Vitrectomy with fovea-sparing ILM peeling versus total ILM peeling for myopic traction maculopathy: A meta-analysis

2024 Chew Sek Jin Memorial Lecture: "Are we there yet?"

The journey from myopia being an intriguing scientific puzzle to part of clinical practice has been a long and varied path. Chew Sek Jin was one of the pioneers on this journey and, as director of the Singapore Eye Research Institute, initiated an ambitious research program that has helped us get to where we are today. His work was data-driven, embracing the power of epidemiological and longitudinal studies. He emphasized both the public health aspects and clinical management of myopia, pioneering the use of atropine in Singapore. With his work with Josh Wallman, he recognized the importance of research into the biological mechanisms of myopia.

Fovea-Sparing Internal Limiting Membrane (ILM) Peeling and ILM Plug: A Novel Approach for Managing Optic Disc Pit Maculopathy

Purpose

To evaluate the efficacy of fovea-sparing internal limiting membrane (ILM) peeling combined with ILM plug placement in patients with optic disc pit maculopathy (ODP-M).

Patients and Methods

This retrospective study included seven eyes from seven patients diagnosed with ODP-M, treated with fovea-sparing ILM peeling and ILM plug placement. All patients underwent pars plana vitrectomy (PPV), with either SF6 gas or silicone oil used as tamponade. Outcome measures included best-corrected visual acuity (BCVA), central macular thickness (CMT), retinal reattachment, and resolution of retinoschitic lesions (RL). Data were collected at baseline and during follow-ups at 1, 3, 6, and 12 months.

Results

The mean age of the study patients was 31 (± 13.14) years, with a marginal male preponderance (M: F = 4:3). All patients achieved complete retinal reattachment, with a significant reduction in CMT from 503.57 (± 154.74) µm preoperatively to 286.29 (± 22.43) µm at 12 months (P=0.02). BCVA improved in 85.7% of patients, from a mean of 0.77 (± 0.19) logMAR to 0.5 (± 0.25) logMAR by 12 months, though this was not statistically significant (P=0.27). Complete resolution of RL was observed in 71.4% of eyes, while 2 eyes showed partial resolution. One patient developed retinal detachment postoperatively, which was successfully managed with additional surgery.

Conclusion

Fovea-sparing ILM peeling combined with ILM plug placement resulted in favorable anatomical and functional outcomes for ODP-M patients, with a 100% retinal reattachment rate and significant CMT reduction. This technique offers a viable alternative to conventional approaches, preserving foveal architecture while providing a mechanical barrier to fluid accumulation.

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.

Novel surgical approaches for treating myopic traction maculopathy: a meta-analysis

BACKGROUND

Myopic traction maculopathy (MTM) is a complication of pathological myopia and encompasses various pathological conditions caused by tractional changes in the eye. These changes include retinoschisis, foveal retinal detachment, and lamellar or full-thickness macular holes (FTMHs). This meta-analysis evaluated the safety and efficacy of novel surgical for treating MTM.

METHODS

To compare the outcomes of different surgical approaches for MTM, multiple databases, including Web of Science, PubMed, Scopus, ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Embase, and the Meta-Register of Controlled Trials, were comprehensively searched. The meta-analysis was performed using RevMan 5.1.

RESULTS

Nine comparative studies involving 350 eyes were included in this meta-analysis. There were significant differences between fovea-sparing internal limiting membrane peeling (FSIP) and standard internal limiting membrane peeling (ILMP). Preoperative best-corrected visual acuity BCVA (standard mean difference (SMD): -0.10, 95% CI: -0.32 to 0.12) and central foveal thickness CFT (SMD: 0.05, 95% CI: -0.22 to 0.33) were not significantly different (p = 0.39 and p = 0.71, respectively). However, the postoperative BCVA improved significantly (SMD = - 0.47, 95% CI: - 0.80, - 0.14, p = 0.006) in the FSIP group compared to the standard ILMP group. Postoperative CFT did not differ significantly between the two groups (p = 0.62). The FSIP group had a greater anatomical success rate than the other groups, although the difference was not statistically significant (p = 0.26). The incidence of postoperative macular hole formation was significantly lower (OR = 0.19, 95% CI = 0.07-0.54; p = 0.05) in the FSIP group than in the standard ILMP group. The unique characteristics of highly myopic eyes, such as increased axial length and structural changes, may have contributed to the greater incidence of FTMH in the ILMP group.

