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.

Changes in macular pigment optical density after full-thickness macular hole closure using inverted flap technique

Full-thickness macular hole (FTMH) is a debilitating retinal disorder, particularly in its advanced forms, necessitating surgical intervention for vision restoration. This case report details the successful closure of a large FTMH using the inverted flap technique, highlighting the essential role of multimodal imaging, and particularly macular pigment optical density (MPOD) assessment, in preoperative and postoperative evaluation. A 55-year-old patient presented with severe vision loss in one eye due to a large FTMH. Surgery was performed by an expert vitreoretinal surgeon, resulting in significant postoperative improvements in visual acuity and retinal architecture. Multimodal imaging, including MPOD assessment, played a pivotal role in preoperative evaluation and postoperative monitoring. The notable increase in MPOD following successful surgery suggests its potential role as a valuable adjunctive biomarker associated with a good visual prognosis following this type of macular hole surgical interventions.

Successful Management of Familial Exudative Vitreoretinopathy with a Large Macular Hole Using Inverted Internal Limiting Membrane Flap Technique

Introduction

This case report aims to shed light on a rare presentation of familial exudative vitreoretinopathy (FEVR) co-existing with a large full-thickness macular hole (FTMH) in a 16-year-old male and discuss its successful surgical management, thereby adding to the limited existing knowledge on this topic.

Case Presentation

Over an 8-month period, the patient had experienced progressively worsening visual blurring and distortion in his left eye. Following a comprehensive examination, diagnosis confirmed FEVR and an accompanying large FTMH. It was hypothesized that this unusual manifestation resulted from the tractional forces exerted by a thick posterior vitreous membrane and a thin epiretinal membrane - a distinctive attribute of FEVR. The patient underwent surgical intervention, which included pars plana vitrectomy (PPV), internal limiting membrane (ILM) peeling, gas tamponade, and the inverted ILM flap technique. Postoperative outcomes were favorable, with the FTMH successfully closed and substantial improvement observed in the patient's visual acuity at the 3-month follow-up visit.

Conclusion

This case report highlights a rare association of FEVR with FTMH, thereby broadening our understanding of potential complications in patients with FEVR. The successful surgical intervention reinforces the utility of the PPV and the inverted ILM flap technique in managing such complications. It underscores the need for clinicians to maintain vigilance for such atypical manifestations in FEVR patients.

Surgical Management of Full-Thickness Macular Holes in Macular Telangiectasia Type 2: A Global Multicenter Study

PURPOSE

To report on macular hole repair in macular telangiectasia type 2 (MacTel2).

DESIGN

Global, multicenter, retrospective case series.

PARTICIPANTS

Patients undergoing surgery for MacTel2-associated full-thickness macular hole (MTMH).

METHODS

Standardized data collection sheet distributed to all surgeons.

MAIN OUTCOME MEASURES

Anatomic closure and visual outcomes of MTMH.

RESULTS

Sixty-three surgeries in 47 patients with MTMH were included from 30 surgeons. Mean age was 68.1 years, with 62% female, 72% White, 21% East or South Asian, 2% African American, and 2% Hispanic or Latino. Procedures included 34 internal limiting membrane (ILM) peeling alone, 22 ILM flaps, 5 autologous retinal transplantations (ARTs), 1 retinotomy, and 1 subretinal bleb. For ILM peeling, preoperative visual acuity (VA) was 0.667 ± 0.423 logarithm of the minimum angle of resolution (logMAR). Minimum hole diameter (MHD) was 305.5 ± 159.4 μm (range, 34-573 μm). Sixteen of 34 ILM peels (47%) resulted in MTMH closure. At postoperative month 6, VA was stable at 0.602 ± 0.516 logMAR (P = 0.65). VA improved by at least 2 lines in 43% and at least 4 lines in 24%. For ILM flaps, preoperative VA was 0.878 ± 0.552 logMAR. MHD was 440.8 ± 175.5 μm (range, 97-697 μm), which was significantly larger than for ILM peels (P < 0.01). Twenty of 22 ILM flaps (90%) resulted in MTMH closure, which was significantly higher than for ILM peels (P < 0.01). At postoperative month 6, VA improved to 0.555 ± 0.405 logMAR (P < 0.05). VA improved by at least 2 lines in 56% and at least 4 lines in 28%. For ARTs, preoperative VA was 1.460 ± 0.391 logMAR. MHD was 390.2 ± 203.7 μm (range, 132-687 μm). All 5 ARTs (100%) resulted in MTMH closure. At postoperative month 6, VA was stable at 1.000 ± 0.246 logMAR (P = 0.08). Visual acuity improved at least 2 lines in 25%.

CONCLUSIONS

Surgical closure of macular holes improved VA in 57% of MTMHs. Internal limiting membrane flaps achieved better anatomic and functional outcomes than ILM peeling alone. Autologous retinal transplantation may be an option for refractory MTMHs.

FINANCIAL DISCLOSURE(S)

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

Surgery for idiopathic full-thickness macular holes within four months of symptom onset yields superior visual outcomes: Results from an Irish patient cohort

PURPOSE

To describe the anatomical, visual, and safety results of full-thickness macular hole (FTMH) repair surgery and determine factors influencing outcomes.

PATIENTS AND METHODS

A retrospective chart review was performed on all patients who underwent primary FTMH repair surgery by a single surgeon over a 3-year period. For comparisons, Snellen visual acuity (VA) was converted to logMAR equivalent. Anatomical hole closure, visual improvement, and final VA of ≤ 0.30 logMAR were the primary outcome measures.

