Epiretinal Membrane in Dome-Shaped Macula Complicated with Serous Retinal Detachment: Transient Efficacy of Surgery

Dome-shaped macula (DSM) is an entity recently described as a convex anterior protrusion of the macular area within a posterior myopic staphyloma. Specific complications were associated with DSM, like serous retinal detachment (SRD). We describe a woman presenting with a decreased vision at 20/50. SD-OCT scans were performed, showing a macular bulge. SRD was present and an epiretinal membrane could also be observed. Fluorescein angiography and indocyanin green angiography did not show any leakage nor choroidal neovascularization. Epiretinal membrane peeling was performed, and 3 months after surgery, SRD completely disappeared. However, SRD reappeared 1 year after surgery and enlarged within 2 years following surgery. In conclusion, two mechanisms could be considered for physiopathology of SRD: first, the epiretinal membrane may have exerted traction on the macular retina, second, vitreous body might constitute a tank for cytokines and/or other factors, triggering subretinal fluid accumulation, leading to SRD.

Epiretinal membrane development after submacular perfluorocarbon liquid removal

Optical coherence tomography of submacular perfluorocarbon liquid and its safe removal with a small gauge cannula have been presented in the report. This case was complicated by development of an epiretinal membrane, though visual acuity was preserved.

Multilayer Microstructure of Idiopathic Epiretinal Macular Membranes

PURPOSE

To identify the ultramicroscopic structure of idiopathic epiretinal macular membranes (iEMMs) by scanning electron microscopy (SEM).

METHODS

We examined 28 iEMMs surgically removed from 28 eyes of 28 patients. All specimens, previously observed at stereomicroscope, were treated with an osmium maceration technique. Fine resolution of iEMMs' 3D architecture and their interaction with the retina were studied using a Philips SEM-FEG XL-30 microscope.

RESULTS

The specimens appeared as laminar connective structures partially or completely adherent to the inner limiting membrane (ILM). We identified 4 types of structures: ( 1 ) distinct layers of thin sheets of woven fibers; ( 2 ) folded layers of inhomogeneous thickness of fibrous material more consistent; ( 3 ) thicker and more rigid layers recognizable as collagen fibrils with typical 64-nm period, collagen fibrils isolated or intermingled between them; ( 4 ) lacunar structures with inflammatory and/or necrotic material. The first 3 types of structures appear to thicken towards a centripetal direction from the ILM to the vitreous in order from 1 to 3. The interface of ILM-iEMM tissue shows particular small bridges of connection. Cells are rarely found, especially in the tissue near the ILM.

CONCLUSIONS

Layers of various materials follow one another in iEMMs. Cells are rarely found. The interface ILM-iEMM tissue shows particular small bridges of connection. The dynamic modeling of bended layers begins in soft tissue.

Eccentric Macular Hole after Pars Plana Vitrectomy for Epiretinal Membrane Without Internal Limiting Membrane Peeling: A Case Report

Introduction

Postoperative eccentric macular hole formation is an uncommon complication after pars plana vitrectomy (PPV) without internal limiting membrane (ILM) peeling for the treatment of epiretinal membrane (ERM). We present a case of eccentric macular hole formation after PPV for ERM without ILM peeling.

Case report

A 68-year-old male patient presented with ERM and visual acuity of 6/24 in his left eye. He underwent 23-gauge PPV without ILM peeling for treatment of ERM. One week postoperatively the retina was attached and the epiretinal membrane was successfully removed, while visual acuity was 6/9. One month after PPV, a single eccentric retinal hole below the macula was detected using fundoscopy and subsequently confirmed by optical coherence tomography. At this time the visual acuity was 6/9 and the patient reported no symptoms. No further intervention was attempted and at the 9-month follow-up, the visual acuity and the size of the eccentric macular hole remained stable.

Conclusion

Eccentric macular holes can be developed after PPV even without ILM peeling and are usually managed conservatively by observation.

Correlation between Uncorrected Visual Acuity and Macular Distortion in Idiopathic Epiretinal Membrane Patients

Purpose

To evaluate the association between degree of retinal abnormalities and uncorrected visual acuity (UCVA) in idiopathic epiretinal membrane (ERM) patients with a small amount of refractive error.

Methods

We retrospectively reviewed 49 eyes (37 patients) of idiopathic ERM patients. We investigated the association between visual acuity and macular status (central macular thickness [CMT], outer retinal integrity score, and inner retinal irregularity index) that was assessed by optical coherence tomography using multiple linear regression analysis. We defined visual acuity difference (VAD) as the difference between UCVA and best-corrected visual acuity (BCVA). We divided patients into two groups according to VAD size and compared clinical characteristics between the two groups. We also investigated factors associated with VAD using multiple linear regression analysis.

