A new approach to treating retinal detachment with macular hole

Efficacy of inverted internal limiting membrane flap technique for the treatment of macular hole in high myopia

PURPOSE

To determine the effect of pars plana vitrectomy (PPV) with inverted internal limiting membrane (ILM) flap technique for macular hole with or without retinal detachment in highly myopic eyes.

DESIGN

Retrospective, interventional case series.

METHODS

Ten eyes of 10 patients with macular hole with (4 eyes) or without (6 eyes) retinal detachment in high myopia (axial length more than 26.5 mm) were treated by PPV with inverted ILM flap technique.

RESULTS

Macular hole closure was observed in 8 eyes (80%) following the initial surgery (in 5 eyes without retinal detachment and in 3 eyes with retinal detachment). In 4 eyes with retinal detachment caused by macular hole, retinas of 3 eyes were reattached by the initial surgery. Postoperative best-corrected visual acuity improved by more than 2 lines in 5 eyes (50%), was unchanged in 4 eyes (40%), and worsened by more than 2 lines in 1 eye (10%).

CONCLUSIONS

Inverted ILM flap technique might contribute to a high closure rate of macular hole and be a preferable adjuvant to the treatment of macular hole in high myopia with or without retinal detachment.

Primary vitrectomy for the treatment of retinal detachment in highly myopic eyes with axial length over 30 mm

OBJECTIVE

To assess the functional and anatomical outcome of primary vitrectomy without scleral buckling for rhegmatogenous retinal detachment (RRD) in highly myopic eyes with axial length over 30 mm.

METHODS

In this retrospective, interventional case series, we evaluated the outcome of primary vitrectomy without scleral buckling in 67 highly myopic patients (67 eyes) with RRD. Anatomical success rate was defined as complete reattachment of the retina without definitive silicone oil tamponade.

RESULTS

Retinal reattachment was achieved with a single surgery in 49 of 67 eyes (73.1%) and after 2 or 3 surgeries in 54 eyes (80.6%). The characteristics of retinal tears did not influence the final outcome. Multivariate analysis revealed that a longer axial length was the only factor associated with a higher failure rate, p = 0.0061. Mean preoperative visual acuity significantly increased after surgery, p = 0.0003.

CONCLUSION

The study demonstrated fair efficacy of vitrectomy and fluid-gas exchange in the treatment of retinal detachment in highly myopic eyes with an axial length over 30 mm.

Sequential surgical repair of a macular hole-related retinal detachment in a hyperopic patient

PURPOSE

To report a case of macular hole-related retinal detachment in a hyperopic patient and a sequential surgical approach to repair.

METHODS

Case report.

PATIENTS

A single patient with acute macular hole-related retinal detachment.

CONCLUSION

Retinal detachment secondary to macular hole typically occurs in highly myopic patients and is rare in patients with hypermetropia. Surgical repair may involve a combined or sequential approach to close the macular hole.

Vitreous surgery for macular hole-related retinal detachment after phacoemulsification cataract extraction: 10-year retrospective review

PURPOSE

To evaluate the visual and anatomical results of surgery for macular hole-related retinal detachment (MHRD) after phacoemulsification cataract extraction.

METHODS

Data for all patients who underwent surgery for MHRD after phacoemulsification cataract extraction from 1 December 1998 to 30 September 2008 in one hospital were evaluated. Patient characteristics, best-corrected visual acuity (VA) preoperatively and at last examination, surgical technique, anatomical success, and follow-up period were extracted and analysed statistically.

RESULTS

A total of 13 625 eyes of 10 076 patients who had phacoemulsification cataract surgery were included. In the follow-up period, 10 cases of MHRD in nine patients were observed, of which seven eyes had high myopia. The mean axial length was 30.97 ± 1.36 mm (29.19, 32.97) and mean myopia was-19.35 ± 1.93 (-7.5,-3.5) dioptres. Overall anatomical success was achieved in 90% (9 out of 10 eyes). There was no statistically significant difference (P=0.240) between the logarithm of the MAR VA before the phacoemulsification cataract extraction and after MHRD surgical repair. VA increased in three eyes but decreased in the other seven after MHRD surgery.

CONCLUSIONS

As a primary procedure, vitreous surgery combined with other necessary adjunct procedures such as membrane peeling and retinal tamponade seems to be successful in achieving anatomical success. However, VA improvement is dependent on the type of macular lesion and not the surgical procedure.

