The Role of the Outer Lamellar Macular Hole in the Surgical Management of Myopic Traction Maculopathy

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

PURPOSE

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

RESULTS

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

CONCLUSION

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

Long-Term results of macular buckle for MTM stage 3-4 With maculoschisis and macular detachment without and With lamellar macular hole

PURPOSE

To report the long-term anatomical and functional results of macular buckle for Myopic Traction Maculopathy (MTM) in stages 3a, 3b, 4a, and 4b according to the MTM Staging System (MSS).

METHODS

Retrospective observational cohort study involving 55 consecutive patients with MTM in stages 3a, 3b, 4a, and 4b who underwent macular buckle (MB). Postoperative outcomes, including optical coherence tomography (OCT) scans to evaluate the MTM stage and its progression, were evaluated 1-month postoperatively (i.e., "intermediate follow-up") and at last follow-up ranging between 6 and 156 months postoperatively (i.e., "final follow-up").

RESULTS

Fifty-five eyes affected by MTM who underwent MB were enrolled. The mean preoperative and postoperative axial length was 31.13 ± 2.14 and 29.73 ± 2.16 mm, respectively (p < 0.01), with a mean axial shift of 1.32 ± 0.77 mm. The mean sample best corrected visual acuity (BCVA) at baseline, intermediate, and final follow-ups was 0.87 ± 0.36, 0.73 ± 0.31, 0.41 ± 0.32 logMar, respectively (p < 0.01). Foveal and retinal anatomical improvements were achieved in 50 (91%) and 53 (96.4%) eyes at intermediate follow-up, respectively. In the final follow-up, 54 (98.2%) and 55 (100%) eyes showed foveal and retinal anatomical improvements, respectively.

CONCLUSIONS

MB as a single procedure, when applied to MTM in stages 3a, 3b, 4a, and 4b, leads to significant anatomical and functional improvement. The MTM Staging System allows us to evaluate the best surgical technique and the surgical timing tailored to the different stages to increase the surgery's success and lower the complications of each technique.

Lamellar macular hole in highly myopic eyes and insights into its development, evolution, and treatment: a mini-review

Lamellar macular holes (LMHs) are a manifestation of myopic tractional maculopathy (MTM). Owing to the complex and multidirectional traction force in the elongated eyeball, the clinical features, development, evolution, and treatment algorithms of LMH in highly myopic eyes may differ from those of idiopathic LMH or MTM in general. This review aimed to specifically explore the LMHs in highly myopic eyes. Several developmental processes of LMH and their association with macular retinoschisis have been demonstrated, with the tractional component identified in all processes. Epiretinal proliferation was more prevalent and more extensive in LMHs in highly myopic eyes than in idiopathic LMHs. LMHs in highly myopic eyes may remain stable or progress to foveal detachment and full-thickness macular hole with or without retinal detachment. The predictive factors associated with disease progression were summarized to facilitate monitoring and guide surgical intervention. The treatment of LMHs in highly myopic eyes was based on an algorithm for treating myopic tractional maculopathy, including gas tamponade, pars plana vitrectomy, macular buckling, and a combination of vitrectomy and macular buckling. New internal limiting membrane (ILM) manipulation techniques such as fovea-sparing ILM peeling or fovea-sparing ILM peeling combined with ILM flap insertion could reduce the risk of developing iatrogenic full-thickness macular holes postoperatively. Further research should focus on the treatment of LMH in highly myopic eyes.

International Validation of Myopic Traction Maculopathy Staging System

BACKGROUND AND OBJECTIVE

The aim of this study was to evaluate the interobserver agreement of the myopic traction maculopathy (MTM) staging system (MSS).

PATIENTS AND METHODS

Each observer was asked to look at the MSS Table and then identify, in each optical coherence tomography scan, one among four stages of MTM in the retina, one among three stages in the fovea, and, as secondary findings, the presence or absence of an outer lamellar macular hole and the presence or absence of epiretinal abnormalities. The interobserver agreement value was calculated using the Gwet's AC1 unweighted and AC2 weighted statistics. The outcomes were interpreted as poor (<0.00), slight (0.00 to 0.20), fair (0.21 to 0.40), moderate (0.41 to 0.60), substantial (0.61 to 0.80), or almost perfect (0.81 to 1.00) agreement.

RESULTS

The agreement, among 65 participants, was 0.62 (AC1) and 0.77 (AC2) for the retina stage; 0.63 (AC1) and 0.81 (AC2) for the fovea stage; 0.56 (AC1) for the outer lamellar macular hole; and 0.26 (AC1) for epiretinal abnormalities.