Results

BCVA showed significant association with CMT and outer retinal integrity score, while UCVA showed significant association with CMT and inner retinal irregularity index. Patients with a large VAD showed a similar level of BCVA compared to the small VAD group (logarithm of the minimum angle of resolution [logMAR], large VAD group 0.11 ± 0.11 vs. small VAD group 0.13 ± 0.12, p = 0.585). However, UCVA was worse (logMAR, large VAD group 0.44 ± 0.14 vs. small VAD group 0.18 ± 0.14, p < 0.001) and inner retinal irregularity was higher (large VAD group 1.06 ± 0.04 vs. small VAD group 1.04 ± 0.03, p < 0.001) in patients with a large VAD. On multiple linear regression analysis, the absolute value of spherical equivalent (standardized coefficient β 0.521, p < 0.001) and inner retinal irregularity index (standardized coefficient β 0.448, p < 0.001) were significantly associated with VAD.

Conclusions

UCVA was associated with inner retinal irregularity in idiopathic ERM patients with a mild degree of refractive error. Inner retinal irregularity was also associated with degree of VAD, suggesting that the effect of refractive error correction is greater in patients with more distorted retina.

Vitrectomy in high myopia: a narrative review

Pathologic myopia is associated with degenerative changes of the globe, especially at the posterior pole. Eyes affected by pathologic myopia have higher odds to undergo posterior segment surgery and, in those eyes, vitreoretinal surgery is challenging. Many practical tips and tricks can make the surgical procedures simpler, significantly preventing sight-threatening intra- and post-operative complications. Moreover, novel surgical techniques and technological advancements (i.e. ad-hoc instrumentation, minimally invasive vitreoretinal surgery, filters, dye staining, intraoperative optical coherence tomography and 3-dimensional surgery) may play role in highly myopic eyes. The aim of the present work is to review practical tips and tricks, novel surgical techniques and technological advancements.

Additive Effect of Oral Steroid with Topical Nonsteroidal Anti-inflammatory Drug for Preventing Cystoid Macular Edema after Cataract Surgery in Patients with Epiretinal Membrane

Purpose

To investigate the additive effect of oral steroid with topical nonsteroidal anti-inflammatory drug (NSAID) on cystoid macular edema (CME) in patients with epiretinal membrane (ERM) after cataract surgery.

Methods

Medical records of subjects who underwent uneventful cataract surgery (n = 1,349) were retrospectively reviewed; among these patients, those with pre-existing ERM (n = 81) were included. Patients were divided into two groups: one group had postoperative administration of oral steroid for 1 week (n = 45) and the other group did not have oral steroid administration (n = 36). Changes in macular thickness and incidence of CME were compared in both groups. Topical NSAIDs were administered in both groups for 1 month postoperatively. Definite CME and probable CME were defined by changes in retinal contour with or without cystoid changes. Change in central macular thickness of more than three standard deviations (≥90.17 µm) was defined as possible CME. Macular thickness was measured at 1 month after the operation by optical coherence tomography.

Results

The incidence of definite, probable, and possible CME were 2.22%, 4.44%, and 8.89% with the use of steroid and 2.78%, 5.56%, and 8.33% without steroid, respectively (p = 0.694, p = 0.603, and p = 0.625), and regardless of treatment group, the incidences in these patients were higher compared to incidences in whole subjects (1.26%, 2.30%, and 4.32%; p = 0.048, p = 0.032, and p = 0.038, respectively). The differences in macular thickness were not statistically different between the two groups. Average changes of central foveal thickness in 3 mm and 6 mm zone were 29.29 µm, 35.93 µm, and 38.02 µm with the use of steroid and 32.25 µm, 44.08 µm, and 45.39 µm without steroid (p = 0.747, p = 0.148, and p = 0.077, respectively).

Conclusions

This study suggests that administration of oral steroid may not have a synergistic effect in reduction of CME and retinal thickness in patients with pre-existing ERM after cataract surgery, when topical NSAIDs are applied.

Epiretinal Membrane: Prevalence and Risk Factors from the Korea National Health and Nutrition Examination Survey, 2008 through 2012

PURPOSE

To investigate the prevalence and risk factors for an epiretinal membrane (ERM) in Korean population.