Management of rhegmatogenous retinal detachment with coexistent macular hole in the era of internal limiting membrane peeling

PURPOSE

To review outcomes of vitrectomy plus or minus scleral buckling for retinal detachment (RD) attributable to peripheral break(s) with noncausal macular hole, plus or minus internal limiting membrane (ILM) peeling.

DESIGN

Retrospective chart review.

METHODS

Forty-nine consecutive patients from March 1, 1998 to March 31, 2009 with RD attributable to peripheral break and macular hole were treated by vitrectomy. Five had no scleral buckle placed. Forty-three underwent ILM peeling.

RESULTS

The main outcome measures were retinal reattachment, macular hole status, and vision. Final retinal reattachment rate was 95.9% (47/49) with 1 and 100% with 2 operations. Final macular hole closure rate was 39/43 with ILM peeling (90.7%), and 2/6 without (33.3%, P value = .0041). Mean final acuity was 20/120, and 20/100 if the macular hole was closed.

CONCLUSION

Vitrectomy, plus or minus scleral buckle, with ILM peeling is effective for repair of RD with macular hole. ILM peeling can increase the rate of macular hole closure.

Clinical presentation and surgical outcomes in primary myopic macular hole retinal detachment

Purpose

To describe the clinical presentation of primary macular hole retinal detachment (MHRD) secondary to high myopia and to evaluate the surgical outcomes.

Methods

Nine eyes of 9 patients with primary myopic MHRD (axial length ≥26.5 mm) were enrolled. A standardized surgical protocol was performed using vitrectomy with preservative-free triamcinolone acetonide–assisted internal limiting membrane (ILM) peeling and silicone oil tamponade and were followed for at least 6 months from the first surgery.

Results

There were 6 women and 3 men with a median age of 52 years. Six (66.6%) patients presented with inferior bullous configuration and 3 had subtotal retinal detachment. The mean preoperative refractive error (spherical equivalent) and mean axial length was 12±3.553 D (range 8.50-19.50) and 28.13±1.65 mm (range 26.50-31.50), respectively. The patients were followed up for a period of at least 6 months. The retina was attached and macular hole closed in all the eyes. There was significant visual acuity improvement from mean preoperative visual acuity of logMAR 1.85±0.11 (range 1.76-1.93) to postoperative visual acuity of logMAR 0.95±0.14 (range 0.84-1.06) (p<0.001).

Conclusions

Retinal detachment in highly myopic eyes can often be secondary to a macular hole with predominance of inferior bullous configuration and primary vitrectomy with ILM peeling with silicone oil tamponade results in good anatomic and functional outcomes.

1000 cSt silicone oil vs heavy silicone oil as intraocular tamponade in retinal detachment associated to myopic macular hole

BACKGROUND

Several surgical techniques have been described for the treatment of retinal detachment (RD) associated to myopic macular hole (MMH). In this retrospective study, the anatomical and functional outcomes of pars plana vitrectomy (PPV) with long-term tamponade, using either 1000 cSt silicone oil (SO) or heavy silicone oil (HSO), are compared.

METHODS

Forty-two eyes affected by RD associated with MMH were included. The surgical technique involved standard 3-port 20-gauge PPV with long-term tamponade. The patients were divided into two groups, according to the intraocular tamponade: SO in group 1 (n = 17), and HSO in group 2 (n = 25). Internal limiting membrane (ILM) removal was performed in 15 cases of group 1 and 20 cases of group 2. Tamponade removal was performed 2 to 5 months after primary surgery. The patients were assessed 1 week and 1 month after primary surgery, and then 1 week and 1 month after tamponade removal or after further surgery if macular redetachment had occurred. The patients were also visited every 2 months for at least 1 year after final tamponade removal. Follow-up was considered closed at 1 year after final tamponade removal.

RESULTS

Preoperative best-corrected visual acuity (BCVA), expressed as LogMar, was 2.8 ± 0.77 for group 1 and 2.1 ± 0.94 for group 2. At the last visit, the BCVA was 1.41 ± 0.96 and 1.48 ± 0.77 for groups 1 and 2 respectively. Retinal reattachment was achieved with one operation in 13 eyes of group 1 (76.5%) and 18 of group 2 (81.8%) (P = 0.69). The average number of surgery needed to achieve retinal attachment by patients of group 1 and 2 was respectively 1.36 ± 0.63 and 1.46 ± 0.59 (P = 0.77). Five patients of group 1 and four of group 2 developed a chronic glaucoma (P = 0.238).