CONCLUSION

The MSS is highly reproducible and helps ophthalmologists to share information on MTM in a more accurate and reliable way. [Ophthalmic Surg Lasers Imaging Retina 2023;54(3):153-157.].

Surgical Outcomes of Myopic Foveoschisis According to the ATN Classification System

INTRODUCTION

This study compared the surgical outcomes in eyes with myopic foveoschisis (MF) according to the recently developed ATN classification system.

METHODS

This was an observational case series of 64 consecutive eyes that underwent vitrectomy for MF. Eyes were classified into severe myopic maculopathy (MM) (n = 43) and non-severe MM (n = 21) groups according to the ATN classification system. The primary outcome measures constituted best-corrected visual acuity (BCVA) and anatomical changes.

RESULTS

In total, BCVA improved from 0.97 to 0.53 (P < 0.001) after surgery. The ATN score was significantly lower in the eyes with vision improvement than those without vision improvement (P < 0.001). In the subgroup, BCVA improved from 0.79 to 0.28 in the non-severe MM group (P < 0.001), and improved from 1.05 to 0.65 in the severe MM group (P = 0.001) after surgery. The non-severe MM group achieved better postoperative BCVA (P = 0.001) and were more likely to gain vision improvement (P < 0.001) after surgery compared with the severe MM group. Anatomical success was achieved in 62 of the 64 eyes (96.88%). Two eyes with anatomical failure developed full-thickness macular holes postoperatively; both were in the severe MM group.

CONCLUSIONS

For patients with MF, different severity of MM based on ATN classification could lead to a significantly different prognosis after surgery. For patients with high ATN scores, the operative decision should be made cautiously for the worse anatomical and visual prognosis. ATN system is instructive in making operative proposals for MF.

Vitrectomy for macular retinoschisis associated with peripapillary intrachoroidal cavitations in a moderately myopic eye

Background

Peripapillary intrachoroidal cavitation (PICC), a cavernous change in the peripapillary choroid, may present with macular lesions. Here, we present a rare case of PICC with outer lamellar macular hole and macular retinoschisis.

Case presentation

A 69-year-old man presented with metamorphopsia in the left eye. Fundus examination revealed macular retinoschisis and PICCs. Pars plana vitrectomy with fovea sparing internal limiting membrane peeling (FSIP) was performed. Three weeks postoperatively, the patient developed rhegmatogenous retinal detachment and underwent a second vitrectomy. The macular retinoschisis resolved without macular hole formation and the patient’s visual acuity improved. There were no recurrent macular lesions over the three years of postoperative follow-up. Postoperative spectral-domain optical coherence tomography scan revealed a communication between the PICC and the vitreous cavity.

Conclusions

This case shed light on understanding development of PICC in non-highly myopic eyes and a rare complication of macular retinoschisis. Vitrectomy with FSIP may effectively resolve macular retinoschisis.

Factors Affecting Visual Prognosis of Myopic Foveoschisis after Macular Buckling

Purpose

To analyze the visual prognosis of macular buckling in patients with high myopia foveoschisis (FS) and to identify factors that predict the final visual outcome.

Methods

We retrospectively included 155 eyes of 155 patients who underwent foveoschisis-related macular buckling. Best-corrected visual acuity (BCVA) and coexisting macular pathologies were assessed as a measure of surgical outcome, and multivariate linear regression was performed to identify factors affecting final visual prognosis.

Results

The mean preoperative BCVA was 1.19 ± 0.55 logMAR (20/308), while the mean postoperative BCVA was 0.82 ± 0.51 logMAR (20/133) (P < 0.001). Anatomical success was achieved in 151/155 eyes (97.42%) after the first surgery and in 155/155 eyes (100%) at the 2-year follow-up visit. Both preoperative and postoperative BCVA were better in eyes without macular hole (MH) than in eyes with MH. In patients with MH, the postoperative BCVA was significantly better than that before surgery when the MH was closed. However, the difference was not significant in patients with unclosed MH. Univariate analysis identified that baseline BCVA, age, MH, atrophic myopic maculopathy category, and postoperative intraretinal cyst were significantly related to BCVA at the postoperative 2-year follow-up. Multivariate analysis revealed that preoperative BCVA and age were significant factors.

Conclusion

Better preoperative BCVA and younger age are predictors of better prognosis. Prompt surgery is advised for patients with myopic foveoschisis to improve their visual prognosis.