METHODS

Using the database of the Korea National Health and Nutrition Examination Survey from 2008 through 2012, 14,772 participants 40 years of age or older with gradable fundus photographs were included. The presence of ERM was determined by using fundus photographs. The prevalence of ERM was estimated and possible risk factors including systemic factors, nutritional status, and blood tests were analyzed via multiple logistic regression analyses.

RESULTS

The prevalence of ERM was 2.9% (95% confidence interval [CI], 2.6% to 3.3%). On multiple logistic regression analysis, the prevalence of ERM was affected by age. The odds ratios (ORs) against the forties were 2.70, 5.48, and 5.69 in the fifties, sixties, and seventies, respectively. ERM was also significantly affected by cataract surgery (OR, 2.82; 95% CI, 2.08 to 3.81) and by the increase in intake of 100-mg calcium (OR, 1.05; 95% CI, 1.00 to 1.11). ERM had negative associations with red blood cell count (OR, 0.66; 95% CI, 0.45 to 0.95).

CONCLUSIONS

The estimated nation-wide prevalence of ERM in Korea is 2.9%. The presence of ERM in the general population is associated with age, cataract surgery, increased dietary calcium, and a low red blood cell count.

Intraoperative optical coherence tomography assisted analysis of pars Plana vitrectomy for retinal detachment in morning glory syndrome: a case report

BACKGROUND

The pathogenesis of non-rhegmatogenous retinal detachment (non-RRD) associated with morning glory syndrome (MGS) is not established, as well as best surgical approach to treat RD. Our purpose was to analyse intraoperative optical coherence tomography data (iOCT) in all steps of pars plana vitrectomy (PPV) for non-RRD in MGS, in order to follow pathophysiological aspects of the disease and to understand the tissues behaviour during surgical workflow.

CASE PRESENTATION

Intraoperative spectral domain optical coherent tomography (iSD-OCT) assisted PPV using Rescan 700 (Carl Zeiss Meditech, Jena, Germany) with epiretinal membrane (ERM) and internal retinal membrane (ILM) peeling, and air endotamponade was performed on the only eye of a 21 years old female with non-RRD associated with MGS. BCVA, pre-, intra- and postoperative OCT were performed along with standard ocular examination. iOCT video and snapshots were analysed intra- and postoperatively using post-processing approach using graphic software. The progression of non-RRD resulted in best corrected visual acuity (BCVA) decrease from 0.8 to 0.2. Triamcinolone enhanced iOCT imaging revealed strong vitreous traction and adhesion above the macula and optic disc. Internal limiting membrane was peeled under iOCT control to prevent the peeling of inner layers of the retinal schisis. No retinal break was detected, and only air endotamponade was performed. The retina reattached during first 4 weeks of follow-up with gradual resolution of intraretinal- and subretinal fluid, and remained stable in 12 months. BCVA improved to 0.8.

CONCLUSION

Based on iSD-OCT findings we assume that non-RRD in this case of MGS is caused primarily by the vitreous traction with further possible formation of the retinal breaks. Retinal reattachment reached only with air endotamponade strongly advocates the tractional component of non-RRD and retinal schisis assotiated with MGS. Early PPV for central non-RRD and retinal schisis with the use of iOCT can be performed in more safe and controlled manner and has to be considered to reduce the risk of retinal break formation and to prevent the central vision loss.

Eplerenone, a new treatment for an old problem: Retinitis pigmentosa with recalcitrant macular edema

CASE REPORT

The case involves a 35-year-old man, with a history of retinitis pigmentosa, who presented with a bilateral cystoid macular oedema associated with bilateral epiretinal membrane, which was resistant to treatment with oral acetazolamide and intravitreal bevacizumab. The treatment with oral eplerenone was able to improve the visual acuity and macular thickness of this patient.

DISCUSSION

A variety of treatments have been proposed for the management of cystoid macular oedema, associated with retinitis pigmentosa, with variable results. The treatment with oral eplerenone might be a good option for the control of this condition.

Analysis of the vitreoretinal surgery learning curve

OBJECTIVE

To describe intra- and post-operative complications, as well as the evolution of the surgical technique in first 4years of work of a novice retina surgeon, and evaluate minimal learning time required to reduce its complications, deciding which pathologies should still be referred to higher level hospitals, until further experience may be achieved.

METHODS

A study was conducted on patients that had undergone vitreoretinal surgery by a novice surgeon in Tarragona between 23rd October 2007 and 31st December 2011. The primary diagnosis, surgeon learning time, surgical technique, intra-operative and post-operative complications were recorded.