CONCLUSION

Based on the findings of this meta-analysis, FSIP is the initial surgical approach for early-stage MTM and has shown promising outcomes. However, to establish the safest and most efficient surgical technique for treating different MTM stages, further comparative studies, specifically those focusing on ILMP and FSIP, are necessary.

TRIAL REGISTRATION

Retrospectively registered.

Risk Factors and Outcomes of Postoperative Macular Hole Formation after Vitrectomy for Myopic Traction Maculopathy: SCHISIS Report No. 2

PURPOSE

To evaluate the incidence, pathogenesis, risk factors, and treatment outcomes of postoperative macular hole (MH) after pars plana vitrectomy (PPV) for myopic traction maculopathy (MTM).

DESIGN

Multicenter, interventional, retrospective case series.

SUBJECTS

Consecutive eyes that underwent PPV for MTM with a minimum 6-month follow-up.

METHODS

We investigated the characteristics and treatment outcomes of postoperative MH after MTM surgery.

MAIN OUTCOME MEASURES

Incidence, risk factors, and anatomic and visual outcomes of postoperative MH.

RESULTS

We included 207 eyes (207 patients) with a mean follow-up of 25.9 months. During follow-up, 24 (11.6%) eyes developed MH (10 with concurrent MH retinal detachment); 15 eyes within 30 days (early), 4 eyes between 31 and 180 days (intermediate), and 5 eyes after 180 days (late). Logistic regression analysis revealed male gender (odds ratio [OR], 2.917; 95% confidence interval [CI], 1.198-7.100; P = 0.018), thinner preoperative choroidal thickness (OR, 0.988; 95% CI, 0.976-1.000; P = 0.048), and use of indocyanine green for internal limiting membrane peeling (OR, 2.960; 95% CI, 1.172-7.476; P = 0.022) as significant risk factors for postoperative MH. Internal limiting membrane peeling with a fovea-sparing technique tended to protect against postoperative MH, but it was not statistically significant (P = 0.096), because 1 eye still developed MH. Postoperative MHs were treated by observation (6 eyes), in-office octafluoropropane (C3F8) gas injection (7 eyes), or PPV (11 eyes). Macular hole closure was achieved in 20 eyes (83%). The hole closure rate was 67% (4/6 eyes) after observation, 71% (5/7 eyes) after C3F8 gas injection, and 91% (10/11 eyes) after PPV. However, visual outcomes were significantly worse for eyes with postoperative MH than those without (0.38 ± 0.43 vs. 0.68 ± 0.46; P = 0.002).

CONCLUSIONS

Postoperative MH may occur in 11.6% of patients with MTM at any time after surgery. Retreatment resulted in relatively favorable anatomic closure but unfavorable visual outcomes.

FINANCIAL DISCLOSURE(S)

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

IMI 2023 Digest

Myopia is a dynamic and rapidly moving field, with ongoing research providing a better understanding of the etiology leading to novel myopia control strategies. In 2019, the International Myopia Institute (IMI) assembled and published a series of white papers across relevant topics and updated the evidence with a digest in 2021. Here, we summarize findings across key topics from the previous 2 years. Studies in animal models have continued to explore how wavelength and intensity of light influence eye growth and have examined new pharmacologic agents and scleral cross-linking as potential strategies for slowing myopia. In children, the term premyopia is gaining interest with increased attention to early implementation of myopia control. Most studies use the IMI definitions of ≤-0.5 diopters (D) for myopia and ≤-6.0 D for high myopia, although categorization and definitions for structural consequences of high myopia remain an issue. Clinical trials have demonstrated that newer spectacle lens designs incorporating multiple segments, lenslets, or diffusion optics exhibit good efficacy. Clinical considerations and factors influencing efficacy for soft multifocal contact lenses and orthokeratology are discussed. Topical atropine remains the only widely accessible pharmacologic treatment. Rebound observed with higher concentration of atropine is not evident with lower concentrations or optical interventions. Overall, myopia control treatments show little adverse effect on visual function and appear generally safe, with longer wear times and combination therapies maximizing outcomes. An emerging category of light-based therapies for children requires comprehensive safety data to enable risk versus benefit analysis. Given the success of myopia control strategies, the ethics of including a control arm in clinical trials is heavily debated. IMI recommendations for clinical trial protocols are discussed.