CONCLUSIONS

PPV with ILM peeling and long-term tamponade was demonstrated to be a good surgical option to treat RD due to MMH; SO and HSO seemed to be equally effective, although the success rates remained far from an ideal 100%.

Does sulfur-hexafluoride tamponade, as an adjunct to vitrectomy and internal-limiting-membrane peeling, suffice for the treatment of retinal detachment associated with macular hole?

OBJECTIVE

To evaluate the efficacy of sulfur hexafluoride tamponade, as an adjunct to vitrectomy and internal-limiting-membrane peeling, for the treatment of retinal detachment (RD) associated with macular hole (MH).

MATERIALS AND METHODS

Our study was a retrospective interventional case series. We evaluated 9 phakic eyes of 9 consecutive patients with retinal detachment secondary to macular hole (MHRD) treated with 20-gauge (g) pars plana vitrectomy, which was followed with trypan blue-assisted internal-limiting-membrane peeling, fluid-air exchange, and 20% sulfur hexafluoride tamponade (SF(6)) gas exchange. All patients underwent optical coherence tomography, best-corrected visual acuity (BCVA) measurement, and dilated fundus examination with indentation, pre- and postoperatively.

RESULTS

The mean (± standard deviation) follow-up time was 13 ± 3 months (range 9-18). Postoperatively, all eyes demonstrated an attached retina, whereas MH closure was achieved in only 1 eye, and in a second eye after additional injection of gas and further posturing. The BCVA improved from 2.2 ± 0.4 logMAR (logarithm of the minimum angle of resolution) at baseline to 2.0 ± 0.5 logMAR at the end of follow-up (p = .05).

CONCLUSION

The failure in MH closure in most of our cases strengthens the view that short-term tamponade with SF(6) may not suffice for achieving MH closure, and either prolonged tamponade (with C(3)F(8) or silicone oil) or additional photocoagulation may be a better option for eyes with MHRDs. In addition, it is possible that intravitreal injection of gas might be an option for the treatment of persistent MHs after vitrectomy for MHRD, especially when the MH is small. Further studies are required to evaluate the above findings, although the implementation of large series studies remains a challenge because of the rarity of cases with MHRDs.

Double peel using triamcinolone acetonide and trypan blue in the management of myopic macular hole with retinal detachment: a case-control study

PURPOSE

To evaluate the safety and efficacy of double peel using triamcinolone acetonide (TA) and trypan blue (TB) in removing epiretinal tissues in vitrectomy for myopic macular hole with retinal detachment (MHRD).

METHODS

Prospective interventional case control study. Patients with myopic MHRD underwent vitrectomy with TA-assisted adherent cortical vitreous (ACV) removal followed by TB-assisted internal-limiting membrane (ILM) peeling and gas tamponade. The results were compared with historical control group without the use of any vital dye or TA.

RESULTS

Ten eyes of 10 study cases were compared with nine eyes of nine control cases. Mean axial length was 28.3 ± 1.4 mm and 29.6 ± 2.4 mm and mean follow-up period was 15 months and 42 months for the study group and the control group, respectively. Reattachment rate was 70% in the study group and 44% in the control group. Mean logMAR visual acuity improvement was 0.02 at 6 months and 0.01 at 12 months for the study group (P < 0.05). Transient intraocular pressure rise was observed in seven eyes in the study group and five eyes in the control group. No other complication was noted.

CONCLUSION

Double peel using TA and TB appeared safe and effective in facilitating removal of ACV and ILM in MHRD. It has higher surgical success rate compared with conventional vitrectomy with epiretinal membrane peeling and gas tamponade.

Prognostic factor analysis in pars plana vitrectomy for retinal detachment attributable to macular hole in high myopia: a multicenter study

PURPOSE

To detect the prognostic factors associated with initial reattachment after primary pars plana vitrectomy (PPV) with gas tamponade for retinal detachment attributable to macular hole (MHRD).

DESIGN

Retrospective, multicenter, interventional case series.

METHODS

This study included 49 eyes of 48 patients with MHRD in high myopia (axial length more than 28.0 mm). All eyes underwent PPV with gas tamponade. We retrospectively reviewed the medical records and performed univariate analysis to detect the presence of any difference between eyes with a successful initial reattachment and those that failed. We performed multivariate logistic regression analysis to assess the influence of each preoperative factor on initial success.