RESULTS

Twenty eyes of 19 patients were included. Mean patient age was 69 years (range 55 to 80 years) and 74% were female. Mean minimum linear diameter (MLD) was 440 μm (range 170 μm to 1200 μm). Mean duration of symptoms before surgery was 16 weeks (range 3 to 39 weeks). 100% of eyes achieved successful anatomical FTMH closure. Mean VA improved from 1.03 ± 0.43 logMAR (Snellen 6/60) preoperatively to 0.35 ± 0.22 logMAR (Snellen 6/15) postoperatively (p = 0.0001). Patients with worse preoperative VA gained more vision than those with better preoperative VA (p = 0.01). Eyes operated on within 4 months of symptom onset were more than twice as likely to achieve a postoperative VA of ≤ 0.30 logMAR (Snellen 6/12 or better) compared to eyes with a longer duration of symptoms (p = 0.03).

CONCLUSION

FTMH repair surgery was safe and effective, with outcomes comparing favourably with published international studies. All patients benefited from surgery regardless of symptom duration, presenting VA or FTMH size. However, surgery performed within 4 months of symptom-onset was particularly beneficial, highlighting the need for prompt referral and surgery.

Relationship between Full-Thickness Macular Hole Onset and Posterior Vitreous Detachment: A Temporal Onset Theory

Purpose

To evaluate the relationship between full-thickness macular hole (FTMH) onset and perifoveal posterior vitreous detachment using OCT data.

Design

Retrospective study.

Participants

A total of 742 patients with FTMH or impending macular hole (MH) in ≥ 1 eye, as determined by ophthalmoscopy and OCT.

Methods

Macular holes were staged using OCT results. Patients with the posterior vitreous membrane clearly detected in the OCT images and vitreoretinal adhesion size ≤ 1500 μm-eyes with MH stages 1-3-were included in the study. The contralateral eyes were also included in the analyses if they showed the focal type of vitreomacular adhesion (VMA) (i.e., vitreoretinal adhesion ≤ 1500 μm). The distance between the posterior vitreous membrane and the surface of the retina was defined as the posterior vitreous separation height (PVSH). Using the OCT images, PVSHs of each eye in 4 directions (nasal, temporal, superior, and inferior) at 1 mm from the center of the MH or fovea were calculated.

Main Outcome Measures

The main outcome measures were PVSHs according to the MH stage and VMA, the relationship of the foveal inner tear with PVSH, and the likelihood of a foveal inner tear based on the direction.

Results

The PVSH trends in each of the 4 directions were as follows: VMA < MH stage 1 = MH stage 2 < MH stage 3. Initial MH stage 2 (onset of FTMH) was defined as the presence of a gap in only 1 of the 4 directions from the center of the MH. With increased PVSH, the likelihood of a gap increased (P = 0.002), and a temporal gap was more likely to occur than a nasal gap (P = 0.002).

Conclusions

At FTMH onset, a foveal inner tear likely appears on the temporal side or the side showing a high PVSH value.

Financial Disclosures

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Characteristics and outcomes of full-thickness macular holes created during vitrectomy for proliferative diabetic retinopathy

PURPOSE

To investigate the clinical features, management, and prognosis of full-thickness macular holes (FTMHs) inadvertently created during vitrectomy for eyes with proliferative diabetic retinopathy (PDR) and fibrovascular proliferation (FVP).

METHODS

Eyes with PDR and FVP that had intraoperatively created FTMHs were retrospectively collected as the study group, and age- and sex-matched subjects with PDR and FVP who did not have intraoperative FTMHs were selected as the control group. Fundus abnormalities, optical coherence tomography (OCT) features, and anatomical and functional outcomes were compared between the two groups.

RESULTS

Eleven eyes of 11 patients (5 male and 6 female) were identified as the study group. Follow-up duration was 36.8 ± 47.2 months. FTMHs were managed by ILM peeling or the inverted ILM flap technique. Anatomical success and MH closure were achieved in 100% of eyes in the study group. In comparison to the control group, the study group had a higher proportion of condensed prefoveal tissue (63.6% vs. 22.7%, p = 0.028), and a higher ratio of silicone oil tamponade (63.6% vs. 18.2%, p = 0.014), whereas there were no differences in preoperative and final BCVA, and the severity, activity, and locations of FVP between the two groups.

CONCLUSION

Condensed prefoveal tissue was a risk factor of FTMHs created during operation for eyes with PDR and FVP. The ILM peeling or the inverted ILM flap technique may be beneficial for the treatment with favorable anatomical and functional outcomes.

The effect of ethnicity on anatomic success following macular hole surgery: a multicentre cohort study

PURPOSE

The purpose is to assess the effect of ethnicity on surgical macular hole closure.

METHODS

A retrospective cohort study was undertaken in five UK National Health Service Hospitals. We included all patients with known ethnicity undergoing vitrectomy, internal limiting membrane peel, and gas/oil tamponade for all stages of primary full-thickness macular hole (FTMH). The primary outcome was anatomic success, defined as FTMH closure with one operation. The secondary outcome was mean change in best-corrected visual acuity (BCVA) comparing baseline with final review.