RESULTS

A total of 247 surgeries were studied. The percentage of use of 20G and 23G calibres during the time, marks a change towards trans-conjunctival surgery from the ninth trimester (98 surgeries). Surgical complications decreased towards twelfth trimester (130 surgeries) with an increase in the previous months.

CONCLUSIONS

The shift towards 23G technique around 100 surgeries is interpreted as greater comfort and safety by the surgeon. Increased surgical complications during the following months until its decline around 130 surgeries can be interpreted as an 'overconfidence'. It is arguable that the learning curve is slower than what the surgeon believes. An individual analysis of the complications and surgical outcomes is recommended to ascertain the status of the learning curve.

[Observation of single-layered inverted internal limiting membrane flap technique for macular hole with retinal detachment in high myopia]

Objective: To compare the outcome of pars plana vitrectomy (PPV) with a single-layered inverted internal limiting membrane (ILM) flap versus PPV with ILM peeling for the treatment of macular hole associated retinal detachment (MHRD) in high myopia. Methods: In a retrospective cohort study, PPV with 2 kinds of adjuvant surgical procedures were used in 35 moderately high myopia eyes with MHRD. These eyes were divided into 2 groups: group 1 (17 eyes) receiving PPV and ILM peeling and group 2 (18 eyes) receiving PPV with a single-layered inverted ILM flap. Anatomical reattachment of the retina, macular hole closure, and best-corrected visual acuity (BCVA) were measured at 6 months after surgery. Results: The retina was successfully reattached in all cases. The difference of the retinal reattachment rate between the two groups was not statistically significant (Fisher's exact test, P=1.000). The rate of macular hole closure was 47.1% in group 1 (8 eyes) and 88.9% in group 2 (16 eyes). The difference of the macular hole closure rate between the two groups was statistically significant (Fisher's exact test, P= 0.012). Significant improvement in logarithm of minimal angle of resolution (logMAR) BCVA was achieved in both groups. There was no difference in the initial, final, or improved logMAR BCVA in the 2 groups. Conclusion: Single-layered inverted ILM flap technique effectively helps close the macular hole in moderately high myopia with MHRD. This may prevent the possible redetachment from the macular hole. (Chin J Ophthalmol, 2017, 53: 338-343).

[Intraoperative risk factors associated with visual acuity outcomes of pars plana vitrectomy in idiopathic epiretinal membrane]

Objective: To evaluate intraoperative risk factors related to the postoperative visual acuity in idiopathic epiretinal membrane (IERM) . Methods: According to the well-established study criterion, a retrospective observational study was carried out on 37 eyes of 37 patients with epiretinal membrane peeling surgery for IERM between January 2014 and January 2015. Intraoperative situations during membrane peeling were documented, including complexity of operation, superficial hemorrhage and the state of indocyanine green (ICG) staining. Best-corrected visual acuity (BCVA) measurement and optical coherence tomography were performed before and 1, 3, 6 and 12 months after surgery. Multifocal electroretinography and fundus fluorescein angiography were conducted at 6 months postoperatively. The patients were divided into two groups based on the BCVA (≥0.5 and<0.5) at 6 months after surgery. The BCVA was converted to logarithm of the minimum angle of resolution (logMAR) equivalents for statistical analysis. The relationship between intraoperative factors and postoperative visual acuity was analyzed by multiple logistic regression analysis. Results: All patients completed follow-ups in an average duration of (14.41±2.33) months. Among the 37 patients, 28 patients (75.7%) were in the BCVA ≥0.5 group. and 9 patients (24.3%) were in the BCVA<0.5 group. Statistical analysis revealed that superficial hemorrhage during membrane peeling was associated with poor visual acuity after surgery (OR: 7.221, 95% CI: 1.775-29.372, P=0.006) . The peeling complexity was positively increased with presence of superficial hemorrhage (γ=0.336, P=0.042) and ICG staining (γ=0.593, P=0.000) . The electroretinography revealed that the average latency of N1 wave at ring 1 in eyes with superficial hemorrhage (16.88±1.27)ms was longer than that in eyes without superficial hemorrhage (12.80±4.21)ms at 6 months postoperatively (t=-2.187, P= 0.042). The fluorescein angiography showed 8 in 10 eyes with superficial hemorrhage had leakage on the macular fovea. Conclusions: Superficial hemorrhage in IERM peeling is a risk factor for the poor postoperative visual function. Complex peeling contributes to superficial hemorrhage and the positive staining of ICG. (Chin J Ophthalmol, 2017, 53:344-351).