RESULTS

Success rate of initial reattachment was 69%. Postoperative best-corrected visual acuity (BCVA) of 34 eyes with initial success was significantly better than those of 15 eyes with initial failure (P < .05); preoperative BCVA was not significantly different (P = .43). The axial length of eyes with initial success (29.26 +/- 0.94 mm) was shorter than that of eyes with initial failure (30.04 +/- 1.49 mm) with borderline significance (P = .049). There were no significant differences noted for other factors such as use of ILM peeling (P = .43) or type of tamponade gas (P = .99). Multiple logistic regression analysis using preoperative factors indicated that only axial length was significantly associated with initial success (odds ratio, 0.49; 95% confidence interval, 0.26 to 0.93; P < .05).

CONCLUSIONS

Initial reattachment is important for visual prognosis, and axial length is a prognostic factor for initial reattachment after PPV with gas tamponade for MHRD in high myopia.

Diagnose und Evaluierung von Makulaforamina mit dem HRT 2 Retina Modul

BACKGROUND

This prospective study analyzed the usefulness of the HRT 2 retina module as a diagnostic tool for macular hole diagnosis. The influence of the preoperative status on postoperative anatomic and functional results is also discussed. Preoperative and postoperative retinal tomography maps (HRT 2) were compared with optical coherent tomography (OCT III) and spectral optical coherent tomography (SOCT).

METHODS

Fifty eyes of 46 consecutive patients with stage III/IV macular hole underwent vitrectomy with internal limiting membrane peeling and fluid/air exchange. HRT 2, OCT III, and, in eight cases, SOCT images were analyzed.

RESULTS

The mean best corrected visual acuity 1 week before surgery was 0.086+/-0.074 (0.01-0.35). The final best corrected visual acuity 12 months after surgery was 0.32+/-0.24 (0.01-1.0). Anatomic success was noted in 46/50 eyes 1 month after the first surgery and in all eyes after the second intervention. In 33/50 eyes (66%), visual acuity improved over two lines. In 13 eyes visual acuity remained stable, and in four eyes worse visual acuity was noted postoperatively. The mean macular hole diameter in HRT 2 was 497.2 microm and in OCT III was 490 microm. Different values were observed in cases of oval macular holes. The mean macular hole area was 0.193 mm(2). The macular hole radius in HRT 2 can be compared with the minimal diameter in OCT III. It influences the final visual acuity 12 months after surgery.

CONCLUSIONS

The HRT 2 macular module enables diagnosis of macular hole and evaluation of its postoperative status. This technique has some advantages because it enables measurement of the macular hole's radius, area, and depth. In cases when the macular hole's radius as measured in HRT and OCT III differs, HRT seems to give more exact data because it shows the entire surface rather than just a cross-section of the retina. Macular hole radius and area as measured with HRT 2 can influence postoperative functional results.

[Triamcinolone-assisted vitrectomy in the treatment of recurrent retinal detachment due to myopic macular hole]

PURPOSE

To report the use of triamcinolone-assisted vitrectomy to assess the cause of vitrectomy failure in the treatment of retinal detachment due to myopic macular hole.

OBSERVATIONS

We report the cases of three myopic patients presenting with recurrent retinal detachment due to macular hole after initial vitrectomy treatment with posterior vitreous detachment, a systematic attempt at membrane peeling, and gas injection (SF6). No retinal traction or tear other than the macular hole was observed. The recurrence of retinal detachment was treated with vitrectomy and intraoperative use of triamcinolone, which demonstrated persistent posterior hyaloid and thin and strongly adherent membrane remnants in each case. Anatomic success was obtained after peeling these structures.

CONCLUSION

Intraoperative use of triamcinolone reduces the risk of overlooking hyaloid or membrane remnants during vitrectomy for the treatment of myopic retinal detachment. Transparent remnants of posterior hyaloid and membranes were visualized by triamcinolone-assisted vitrectomy. They could lead to traction on the retina and explain the failure of the initial vitrectomy. Anatomic success was obtained after peeling these structures.

Surgical management of retinal detachment in highly myopic eyes with macular hole

BACKGROUND AND OBJECTIVES

To evaluate the visual and anatomical outcomes of surgery for retinal detachment due to macular hole in highly myopic eyes with pronounced posterior staphyloma.