RESULTS

Of 334 operations, the ethnicity profile comprised 78.7% White patients, 11.7% Black patients, 8.1% Asian patients, and 1.5% in mixed/other ethnicities. Mean age was 69.7 years with 68.5% females. Overall, 280 (83.8%) had anatomic success. Anatomic failure occurred in 38.5% of Black patients versus 12.6% of White patients (relative risk: 1.788; 95% CI: 1.012 to 3.159; P = 0.045). Overall, baseline logarithm of the minimum angle of resolution BCVA improved by 0.34, from 0.95 (95% CI: 0.894 to 1.008) to 0.62 (95% CI: 0.556 to 0.676). Mean BCVA improved by 0.35 in White patients, 0.37 in Black patients, 0.23 in Asian patients, and 0.38 in mixed/other ethnicity (P = 0.689). Greater FTMH minimum linear diameter was associated with an increased risk of anatomic failure (relative risk: 1.004; 95% CI: 1.002 to 1.005; P < 0.0001), whereas better pre-operative BCVA (F [1,19] = 162.90; P < 0.0001) and anatomic success (F [1,19] = 97.69; P < 0.0001) were associated with greater BCVA improvement. Socio-economic status did not significantly influence anatomic success or BCVA change.

CONCLUSIONS

Black ethnicity is associated with an approximately twofold greater risk of failed FTMH surgery. The reasons for this difference warrant further study.

Macula-Off Retinal Detachment with Refractory Macular Hole Previously Closed with Autologous Platelet-Rich Plasma: A Case Report

The purpose of this report was to present a case of a refractory full-thickness macular hole (FTMH) complicated with recurrent retinal detachment (RD) previously treated with an autologous platelet-rich plasma (aPRP) plug. A 65-year-old male patient presented to our department with a FTMH, RD, and a giant retinal break. Preoperative best corrected visual acuity (BCVA) was 1.40 logMAR (20/500). A 25-G pars plana vitrectomy (PPV) was performed, with peripheral retinal-breaks laser barrage, peeling of the internal limiting membrane, and silicon oil injection. One month later, spectral domain optical coherence tomography (SD-OCT) showed the persistence of the FTMH with a diameter of 712 μm. Therefore, the patient underwent silicon oil removal and aPRP injection with good anatomical outcome and improvement of BCVA to 0.6 log-MAR (20/80). Two months later a recurrence of macula-off RD was detected, but SD-OCT showed that the aPRP plug was still in place and kept the two margins of the macular hole together. The patient underwent a further PPV with silicon oil injection and subsequent silicon oil removal with no postoperative complications. Two months later, the retina remained attached, SD-OCT confirmed FTMH closure and BCVA was 0.52 logMAR (20/63). In conclusion, this case report aims to underline the remarkable efficacy of aPRP in promoting FTMH closure, which was maintained despite subsequent recurrence of macula-off RD.

Postoperative microstructural re-modelling and functional outcomes in idiopathic full thickness macular hole

Purpose:

To analyze the effect of various macular hole indices and postoperative microstructural changes of all retinal layers on postoperative functional outcomes in patients with idiopathic full-thickness macular hole (FTMH).

Methods:

In this prospective study, pre and post-operative optical coherence tomography (OCT) scans of 36 eyes with idiopathic FTMH were analyzed. Hole indices and microstructural changes of all retinal layers such as ellipsoid zone (EZ), external limiting membrane (ELM) integrity, outer and inner retinal defects, and cystoid resolution were studied on follow-up visits.

Results:

Out of 36 eyes, type-1 closure was achieved in 23 eyes (65.7%) and type-2 closure in 11 eyes (31.42%), one eye showed persistent hole, and one eye was lost to follow-up. The mean minimum diameter of hole (P = 0.026), mean MHI (P = 0.001), DHI (P = 0.158), THI (P = 0.001), and HFF (P < 0.001) showed statistical significance with the type of hole closure. Postoperatively, eyes with intact ELM and EZ had better BCVA at the final visit. The BCVA was better by logMAR 0.73 ± 0.38 (P < 0.001) in patients with absent outer retinal defects. There was a significant difference in BCVA of 0.52 ± 0.35 at 1 month and 0.64 ± 0.34 at 6 months in eyes without inner retinal defects (P < 0.001). At 6 months, cystoid resolution was observed in 28 (80%) eyes. BCVA was significantly better at 1 month (P < 0.001) and at 6 months (P = 0.001) in eyes with no DONFL.

Conclusion:

Macular hole indices determine the closure type. Postoperative regeneration of outer retinal layers and resolution of retinal defects significantly influence the final visual outcomes. ELM recovery is seen as a prerequisite for EZ regeneration with no new IRD after a period of 3 months.

Long-Term Continuous Assessment of Internal Limiting Membrane Filling Induced Super-Large Macular Hole Healing

PURPOSE

To assess the long-term continuous anatomical and functional healing process of a super-large full-thickness macular hole (FTMH) after internal limiting membrane (ILM) filling and air tamponade.

DESIGN

Prospective, interventional case series.

METHODS

Pars plana vitrectomy with ILM filling and air tamponade was performed in eyes with idiopathic super-large FTMH (> 900 µm). Patients were divided into 3 groups according to the macular hole (MH) diameter: group A, < 1000 µm; group B, 1000 to 1100 µm; and group C, > 1100 µm. The MH closure pattern was analyzed using optical coherence tomography. The preoperative and postoperative macular hole sensitivity, parafoveal sensitivity, and fixation status were assessed using a Microperimeter-3. The preoperative and postoperative best corrected visual acuity were measured. A monthly follow-up was conducted for 15 months postoperatively.