Long-term follow-up of fellow eye in patients with lamellar macular hole

BACKGROUND

To evaluate macular changes in fellow eyes of patients diagnosed with lamellar macular hole (LMH) using spectral-domain optical coherence tomography (SD-OCT) and blue fundus autofluorescence (B-FAF).

METHODS

Fellow eyes of patients diagnosed with a LMH were retrospectively evaluated on OCT. Best-corrected visual acuity (BCVA) and central foveal thickness (CFT) were recorded. Corresponding B-FAF images, vitreo-macular relations, and type of epiretinal membranes (ERMs) were also examined.

RESULTS

Thirty-five patients were included. At baseline, six fellow eyes (17%) showed a normal foveal profile, 26 (74%) had a tractional ERM, and three cases (9%) revealed a bilateral LMH, one of them with a lamellar hole-associated epiretinal proliferation (LHEP). A posterior vitreous detachment (PVD) was present in 29 patients (83%), four (11%) had only a vitreo-papillary adhesion (VPA), and two (6%) had both vitreo-macular adhesion (VMA) and VPA. After a mean follow-up of 4.6 ± 1.9 years, one eye (3%) developed a vitreous detachment from the macula with persistent VPA, and one developed a PVD from a VPA with subsequent ERM formation. BCVA and mean CFT remained stable in 35 eyes (100%). Likewise, no B-FAF signal variations were detected. One patient developed a LMH during the 3rd year of follow-up.

CONCLUSIONS

Our data suggest that the presence of a LMH in one eye does not increase significantly the risk of developing the same condition in the fellow eye after 4 years. Bilateral condition is uncommon, and an ERM is often detected in the fellow eye. LHEPs were not observed in fellow eyes with foveal integrity, and all LHEPs observed (in main and fellow eyes) were always associated with LMHs; this supports the hypothesis that LHEP is a consequence and not a causative factor for LMHs. The occurrence of a LMH in one fellow eye after 3 years follow-up may suggest that a higher incidence of bilateral disease could develop in a longer time span.

Retinal vascular changes after vitrectomy for idiopathic epiretinal membrane: a pilot study with dynamic vessel analysis

PURPOSE

To investigate, using the Dynamic Vessel Analyzer (DVA), the retinal vascular changes that may occur after vitrectomy for idiopathic epiretinal membrane (ERM).

METHODS

Twenty-six eyes of 13 patients affected by unilateral idiopathic ERM were prospectively analyzed. 13 fellow eyes were used as control. The static (central retinal artery and vein equivalents) and dynamic (after flicker light stimulus) DVA analysis was performed at baseline (1 day before surgery) and 6 months after vitrectomy.

RESULTS

The static DVA analysis did not highlight any significant change between investigational eyes and controls at baseline and 6 months after surgery. The DVA dynamic analysis showed similar arterial flicker response between cases and controls at baseline (p = 0.3396), but disclosed a significant reduction of the arterial flicker response after surgery in the study eyes compared to fellow eyes (p = 0.0024). No significant changes were appreciated in the venous flicker response after surgery between cases and controls, both at baseline (p = 0.3450) and at the follow-up examination (p = 0.4214).

CONCLUSIONS

The physiological flicker-induced vasoconstriction is reduced after vitrectomy in arteries. The oxygen saturation change occurring after vitrectomy might have a role in the vascular tone modification.

Vitrectomy for vitreopapillary traction in a nondiabetic 16-year-old girl

Vitreopapillary traction (VPT) is an unusual clinical entity and its management and prognosis have been sparsely studied. It has been described in adults with various vitreomacular pathologies and the possible effects on visual functions. However, the role of surgical intervention in altering the course of the disease is not well understood. Hereby, we describe a case of idiopathic VPT in a 16-year-old girl who presented with decreased vision and visual field changes corresponding to the area of retinal traction. This case was managed with pars plana vitrectomy and epiretinal membrane removal that resulted in improved visual field sensitivity; thus, emphasizing the role of surgical intervention in such eyes.

Surgical treatment in combined hamartoma of the retina and retinal pigment epithelium

CASE REPORT

The case is presented of a 39 year-old man with a combined hamartoma of the retina and retinal pigment epithelium, who experienced progressive visual loss and worsening of metamorphopsia. The patient underwent vitrectomy and epiretinal component peeling, with improvement in visual acuity, metamorphopsia, and retinal architecture, assessed by optical coherence tomography.

DISCUSSION

Selected patients with combined hamartomas of the retina and retinal pigment epithelium may benefit from surgical management.