PATIENTS AND METHODS

Data for all patients with high myopia who underwent surgery for retinal detachment resulting from macular hole from 1993 to 2002 in one hospital were evaluated. Patient characteristics, best-corrected visual acuity preoperatively and at last examination, surgical technique, anatomical success, and follow-up period were extracted and analyzed statistically.

RESULTS

Twenty-six of the 27 patients (28 eyes) were female (96%) with a mean age of 59.8 years; mean follow-up was 17.3 months. Mean axial length was 29.1+/-2.74 mm; mean myopia was -16.4 +/- 3.1 diopters. Marked posterior staphyloma was detected in 71%. Seven eyes had undergone failed scleral buckling as the primary procedure; intravitreal SF6 injection was the primary procedure in 12 eyes. Twenty-three eyes underwent deep vitrectomy with use of high viscosity silicone oil. Overall anatomical success was achieved in 92.9% (26 of 28 eyes); 78.6% had visual improvement.

CONCLUSIONS

Vitreous surgery combined with other necessary adjunct procedures such as membrane peeling and use of retinal tamponade, as a primary or a secondary procedure, seems to be successful in achieving retinal reattachment in eyes with macular hole and posterior staphyloma.

Incidence of fellow eye retinal detachment resulting from macular hole

PURPOSE

To determine the incidence of retinal detachment resulting from macular hole (MHRD) in fellow eyes.

DESIGN

Observational case series.

METHODS

The medical records of 59 normal fellow eyes of cases with MHRD diagnosed between 1994 and 2004 at Osaka Rosai Hospital were retrospectively reviewed. Thirty-nine of the 59 fellow eyes were highly myopic. The average follow-up period was 42 months with a range of seven to 132 months. The incidence of MHRD in fellow eyes, and the interval between the onset of MHRD in the first eye and the fellow eye were determined. The Kaplan-Meier method was used to estimate the probability of the fellow eye developing MHRD at 18 months and five years, and the probability of high myopia in the development of MHRD with log-rank test.

RESULTS

Five eyes (8.5%) developed MHRD during the follow-up period. All affected eyes were highly myopic, and the incidence of MHRD among the highly myopic fellow eyes was 12.8%. The average interval was 51 months. The Kaplan-Meier estimated probability of the fellow eye developing MHRD was 3.7% (0% to 8.7% for 95% confidence interval [CI]) at 18 months and 8.0% (0% to 17.7% for 95% CI) at five years. The probability of the fellow eyes with high myopia developing MHRD was significantly higher than that of eyes without high myopia (P = .0304).

CONCLUSIONS

The high incidence of MHRD developing in the fellow eye indicates that the fellow eyes should be examined and followed carefully.

Effect of Indocyanine Green Staining in Peeling of Internal Limiting Membrane for Retinal Detachment Resulting from Macular Hole in Myopic Eyes

PURPOSE

To investigate the effect of using indocyanine green (ICG) to stain the internal limiting membrane (ILM) during vitrectomy in eyes with retinal detachment resulting from macular hole (MHRD).

DESIGN

Nonrandomized comparative trial.

PARTICIPANTS

Thirty-two cases of MHRD.

INTERVENTION

The medical records of the cases were reviewed retrospectively. During the initial vitrectomy, the ILM was peeled in 22 eyes with ICG (group A) and in 10 eyes without ICG (group B).

MAIN OUTCOME MEASURES

Anatomic reattachment, visual acuity, and optical coherence tomography-determined macular hole closure were measured.

RESULTS

The initial reattachment rate in group A (86%) was significantly higher than in group B (40%; P = 0.013, Fisher exact test). The postoperative visual acuity at 6 months and the visual improvements at 6 and 12 months in eyes with an initial reattachment were not significantly different between the 2 groups (P = 0.123, Mann-Whitney rank-sum test; P = 0.17, t test; P = 0.237, t test). The postoperative visual acuity at 12 months with an initial reattachment in group A was significantly better than in group B (P = 0.039, t test). The macular hole closure rate with an initial reattachment was 6 of 17 eyes (35%) in group A and 0 of 4 eyes (0%) in group B, and this difference was not significant (P = 0.281, Fisher exact test).

CONCLUSIONS

These results show that ICG staining improves the initial reattachment rate and is associated with better postoperative visual acuity at 12 months. Therefore, ICG staining should be used during vitrectomy for MHRD because the complete removal of the ILM with ICG ensures the removal of the tangential traction by an epiretinal membrane and the inverse traction by the retina that cannot follow the posterior enlargement of a staphyloma.