RESULTS

Ninety-seven eyes from 96 consecutive patients with super-large FTMH were included in the study. Primary closure was seen in 93 of 97 eyes (95.88%), in which 88 of 97 eyes (90.72%) had a closed MH 1 week after surgery. The MH closure pattern continuously improved and significantly differed in the 3 groups (P < .05). Significant improvements in best corrected visual acuity (P < .01), parafoveal sensitivity (P < .05), and fixation stability (P < .01) were observed in all groups.

CONCLUSIONS

Super-large FTMH (> 900 µm) closed promptly within 1 week postoperatively after ILM filling and air tamponade. The morphological and functional improvement lasted over an extended period postoperatively. No central scotoma enlargement was found regardless of the closure patterns, and there was significant retinal sensitivity and fixation status improvement.

Müller cells and astrocytes in tractional macular disorders

Tractional deformations of the fovea mainly arise from an anomalous posterior vitreous detachment and contraction of epiretinal membranes, and also occur in eyes with cystoid macular edema or high myopia. Traction to the fovea may cause partial- and full-thickness macular defects. Partial-thickness defects are foveal pseudocysts, macular pseudoholes, and tractional, degenerative, and outer lamellar holes. The morphology of the foveal defects can be partly explained by the shape of Müller cells and the location of tissue layer interfaces of low mechanical stability. Because Müller cells and astrocytes provide the structural scaffold of the fovea, they are active players in mediating tractional alterations of the fovea, in protecting the fovea from such alterations, and in the regeneration of the foveal structure. Tractional and degenerative lamellar holes are characterized by a disruption of the Müller cell cone in the foveola. After detachment or disruption of the cone, Müller cells of the foveal walls support the structural stability of the foveal center. After tractional elevation of the inner layers of the foveal walls, possibly resulting in foveoschisis, Müller cells transmit tractional forces from the inner to the outer retina leading to central photoreceptor layer defects and a detachment of the neuroretina from the retinal pigment epithelium. This mechanism plays a role in the widening of outer lameller and full-thickness macular holes, and contributes to visual impairment in eyes with macular disorders caused by conractile epiretinal membranes. Müller cells of the foveal walls may seal holes in the outer fovea and mediate the regeneration of the fovea after closure of full-thickness holes. The latter is mediated by the formation of temporary glial scars whereas persistent glial scars impede regular foveal regeneration. Further research is required to improve our understanding of the roles of glial cells in the pathogenesis and healing of tractional macular disorders.

Case of Macular Hole Secondary to Ocular Toxoplasmosis Treated Successfully by Vitrectomy with Inverted Internal Limiting Membrane Flap

We report a case of ocular toxoplasmosis that developed a full-thickness macular hole (FTMH) which was successfully treated by pars plana vitrectomy combined with an inverted internal limiting membrane (ILM) flap. A 49-years-old Japanese man was aware of blurred vision in his right eye. Slit-lamp biomicroscopy, ophthalmoscopy, and optical coherence tomography (OCT) of the right eye showed that there was a grayish-white subretinal lesion at the macula accompanied by retinal exudation and mild vitreous flare and iritis. An increase in the level of serum IgM for toxoplasma led to a diagnosis of ocular toxoplasmosis. He developed a FTMH adjacent to the lesion 2 weeks after administering sulfamethoxazole/trimethoprim, and his decimal visual acuity was 0.15. Because the FTMH remained 3 months after the resolution of inflammation and his metamorphopsia persisted, vitrectomy with an inverted ILM flap was performed. After the surgery, the visual acuity improved to 0.2 with the closure of the FTMH confirmed by OCT. A FTMH in an eye with ocular toxoplasmosis was successfully closed by vitrectomy with an inverted ILM flap.

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

Foveoschisis in association with contractile epiretinal membrane is frequently misdiagnosed as lamellar macular hole (LMH). The progression of true LMH with associated epiretinal proliferation to full-thickness macular hole (FTMH) is probably underestimated. We report a case of bilateral FTMH progressing from LMH with epiretinal proliferation. A 72-year-old male presented with increased blurring of vision in left eye. Visual acuity was 20/40 in right and 20/50 in left eye. Examination showed FTMH with epiretinal proliferation in left eye and LMH with epiretinal proliferation in right eye. Surgery of the left eye achieved successful closure of macular hole with improvement in vision. He presented again a month later with further deterioration of vision in right eye. Examination revealed FTMH in right eye with epiretinal proliferation. Surgery of the right eye also achieved optimum functional and morphological results. This case demonstrates that LMH with epiretinal proliferation may have a propensity to progress to FTMH.

Degenerative lamellar macular holes: tractional development and morphological alterations

Purpose

The development of degenerative lamellar macular holes (DLH) is largely unclear. This study was aimed at documenting with spectral-domain optical coherence tomography the tractional development and morphological alterations of DLH.

Methods

A retrospective case series of 44 eyes of 44 patients is described.

Results

The development of DLH is preceded for months or years by tractional deformations of the fovea due to the action of contractile epiretinal membranes (ERM) and/or the partially detached posterior hyaloid, or by cystoid macular edema (CME). DLH may develop after a tractional stretching and thickening of the foveal center, from a foveal pseudocyst, after a detachment of the foveola from the retinal pigment epithelium, a disruption of the foveal structure due to CME, and after surgical treatment of tractional lamellar or full-thickness macular holes (FTMH). The foveal configuration of a DLH can be spontaneously reestablished after short transient episodes of CME and a small FTMH. A DLH can evolve to a FTMH by traction of an ERM. Surgical treatment of a DLH may result in an irregular regeneration of the foveal center without photoreceptors.