Vitreoretinal interface abnormalities in patients treatedwith ranibizumab for diabetic macular oedema

Purpose

Intravitreal anti-vascular endothelial growth factor (VEGF) agents are effective in the treatment of central involving diabetic macular oedema (DMO). Vitreoretinal interface abnormalities (VRIA) are common in patients with DMO, and the effect of these on the response to anti-VEGF treatment is unclear. Furthermore the effect of anti-VEGF agents on the VRIA itself is uncertain.

Method

Prospective study of consecutive patients treated with ranibizumab (RZB) for DMO as part of routine clinical care in one eye unit over a 1-year period. Visual acuity (Va), central retinal thickness (CRT) and injection frequency data was recorded on an electronic database. Treatment was initiated with four monthly RZB injections and then a monthly PRN regime. All patients underwent high-density spectral-domain optical coherence tomography (SDOCT) at baseline and 12 months. The SDOCTs were graded by two observers masked to the outcome.

Results

One hundred and four eyes (77 patients) were included in the analysis. The mean age was 62 years, and 62% were male. The mean presenting vision was 62 letters and CRT 472 μm. Eighty eyes retained stable Va, and 17 had an improvement in Va. At baseline, 39 eyes had associated focal vitreomacular adhesion (VMA) and by 12 months this reduced to 30 (p = 0.04), with 12 releasing VMA and three developing it. Patients with VMA had significantly better final Va than those without VMA. Improvement in CRT was greatest in those where VMA released during the study. Forty-five eyes had some degree of foveal involving epiretinal membrane (ERM) at baseline, and 28 were considered to have clinically significant ERM. There was no clinically relevant change in ERM during the study. Patients with significant ERM at baseline had a lower final vision. Multivariate analysis showed that ERM and more severe retinopathy at baseline were predictive of less visual improvement (p < 0.01). Shorter intraretinal cyst length, ERM and the absence of VMA at baseline were predictive of a worsened anatomical response (p < 0.001).

Conclusion

VRIA are related to outcome in patients treated with RZB. ERM was associated with a worsened visual and anatomic response, and VMA with an improved anatomical response particularly when spontaneous VMA release occurred during treatment. The presence and severity of ERM was not affected by RZB treatment.

Electronic supplementary material

The online version of this article (doi:10.1007/s00417-016-3562-0) contains supplementary material, which is available to authorized users.

Deep and superficial OCT angiography changes after macular peeling: idiopathic vs diabetic epiretinal membranes

BACKGROUND

To assess changes in deep and superficial perifoveal capillary plexus after macular peeling in idiopathic and diabetic epiretinal membrane (iERM and dERM, respectively).

METHODS

Cross-sectional comparative study. We included 40 eyes from 40 patients affected by iERM (20 eyes) and dERM (20 eyes), as well as 34 eyes from 17 healthy, age-matched patients. Patients received a complete ophthalmic evaluation including axial and en-face scanning spectral-domain analysis, optical coherence tomography angiography, and microperimetry. Split-spectrum amplitude-decorrelation angiography images were obtained to quantify the deep and superficial layers of perifoveal capillary-free zone (CFZ). The main outcome measures were: (i) differences at baseline between deep and superficial CFZ in iERM and dERM vs control, and (ii) changes in deep and superficial CFZ plexus after surgery in iERM vs dERM.

RESULTS

The deep CFZ only significantly increased in dERM at the end of the follow-up period (6 months). No statistically significant differences were found between preoperative and postoperative superficial vascular plexus in iERM or dERM. At the end of the follow-up, statistically significant differences between preoperative and postoperative ganglion cell complex (GCC) average were found only in the iERM group. Best-corrected visual acuity significantly improved after surgery both in the iERM (P = 0.0053) and dERM (P < 0.0001) groups. After 6 months, macular sensitivity increased in the iERM group, but there was no statistically significant change in the dERM group.

CONCLUSIONS

In dERM, the deep CFZ significantly increases after ILM peeling, whereas postoperative angiography changes were not significant in iERM. This could be because the impaired diabetic perifoveal capillary plexus are more sensitive to the iatrogenic damage to Müller cells, induced by peeling.

Heads-Up Macular Surgery with a 27-Gauge Microincision Vitrectomy System and Minimal Illumination

OBJECTIVE

We combined heads-up 3-dimensional (3D) 27-gauge microincision vitrectomy surgery (27GMIVS) with a very low-intensity illumination system.

METHODS

This study was based on a retrospective, interventional case series of 6 eyes of 6 patients with macular disease. All patients underwent heads-up 3D 27GMIVS and the power of the intraocular illuminator was set to its minimum level, 1% (approximately 0.1 lm), throughout the surgery.