Results of high-density silicone oil as a tamponade agent in macular hole retinal detachment in patients with high myopia

BACKGROUND

To evaluate the use of high-density silicone oil (HDSO) as a tamponade agent for retinal detachment secondary to myopic macular hole.

METHODS

12 eyes of 12 patients with macular hole retinal detachment underwent pars plana vitrectomy, internal limiting membrane peeling and HDSO tamponade. No posturing was required postoperatively and HDSO was removed 3-4 months later. Outcome measures included macular hole closure and retinal attachment rates, best-corrected visual acuity (BCVA), and intraoperative and postoperative complications.

RESULTS

The mean age of the patients was 67.8 years and the mean spherical equivalent refractive error was -13.4 diopters. After the removal of HDSO, 10 (83%) eyes had macular hole closure with retinal reattachment without any tamponade. One eye had retinal reattachment after re-operation and the other refused further surgery. At the last follow-up, the median BCVA improved from 20/800 to 20/600 (p = 0.046). A transient increase in intraocular pressure was observed in 5 (42%) eyes and one eye each developed mild oil emulsification and transient peripheral choroidal detachment. None of the eyes was found to have severe intraocular inflammation postoperatively.

CONCLUSIONS

HDSO seemed to be an effective tamponade agent for myopic macular hole retinal detachment. Further prospective controlled studies seem warranted.

ANATOMICAL AND VISUAL OUTCOMES AFTER EPISCLERAL MACULAR BUCKLING COMPARED WITH THOSE AFTER PARS PLANA VITRECTOMY FOR RETINAL DETACHMENT CAUSED BY MACULAR HOLE IN HIGHLY MYOPIC EYES

PURPOSE

To report anatomical and visual outcomes after episcleral macular buckling (EMB) and pars plana vitrectomy (PPV) for retinal detachment caused by macular hole in highly myopic eyes with posterior staphyloma.

PATIENTS AND METHODS

This retrospective, interventional case series included 58 eyes of 58 patients with retinal detachment caused by macular hole in highly myopic eyes with posterior staphyloma and geographic chorioretinal atrophy. The cases were assigned to 2 groups according to the surgical technique: the EMB group (30 eyes) underwent posterior episcleral buckling using a solid silicone plate specifically designed for macular indentation, and the PPV group (28 eyes) underwent PPV combined with fluid-gas exchange. Baseline clinical data including age, sex, refractive errors, and degree of retinal detachment did not differ between EMB and PPV groups. Main outcome measures included ophthalmoscopy findings, three-mirror contact lens biomicroscopy results, and visual acuity at the end of follow-up (mean follow-up, 52.8 months in the EMB group and 44.1 months in the PPV group). Optical coherence tomography was performed in selected cases in the EMB group.

RESULTS

In the EMB group, the retinal reattachment rate was 93.3% after primary surgery and 100% after secondary surgery. In the PPV group, the retinal reattachment rate was 50% after primary surgery and 86% after secondary surgery using the EMB procedure, thus indicating a better anatomical success rate after primary EMB than after primary PPV. The mean logarithm of the minimum angle of resolution (logMAR) visual acuity +/- SD in the EMB group increased significantly from 1.45 +/- 0.50 before surgery to 0.92 +/- 0.42 at the end of follow-up (P < 0.001). The mean logMAR visual acuity in the PPV group increased significantly from 1.70 +/- 0.45 before surgery to 1.35 +/- 0.61 at the end of follow-up (P < 0.02). Visual acuity improvement at the end of follow-up was significantly better after EMB than after PPV (P < 0.005). Optical coherence tomography revealed that 10 of 12 eyes with successful indentation of the macular hole area after EMB had complete closure of the macular hole as well as reattachment of the retina, and the remaining 2 eyes had persistent retinal reattachment with the foveal defect.

CONCLUSIONS

EMB is a preferred surgical procedure for the repair of retinal detachment and macular hole closure in highly myopic eyes with posterior staphyloma.

Pars plana vitrectomy and perfluoropropane (C3F8) tamponade for retinal detachment due to myopic macular hole: a prognostic factor analysis

PURPOSE

To determine the prognostic factors associated with anatomical success in the treatment of retinal detachment (RD) due to myopic macular hole by pars plana vitrectomy (PPV) and perfluoropropane (C3F8) gas tamponade.

DESIGN

Retrospective, interventional, comparative case series.