Conclusions

Tractional forces play an important role in the development of DLH and in the further evolution to FTMH. It is suggested that a DLH is the result of a retinal wound repair process after a tractional disruption of the Müller cell cone and a degeneration of Henle fibers, to prevent a further increase in the degenerative cavitations.

Different modes of full-thickness macular hole formation

Full-thickness macular holes (FTMH) are an important cause of visual deterioration. However, different modes of FTMH formation are less investigated. It is also not clear whether the development of edematous cysts contributes to FTMH formation. In this retrospective case series of 30 eyes of 30 patients, we describe using spectral-domain optical coherence tomography different modes of FTMH formation. Morphological alterations of established FTMH are shown in 5 eyes of 5 patients. We found in 2 of 30 eyes investigated that anterior hyaloidal traction induced a hyperreflectivity of the inner Müller cell layer of the foveola prior to FTMH formation. In 3 eyes, FTMH were caused by anterior hyaloidal traction which produced foveal pseudocysts that developed to an outer lamellar hole (OLH) characterized by a disruption of the central outer retina. The OLH developed to a FTMH by the disruption of the inner layer of the foveola. FTMH formation from an OLH by hyaloidal traction was observed also in further 7 eyes. In 2 eyes, the OLH, which preceded FTMH formation, was generated by a serous retinal detachment. In 3 eyes, anterior hyaloidal traction caused a detachment of the fovea from the retinal pigment epithelium (RPE); the subsequent disruption of the foveola resulted in a FTMH. Six eyes showed the development of a FTMH from a degenerative lamellar hole (DLH). In 5 eyes with macular pucker, FTMH were formed by traction of epiretinal membranes (ERM) or hyaloidal traction. Two eyes showed the development of a FTMH by anterior or tangential hyaloidal traction likely without a formation of an OLH. FTMH formation from an OLH proceeded with or without an enlargement of cystic cavities in the foveal walls. The formation of FTMH from a DLH, after a detachment of the fovea, and in macular pucker eyes was associated with a formation of cystic cavities in the foveal walls. The best-corrected visual acuity (BCVA) of eyes with an OLH or FTMH was inversely correlated to the base and minimum diameters of the holes, and with the height of the foveal walls; the highest correlation coefficients were found between the BCVA and the base diameter. The data show that FTMH may be formed via different modes by hyaloidal traction and/or traction of ERM, or after a serous retinal detachment. It is suggested that, after FTMH formation, the impaired fluid clearance through the RPE after detachment of the central outer retina causes the development of edematous cysts in the foveal walls which enlarges the FTMH. The BCVA of eyes with an OLH or FTMH mainly depends on the size of the central photoreceptor-free area.

Management of Full-Thickness Macular Hole in A Genetically Confirmed Case with Usher Syndrome

INTRODUCTION

Full-thickness macular hole (FTMH) formation is rarely seen in patients with retinitis pigmentosa (RP) and can have an adverse impact on their residual visual function. The underlying mechanisms are unknown, and clinical experience is limited regarding surgical outcomes. Here, we describe the surgical management of FTMH in a young patient with genetically confirmed Usher syndrome, the most common form of syndromic RP.

CASE REPORT

A 28-year-old woman presented with blurred vision in her right eye (RE). She had a history of RP and bilateral hearing impairment since childhood. Fundoscopy and spectral-domain optical coherence tomography revealed a FTMH in the RE along with typical RP features bilaterally. After pars plana vitrectomy (PPV) with internal limiting membrane peel and gas tamponade, the FTMH closed. Six months after PPV the patient underwent cataract surgery in the affected eye, and the visual acuity remained stable compared to baseline. The clinical diagnosis of Usher syndrome was genetically confirmed by whole exome sequencing (WES), which revealed the presence of two pathogenic nucleotide variants in trans (compound heterozygosity) in the gene USH2A.

CONCLUSION

We report a rare case of successful closure of a FTMH in a patient with Usher syndrome. Surgical treatment of FTMH can help preserve the central vision in RP patients, whose peripheral vision is severely affected.

Two different populations of Müller cells stabilize the structure of the fovea: an optical coherence tomography study

PURPOSE

To document with spectral-domain optical coherence tomography the structural stabilization of the fovea and the sealing of outer macular defects by Müller cells.

METHODS

A retrospective case series of 45 eyes of 34 patients is described.

RESULTS

In cases of a cystic disruption of the foveola as in macular telangiectasia type 2 and vitreomacular traction, the Müller cell cone provides the structural stability of the fovea. In cases of a detachment or disruption of the Müller cell cone, e.g., in foveal pseudocysts, outer lamellar holes, and degenerative and tractional lamellar holes, Müller cells of the foveal walls may provide the structural stability of the fovea by the formation of a hyperreflective external limiting membrane (ELM) which bridges the holes in the central outer nuclear layer (ONL). Müller cells of the foveal walls and parafovea mediate the regeneration of the foveal architecture in cases of outer lamellar and full-thickness macular holes. The regeneration proceeds by a centripetal displacement of photoreceptor cell somata which closes the holes in the central ONL. The closure may be supported by the formation of a glial tissue band at the ELM which seals the hole.

CONCLUSIONS

The Müller cell cone provides the foveal stability in cases of a cystic disruption of the foveola. The structural stability of the outer foveal layers is mainly provided by the Müller cells of the foveal walls and parafovea; these cells also mediate the regeneration of the outer fovea in cases of a defect of the central ONL.