RESULTS

We found that the procedure was easy when the heads-up 3D system was used, but not through the eyepiece of a microscope. All surgeries were successfully finished without any complications. Postoperative visual acuity was restored or maintained in all eyes during the follow-up period.

CONCLUSION

Heads-up, 3D system-assisted 27GMIVS with minimal illumination enabled excellent intraoperative visualization of retinal tissues, caused minimal phototoxicity to the macular retinal cells, and might therefore represent the next step in the development of an ideal, minimally invasive method of treating macular disease.

Direct cost of pars plana vitrectomy for the treatment of macular hole, epiretinal membrane and vitreomacular traction: a bottom-up approach

PURPOSE

The direct cost to the National Health Service (NHS) in England of pars plana vitrectomy (PPV) is unknown since a bottom-up costing exercise has not been undertaken. Healthcare resource group (HRG) costing relies on a top-down approach. We aimed to quantify the direct cost of intermediate complexity PPV.

METHODS

Five NHS vitreoretinal units prospectively recorded all consumables, equipment and staff salaries during PPV undertaken for vitreomacular traction, epiretinal membrane and macular hole. Out-of-surgery costs between admission and discharge were estimated using a representative accounting method.

RESULTS

The average patient time in theatre for 57 PPVs was 72 min. The average in-surgery cost for staff was £297, consumables £619, and equipment £82 (total £997). The average out-of-surgery costs were £260, including nursing and medical staff, other consumables, eye drops and hospitalisation. The total cost was therefore £1634, including 30 % overheads. This cost estimate was an under-estimate because it did not include out-of-theatre consumables or equipment. The average reimbursed HRG tariff was £1701.

CONCLUSIONS

The cost of undertaking PPV of intermediate complexity is likely to be higher than the reimbursed tariff, except for hospitals with high throughput, where amortisation costs benefit from economies of scale. Although this research was set in England, the methodology may provide a useful template for other countries.

Outcomes of vitrectomy, membranectomy and internal limiting membrane peeling in patients with refractory diabetic macular edema and non-tractional epiretinal membrane

Purpose

To evaluate the efficacy of vitrectomy, membranectomy, and internal limiting membrane (ILM) peeling on macular thickness and best corrected visual acuity (BCVA) in patients with refractory diffuse diabetic macular edema (DME) and non-tractional epiretinal membrane (NT-ERM).

Methods

This prospective interventional case series included eyes with refractory DME (central subfield macular thickness [CSMT] > 300 μm) after at least two intravitreal injections of bevacizumab (IVB) and one intravitreal injection of triamcinolone (IVT), and accompanying NT-ERM. Complete ophthalmic examination, baseline spectral domain optical coherence tomography (SD-OCT), and fluorescein angiography (FA) were performed prior to 23 gauge pars plana vitrectomy with membranectomy and internal limiting membrane (ILM) peeling. Postoperative evaluation was done with clinical examination and SD-OCT. Linear mix model analysis was used to study postoperative results.

Results

Twelve eyes from 11 patients (5 males) with a mean age of 60.33 ± 9.01 (range 46–73 years) were included. The mean follow-up time was 13.5 ± 4.48 months (range 4–20 months). A significant reduction in CSMT was found (from 559 ± 89 μm to 354 ± 76 μm; P = 0.001), with a non-significant BCVA change (from 0.84 ± 0.32 logMAR to 0.72 ± 0.2 logMAR; P = 0.967). There was no significant correlation between CSMT and BCVA (partial correlation = −0.115, P = 0.445) and also between estimated mean CSMT change per month and estimated mean BCVA change per month (r = 0.337, P = 0.283).

Conclusion

In this series, our results did not show that vitrectomy, membranectomy, and ILM peeling result in significant improvement of BCVA in eyes with refractory DME and non-tractional ERM in spite of central macular thickness reduction.