PROGRESSION OF MYOPIC MACULOPATHY IN PATIENTS WITH MYOPIC TRACTION MACULOPATHY AFTER VITRECTOMY

PURPOSE

To compare the progression of myopic maculopathy with or without vitrectomy in patients with myopic traction maculopathy (MTM).

METHODS

Seventy-seven eyes with MTM were classified into either the observation group (n = 38) or the vitrectomy group (n = 39). Progression of myopic maculopathy was assessed with fundus photography using infrared images. Progression within stage was evaluated as an increase in the area of atrophic lesions on infrared images using ImageJ software. The rate of progression was compared using the paired t -test.

RESULTS

The mean follow-up period was 60.0 ± 47.5 months. The initial mean stage of myopic maculopathy for the observation group was 1.86 ± 0.86, and it progressed to 2.00 ± 0.83 ( P = 0.023) at the last visit. For the vitrectomy group, the stage progressed from 1.82 ± 0.96 to 2.05 ± 1.09 ( P = 0.011). Four eyes (10.5%) in the observation group showed progression at 87.3 months, and seven eyes (17.9%) in the vitrectomy group showed progression at 31.3 months.

CONCLUSION

Surgery in patients with MTM may accelerate the progression of myopic maculopathy. Therefore, care should be taken when considering surgery for patients with MTM.

Fovea sparing versus complete internal limiting membrane peeling for myopic traction maculopathy: a meta-analysis

PURPOSE

Myopic traction maculopathy (MTM) is the leading cause of visual loss in high myopia. The purpose of this study was to compare the outcomes of pars plana vitrectomy (PPV) with fovea-sparing internal limiting membrane (ILM) peeling and complete ILM peeling for MTM.

METHODS

A comprehensive literature search was performed to find relevant studies. A meta-analysis was conducted by comparing the weighted mean differences (WMD) in the change of best-corrected visual acuity (BCVA) and central foveal thickness (CFT) from baseline and calculating the odd ratios (OR) for rates of complete reattachment (CR) and postoperative macular hole (MH) formation.

RESULTS

Ten studies were selected, including 417 eyes (172 eyes in the fovea-sparing ILM peeling group (FSIP) and 245 eyes in complete ILM peeling group (CIP)). There was no significant difference in terms of mean change in CFT from baseline and the rate of CR(WMD = 3.53, 95% CI, -25.56 to 32.63, P = 0.81, and OR = 1.41, 95% CI, 0.81 to 2.44, P = 0.22). FSIP was superior to CIP in terms of mean change of logMAR BCVA post operation (WMD = -0.09, 95% CI, -0.15 to -0.03, P = 0.003), and associated with a significantly lower frequency of postoperative MH formation (OR = 0.19, 95% CI, 0.07 to 0.50, P = 0.0008).

CONCLUSION

FSIP resulted in similar anatomic outcomes compared to CIP, but resulted in better visual acuity and lower rates of postoperative MH development.

Efficiency comparison with fovea-sparing internal limiting membrane peeling and complete internal limiting membrane peeling for treating myopic traction maculopathy

PURPOSE

To explore whether the efficacy of fovea-sparing internal limiting membrane peeling (FS-ILMP) is better than that of complete internal limiting membrane peeling (ILMP).

METHODS

This retrospective clinical study included 34 cases (34 eyes) with myopic traction maculopathy collected from June 2017 to February 2019. Twenty-three-gauge (23-G) pars plana vitrectomy (23G PPV) was performed on all patients. In the FS-ILMP group, 18 eyes retained the internal limiting membrane (ILM) of about 1 to 1.5 papillary diameter centered on fovea centralis, while in the standard ILMP group, the ILM was completely removed from 16 eyes. The best corrected visual acuity (BCVA), central foveal thickness (CFT), and other indexes were collected before and 6 months after surgery.

RESULTS

There was no significant difference in baseline clinical characteristics between the two groups. CFT and BCVA were significantly improved in both FS-ILMP and standard ILMP group, but the postoperative BCVA of the FS-ILMP group was significantly better than that of the standard ILMP group (P < 0.001). Two cases of subretinal effusion in macula were recorded in the FS-ILMP group, and three eyes in the standard ILMP group developed macular holes after surgery. Although both treatments relieved the mechanical traction of macular fovea, the patients in the FS-ILMP group showed better clinical outcomes in various aspects.

CONCLUSION

These results improved our understanding of the clinical application of vitrectomy combined with preservation of ILM upon the fovea centralis, which might lay a foundation for in-depth study on the treatment of myopic traction maculopathy.