Spontaneous formation and closure of full thickness macular hole after treatment with anti-vascular endothelial growth factor therapy in polypoidal choroidal vasculopathy

Full-thickness macular hole (FTMH) formation in Polypoidal choroidal vasculopathy (PCV) after intravitreal anti-vascular endothelial growth factor (anti-VEGF) treatment is a rare complication. Spontaneous closure of FTMH following anti-VEGF therapy has not been described in PCV till date. We present a case of Asian woman with PCV who developed a FTMH following treatment with intra-vitreal anti-VEGF injections which subsequently closed spontaneously on further course of treatment.

Premacular Cells as Source of Neurotrophic Factors in Idiopathic Macular Holes

Purpose: To describe the presence of neurotrophic growth factors and histopathologic characteristics of internal limiting membrane (ILM) specimens obtained from large idiopathic full-thickness macular holes (FTMH). Methods: In 24 eyes of 24 patients with FTMH of diameter >400 µm, ILM specimens were harvested directly at the edge surrounding the macular hole during vitrectomy with peeling. We performed interference and phase contrast microscopy of flat mounts followed by immunostaining and transmission electron microscopy. Primary antigens directed against neurotrophic growth factors as well as antigens to glial and ganglion cells were used. Topographic relationship of cells and collagen was demonstrated by serial ultrathin sectioning. Results: Immunofluorescence microscopy demonstrated the presence of glial-derived neurotrophic factor and ciliary neurotrophic factor. Expression of vimentin, glial fibrillary acidic protein (GFAP), neurofilament, calretinin, and melanopsin was seen positive too. Cellular retinaldehyde-binding protein was seen positive in half of the specimens. Co-localisation of anti-GFAP as well as anti-vimentin with neurotrophic factors was found. Electron microscopy revealed cells exclusively on the vitreal side of the ILM. Cell fragments on the retinal side were rarely seen. Conclusion: In large FTMH, ILM specimens present positive immunolabelling of neurotrophic factors. The co-localization with macroglial cell markers suggests a premacular cell composition as a source of the neurotrophic factors. Ultrastructurally, premacular cells were found on the vitreal side of the ILM and not within the collagen network of the ILM itself.

Tailored internal limiting membrane flap technique for primary macular hole

PURPOSE

To investigate the outcomes of primary full-thickness macular hole (MH) after surgical intervention with tailored internal limiting membrane (ILM) flap technique.

METHODS

Patients were reviewed for their clinical characteristics and surgical outcomes. The technique included incomplete circular peeling of the perifoveal ILM which was then trimmed according to the size of the MH. Fluid-gas exchange was done without further manipulation.

RESULTS

Nineteen eyes of 19 patients were included. The patients were in average 61 years old (range 41-83) and had an average follow-up period of 11.0 months. At baseline visit, minimal linear diameter of the MH was 311.6 μm (range 80-768). After a single surgery, the MH closed in all cases with improvement of mean visual acuity (from 0.9 to 0.4 logarithm of the minimum angle of resolution units, p < 0.0001, Wilcoxon signed-rank test). At the final visit, 15 (78.9%) eyes achieved a visual acuity ≥ 20/40. Outer retinal gliosis was found to be associated with less favorable postoperative visual acuity. Factors related to the formation of outer retinal gliosis were worse preoperative visual acuity and a large MH with a diameter > 400 μm.

CONCLUSION

Tailored ILM flap technique is an effective method for favorable anatomical and visual outcomes for treatment of primary MH.

Surgically Induced Macular Detachment for Treatment of Refractory Full-Thickness Macular Hole: Anatomical and Functional Results

PURPOSE

The purpose of this study was to investigate the efficacy and safety of surgically induced macular detachment (MD) for the treatment of refractory full-thickness macular hole (FTMH).

MATERIALS AND METHODS

Clinical data were age, gender, lens status, and best corrected visual acuity (BCVA). Preoperative tomographic parameters were: FTMH morphology (intraretinal cyst and elevated or flat edges) and FTMH diameter. Postoperative FTMH closure and outer retinal layer (ORL) restoration were evaluated. Fundus autofluorescence (FAF), optical coherence tomography (OCT) findings, and BCVA were analyzed at the 1st, 3rd, and 6th postoperative month. The interval between the first surgery for idiopathic FTMH and the surgically induced MD for refractory FTMH was collected (intersurgical interval, days).

RESULTS

Ten eyes of 10 patients were included. The mean age was 68.8 ± 6.8 years. FTMH closure was obtained in 9 patients; in 8 patients, ORL restoration was detected. BCVA improved from 1.06 ± 0.1 (baseline) to 0.56 ± 0.2 (final) logMAR (p = 0.0001). A negative correlation between the intersurgical interval and postoperative visual gain was demonstrated (r = -0.3618). FAF and OCT showed a permanent retinal pigment epithelium (RPE) damage corresponding to the retinotomy points.

CONCLUSION

This study demonstrates the efficacy of this technique and highlights the risk of RPE damage, suggesting the need to perform the retinotomy points outside the macula.

Anatomical configurations of vitreomacular traction syndrome: influence on clinical course and surgical outcomes

PURPOSE

To develop a new classification system for vitreomacular traction (VMT) syndrome according to spectral-domain optical coherence tomography (SD-OCT) imaging and to investigate the clinical course of VMT patients.