Postoperative eccentric macular holes after vitrectomy and internal limiting membrane peeling

The purpose of this study was to describe the incidence, clinical characteristics, and outcome of eccentric macular holes presenting after vitrectomy and internal limiting membrane (ILM) peeling for the treatment of macular pathology and discuss the pathogenesis of holes formation. A retrospective, noncomparative, interventional case-series study of five patients who developed eccentric macular holes postoperatively following vitrectomy in 198 consecutive patients who underwent ILM peeling for idiopathic macular hole and epiretinal membrane formation between 2008 and 2015. Five patients (2.5 %) developed full-thickness eccentric macular holes postoperatively. Three patients presented with a single eccentric macular hole, one patient had an eccentric hole after a failed idiopathic macular hole surgery and one patient developed four eccentric macular holes. The mean diameter of the holes was 584 μm (range 206-1317 μm) and the average time of holes formation after vitrectomy was 27.7 weeks (range 1-140 weeks). Postoperative best-corrected visual acuity ranged from "counting fingers" to 20/25. The eyes with the holes distant from the fovea had the best final visual acuity. No further intervention was attempted and no complications occurred. The mean follow-up time was 26.8 months. The postoperative macular holes after vitrectomy and ILM peeling were variable in number, size, and time of appearance but remained stable and were not associated with any complications. The pathogenesis of macular holes is most consistent with contraction of the residual ILM or secondary epimacular proliferation probably stimulated by ILM peeling.

Intraretinal changes in the presence of epiretinal traction

BACKGROUND

To determine the correlation between the area of morphological changes on the macular surface, the depth of intraretinal changes and the best-corrected visual acuity (BCVA) in patients with idiopathic epiretinal membrane.

METHODS

In this prospective cross-sectional study, 38 patients underwent BCVA testing with a Snellen eye chart. The depth of traction, photoreceptor outer segment layer (PROS) thickness, central macular thickness (CMT) and presence of intraretinal cysts were measured using the Avanti RTVue XR and 3D Widefield Enface OCT instruments. Enface sections were performed at the inner limiting membrane (ILM) line level (ILM offset). Patients were categorized into two groups: in group 1 (n = 21), the depth of traction was within 90 μm from the ILM, and in group 2 (n = 17) it was beyond 90 μm from the ILM. The main outcome measure was the correlation between area of epiretinal traction and BCVA according to the depth of traction.

RESULTS

In group 1, the depth of traction was 55.15 ± 14.28 μm, the area of traction was 38.95 ± 13.63 mm², PROS thickness was 51.20 ± 7.23 μm, and CMT was 362.65 ± 41.08 μm. In group 2, the depth of traction was 112.24 ± 10.89 μm, the area of traction was 25.18 ± 4.07 mm², PROS thickness was 50.24 ± 9.01 μm, and mean CMT was 534.29 ± 126.81 μm. Statistically significant differences in depth of traction, area of traction and CMT were found between the two groups (P < 0.001). The relationship between structure and function between the area of traction and BCVA was better explained in group 2 (r = 0.814, P < 0.001).

CONCLUSIONS

We found that intraretinal changes were induced by the ERM, and varied according to the depth of traction measured with en face analysis. In the case of traction deeper than 90 μm, we found a significant correlation between the inner area of the epiretinal traction and BCVA. We believe that retinal stress induced by epiretinal traction is better characterized by combining information provided by sagittal and transverse OCT scans, thus defining its prognostic significance in ERM.

Efficacy of vitrectomy and inner limiting membrane peeling in age-related macular degeneration resistant to anti-vascular endothelial growth factor therapy, with vitreomacular traction or epiretinal membrane

PURPOSE

We assessed the efficacy of vitrectomy and inner limiting membrane (ILM) peeling, followed by anti-vascular endothelial growth factor (VEGF) therapy, anti-VEGF-resistant age-related macular degeneration (AMD) due to vitreomacular traction (VMT) or epiretinal membrane (ERM).

METHODS

We identified six patients with anti-VEGF-resistant AMD due to VMT or ERM amongst a total of 588 patients with AMD (821 eyes) referred to Okayama University Hospital between February 2012 and May 2014. These patients underwent vitrectomy to release the VMT (4 cases) or remove the ERM (2 cases), along with ILM peeling. The regimen used for intravitreal injections of anti-VEGF reagents after surgery was based on the severity of exudative changes in each patient. Preoperative and postoperative best-corrected visual acuity (BCVA) and central retinal thickness (CRT) measurements were compared.

RESULTS

After vitrectomy and ILM peeling, all six patients responded to anti-VEGF therapy, which was then able to maintain dry retinas. Mean BCVA did not improve significantly (0.49 ± 0.28 before vs. 0.43 ± 0.38 after surgery, P = 0.538). However, mean CR was significantly decreased after surgery, from 423 ± 83.5 μm to 257 ± 75.8 μm (P = 0.0078).

CONCLUSIONS

Vitrectomy and ILM peeling followed by anti-VEGF therapy may be a useful therapeutic option for anti-VEGF-resistant AMD with VMT or ERM.