any types of the developmental pathways. Three cases developed epiretinal proliferation (EP) during evolution, which showed tendency of decrease in BCVA. Among the three cases, one later developed the degenerative configuration.

Conclusions

In summary, four types of tractional developmental pathways of idiopathic LMH were identified. BCVA was relatively stable during LMH formation and follow-up. Deterioration of visual acuity were found in cases that developed EP during evolution. Transformation into degenerative configuration might be possible after LMH formation.

Primary Lamellar Macular Holes: To Vit or Not to Vit

There is a wide spectrum of macular conditions that are characterized by an irregular foveal contour caused by a break in the inner fovea. These include full-thickness macular hole (FTMH), foveal pseudocyst, lamellar macular hole (LMH) and macular pseudohole (MPH). Clinical examination of vitreomacular interface disorders is notoriously poor in differentiating these conditions. These conditions were initially described with slit-lamp biomicroscopy, and the main goal was to distinguish an FTMH from the others. The introduction of optical coherence tomography (OCT) has revolutionized our understanding of the foveal microstructural anatomy and has facilitated differentiating these conditions from an FTMH. However, the definitions of the other conditions, particularly LMH, has evolved over the past two decades. Initially the term LMH encompassed a wide spectrum of clinical conditions. As OCT became more widely used and observations became more refined, two different phenotypes of LMH became apparent, raising the question of different pathogenic mechanisms for each phenotype. Tractional and degenerative pathological mechanisms were proposed. Epiretinal membranes (ERMs) associated with each phenotype were identified. Typical ERMs were associated with a tractional mechanism, whereas an epiretinal proliferation was associated with a degenerative mechanism. Epiretinal proliferation represents Müller cell proliferation as a reactive process to retinal injury. These two types of ERM were differentiated by their characteristics on SD-OCT. The latest consensus definitions take into account this phenotypic differentiation and classifies these entities into LMH, MPH and ERM foveoschisis. The initial event in both ERM foveoschisis and LMH is a tractional event that disrupts the Müller cell cone in the foveola or the foveal walls. Depending on the extent of Müller cell disruption, either a LMH or an ERM foveoschisis may develop. Although surgical intervention for LMH remains controversial and no clear guidelines exist for pars plana vitrectomy (PPV), eyes with symptomatic, progressive ERM foveoschisis and LMH may benefit from surgical intervention.