METHODS

This study included 68 eyes of 68 consecutive patients who were followed with observation or treated with vitrectomy for idiopathic VMT. Eyes were classified into one of three groups according to SD-OCT findings: group A (foveal pseudocyst, which was defined as the formation of cystoid cavity located in the inner part of the central fovea along with foveal thickening), group B (parafoveal retinoschisis, which was defined as intraretinal cysts or clefts along with no apparent foveal thickening), and group C (outer retinal dehiscence at the fovea, which is sometimes accompanied by foveal thinning). The minimum required follow-up period was 1 year. Clinical course and anatomical and functional outcomes were compared among the groups.

RESULTS

Twenty-seven eyes (39.7%) were included in group A, 22 eyes (32.4%) were included in group B, and 19 eyes (27.9%) were included in group C. Among the 24 eyes that were managed by observation, a significantly larger percentage of patients in group A (6/10 [60%]) exhibited more spontaneous resolution of VMT compared with those in groups B (9.1%) or C (0%) (P = 0.010). In the 44 eyes that were managed with vitrectomy, a significantly larger percentage of patients in group C (4/16 [25%]) experienced subsequent full-thickness macular hole development following vitrectomy compared with those in groups B (0%) or C (0%) (P = 0.014). The percentage of patients with photoreceptor inner segment/outer segment disruption was significantly reduced in group A after vitrectomy, with group C exhibiting the lowest recovery rate. Postoperatively, group A experienced a significantly better visual outcome than group C (P = 0.021).

CONCLUSIONS

A novel configuration system offering insight into the clinical course of VMT is proposed. According to this system, anatomical and functional outcomes were favorable in group A and worse in group C.

Learning curve of three-dimensional heads-up vitreoretinal surgery for treating macular holes: a prospective study

PURPOSES

To compare surgeons' opinions regarding idiopathic full-thickness macular hole (MH) surgery by using traditional microscopy and three-dimensional (3-D) visualization system. To analyze the required time for pars plana vitrectomy (PPV) and for internal limiting membrane (ILM) rhexis by using both visualization methods. To evaluate anatomical surgical results.

METHODS

Four surgeons (surgeon 1, fellows 1, 2, 3) performed the total of 40 surgeries for treating MHs. Each one performed 10 surgeries (5 with traditional microscopy and 5 with 3-D visualization). The completion time for PPV and ILM rhexis was determined by using both methods. Ergonomics, educational value, image sharpness, depth perception, field of view and technical skills were analyzed through answering a questionnaire.

RESULTS

Forty patients were included in the study. The MH size for surgeon 1, fellows 1, 2 and 3 groups, individually, ranged from 237 to 602 μm; 228 to 590 μm, 271 to 611 μm and 289 to 600 μm, respectively. In the 3-D and in the traditional microscopy subgroups (which includes all 4 physicians on the use of one or the other method), the MH size ranged from 228 to 602 μm and 237 to 611 μm, respectively. Comparisons between the average time for full PPV and ILM rhexis by using the two methods were non-significant, neither in each individual case of 3-D surgery for each surgeon. Surgeon 1 had always been faster than his fellows. Depth perception was rated as similar for both methods. Field of view and educational values were rated as superior when using the 3-D system. Image resolution and ergonomics were rated as superior when using traditional microscopy. Technical skills strongly tended toward 'superiority' when using traditional microscopy. Thirty-six (90%) full-thickness MHs were successfully closed with one surgery.

CONCLUSION

The 3-D system for MH surgery had a short learning curve and was a refined educational tool, when used with reduced illumination and precise focus. Concerning MH surgery, heads-up method was similar to traditional microscopy regarding length of time and anatomical surgical results. Heads-up surgery may become a new pattern for ophthalmic surgery as ongoing improvements are applied.

Optical coherence tomography patterns and outcomes of contusion maculopathy caused by impact of sporting equipment

Background

To describe the patterns and outcomes of contusion maculopathy after ocular contusions resulting from accidental impact with sporting equipment.

Methods

We conducted a retrospective study of interventional case series. Patient Population: Twenty-one eyes of 21 patients who sustained blunt ocular trauma while playing a sport. Intervention/Observation Procedure(s): Surgery or observation by optical coherence tomography (OCT). Main Outcome Measure(s): The morphologic changes within the macula in the early stages after injury and changes in visual function in the early and recovery stages after injury.

Results

In the early stage, OCT visualized four injury patterns: type Ι, commotio retinae (14.3%, 3 eyes) with increased reflectivity of the ellipsoid zone and retinal pigment epithelium; type II, incomplete macular hole(38.1%, 8 eyes) with three structural changes, i.e., a partial V-shaped macular hole, a jar-shaped macular hole with retinal tissue at the bottom, and a connective bridge attached to retinal tissues; type III, full-thickness macular hole (33.3%, 7 eyes); and type IV, foveal hemorrhage (14.3%, 3 eyes). During recovery, OCT images of types Ι and II showed almost normal macular morphology with better visual acuity (mean ± SD,0.02 ± 0.1 and 0.14 ± 0.21logMAR.). In types III and IV, the visual prognosis was poor (0.52 ± 0.34 and 0.22 ± 0.16), OCT images showed retinal atrophy at the fovea despite vitrectomy and sulfur hexafluoride (SF6) gas tamponade.

Conclusion

Early OCT images identified four patterns of contusion maculopathy with different treatment outcomes. In types Ι and II, the visual function and retinal morphology remained intact. With types III and IV, respectively, the treatments of vitrectomy and SF6 gas tamponade for patients were effective.

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.

Full-thickness macular hole associated with congenital simple hamartoma of retinal pigment epithelium (CSHRPE)

PURPOSE

To report a unique case of congenital simple hamartoma of retinal pigment epithelium (CSHRPE) associated with full-thickness macular hole (FTMH).

METHODS

A 14-year-old female with a previous diagnosis of simple hamartoma of retinal pigment epithelium in the left eye presented with a 3-week onset of reduced visual acuity in the same eye. Complete ophthalmological examination with spectral domain ocular coherence tomography (SD-OCT) and autofluorescence imaging was carried out. Results were compared with the last 4-year follow-up data.

RESULTS

On examination, visual acuity in the left eye was counting fingers compared to 20/100 documented in the last follow-up. Fundoscopy revealed a nodular, heavily pigmented, circumscribed foveal mass, with 0.5 mm basal diameter and 1.1 mm thickness corresponding to the simple RPE hamartoma. Although the latter remained unchanged throughout the follow-up period, a new lesion at the inferior edge of the hamartoma was noted. SD-OCT confirmed the presence of a FTMH with no evidence of associated epiretinal membrane, vitreomacular traction or posterior vitreous detachment. After explaining the risks and benefits of vitrectomy for FTMH, the patient declined surgery.

CONCLUSIONS

CSHRPE may have associated features such as feeding vessels, retinal surface wrinkling, pigmented vitreous cells, retinal exudation and vitreoretinal adhesion. The case presented herein broadens the clinical spectrum of CSHRPE and emphasizes that despite the benign nature of the lesion, which remains stable without growth, visual loss may occur, attributable to foveal traction and development of FTMH. We postulate that protrusion of the tumor into the vitreous cavity results in tissue stretching and development of anteroposterior and tangential forces which may lead to development of macular hole.

Assessment of intravitreal ocriplasmin treatment for vitreomacular traction in clinical practice

PURPOSE

To assess treatment effects following intravitreal injection of ocriplasmin for vitreomacular traction (VMT), with or without full-thickness macular hole (FTMH), in real-life setting.

METHODS

This is a monocentric, retrospective, consecutive series of 82 eyes from 82 patients who underwent ocriplasmin treatment between July 2013 and December 2016. We included 57 eyes with pure VMT, 17 eyes with small FTMHs, and eight eyes with medium FTMHs. Primary outcome measures were VMT release and MH closure rates. Secondary outcomes were visual acuity (VA), morphological changes, and subjective visual impairment after 1, 3, and 6 months and at last follow-up.

RESULTS

After a median follow-up of 10 months, VMT release was achieved by pharmacologic vitreolysis in 57% of all eyes, whereas the macular hole closure rate was 32%. In those presenting with five or more positive prognostic factors (PPF), eyes with pure VMT showed nonsurgical traction release in 88%, and FTMHs were released in 93%, with a closure rate of 20%. Small FTMHs closed in 41% and medium FTMHs in 13%. The mean change in VA (LogMAR) was -0.07 ± 0.24 (median - 0.10) in all eyes. Subretinal fluid accumulation and ellipsoid zone changes were seen in 31% and 37% of all eyes, respectively. They were more frequent in eyes with traction release, but were self-limited.

CONCLUSIONS

In a real-life setting, release of VMT by ocriplasmin injection can be achieved in the majority of eyes, relying on a strict patient selection. Closure of FTMHs rather correlates with hole diameter than with presence of PPF, and remains a rare finding in medium FTMHs.

Movement of the inner retina complex during the development of primary full-thickness macular holes: implications for hypotheses of pathogenesis

BACKGROUND

The inner retinal complex is a well-defined layer in spectral-domain OCT scans of the retina. The central edge of this layer at the fovea provides anatomical landmarks that can be observed in serial OCT scans of developing full-thickness macular holes (FTMH). Measurement of the movement of these points may clarify the mechanism of FTMH formation.

METHOD

This is a retrospective study of primary FTMH that had a sequence of two OCT scans showing progression of the hole. Measurements were made of the dimensions of the hole, including measurements using the central edge of the inner retinal complex (CEIRC) as markers. The inner retinal separation (distance between the CEIRC across the centre of the fovea) and the Height-IRS (average height of CEIRC above the retinal pigment epithelium) were measured.

RESULTS

Eighteen cases were identified in 17 patients. The average increase in the base diameter (368 microns) and the average increase in minimum linear dimension (187 microns) were much larger than the average increase in the inner retinal separation (73 microns). The average increase in Height-IRS was 103 microns.

CONCLUSION

The tangential separation of the outer retina to produce the macular hole is much larger than the tangential separation of the inner retinal layers. A model based on the histology of the Muller cells at the fovea is proposed to explain the findings of this study.

Reappraisal of spontaneous closure rate of idiopathic full-thickness macular holes

We retrospectively reviewed the records of 142 eyes of 138 patients with idiopathic full-thickness macular hole. Spontaneous closure of idiopathic full-thickness macular hole was observed in five eyes (3.5%) of four patients before the planned vitrectomy. In the era when surgical treatment was not available for macular hole, the rate of spontaneous closure of idiopathic full-thickness macular hole was reported as 6.2%. Among several case reports on spontaneous closure of idiopathic full-thickness macular hole based on the optical coherence tomography images only one study reported the rate of spontaneous closure as 2.7%. According to the previous reports and our results, small idiopathic full-thickness macular holes may close spontaneously in a few percent of all macular hole cases. The rate of spontaneous closure may be affected by the waiting time before vitrectomy.