METHODS

In an institutional setting, 57 eyes with myopic macular hole RDs treated by PPV and C3F8 tamponade, with or without concomitant internal limiting membrane (ILM) peeling, endolaser photocoagulation, and/or phacoemulsification, were analyzed. Outcome measures were anatomical success, defined as closure of macular hole with reattachment of the surrounding retina, and postoperative best-corrected visual acuity (BCVA).

RESULTS

The mean postoperative follow-up was 26.9 +/- 16.5 months. The anatomical success rate after primary PPV and C3F8 tamponade was 63.2%. Regression analysis showed that shorter axial lengths (odds ratio [OR] = 6.73, 95% confidence interval [95% CI] 1.86 to 12.22, P = .010), concomitant ILM peeling (OR 1.59, 95% CI 1.14 to 2.38, P = .013), and shorter duration of macular hole RD (OR 0.81, 95% CI 0.67 to 0.98, P = .033) were associated with a higher anatomical success. The mean pre- and postoperative BCVAs were 1.430 +/- 0.273 (range, 0.523 to 1.700) and 1.403 +/- 0.271 (range, 0.699 to 1.800) logarithm of minimal angle of resolution units, respectively. The postoperative BCVA was significantly better in eyes with macular hole closure than in eyes without (P = .021).

CONCLUSIONS

Axial length, concomitant ILM peeling, and duration were important prognostic factors for PPV and C3F8 tamponade in the treatment of myopic macular hole RDs.

Scleral Resection Technique Combined with Vitrectomy for a Macular Hole Retinal Detachment in Highly Myopic Eyes

PURPOSE

To evaluate scleral resection technique combined with vitrectomy for macular hole retinal detachment of highly myopic eyes.

MATERIALS AND METHODS

Seventeencases (17 eyes) of macular hole retinal detachment in highly myopic eyes, in which the patient underwent vitrectomy combined with scleral resection technique formacular hole retinal detachment between January 1996 and December 2003 at Fukuoka University Chikushi Hospital, were studied. Following pars plana vitrectomy, as much as possible of the residual vitreous and/or epiretinal membrane was removed. A scleral resection was performed in 2 quadrants of the equatorial region of the temporal sclera. Finally, a fluid-air exchange with SF(6) gas injection was performed to achieve retinal attachment. Pre- and postoperative axial length of the eyeballs were measured by B-scan ultrasonography.

RESULTS

All cases had the retina reattached at the initial surgery, and visual acuities were stabilized or improved after the surgery. The posterior staphyloma became obscure in 13 out of 17 eyes (76.8%). The macular hole closed in 14 of 17 eyes (82.4%) ophthalmoscopically. There were no cases in which retinal redetachment occurred during follow-up periods of more than 6 months.

CONCLUSION

In cases of macular hole retinal detachment of a highly myopic eye, scleral resection technique combined with vitrectomy changed the shape of the eyeballs and allowed successful retinal reattachment at the initial surgery.

TREATMENT OF RETINAL DETACHMENT RESULTING FROM POSTERIOR STAPHYLOMA–ASSOCIATED MACULAR HOLE IN HIGHLY MYOPIC EYES

PURPOSE

To evaluate the surgical outcome of retinal detachment resulting from a posterior staphyloma-associated macular hole in highly myopic eyes.

METHODS

Fifty-seven consecutive highly myopic eyes with retinal detachment resulting from a posterior staphyloma-associated macular hole diagnosed between January 1993 and June 2003 were retrospectively studied. Anatomical reattachment of the retina and best-corrected visual acuity were measured.

RESULTS

Six different operative methods were used to treat this condition with diverse retinal reattachment rates: long-acting gas tamponade only (12.5%); pars plana vitrectomy (PPV) with long-acting gas tamponade (42.8%); PPV with epiretinal membrane (ERM) peeling and long-acting gas tamponade (50.0%); encircling scleral buckling combined with PPV and long-acting gas tamponade (57.1%); encircling scleral buckling combined with PPV, ERM peeling, and long-acting gas tamponade (40.0%); and encircling scleral buckling combined with PPV and silicone oil tamponade (75.0%). Overall, successful retinal reattachment was achieved in 25 (43.9%) of 57 eyes after the first surgery. However, the ultimate success rate of retinal reattachment was 77.2% (44 of 57 eyes) after subsequent surgery. The mean preoperative visual acuity +/- SEM (in logarithm of the minimal angle of resolution units) was 2.08 +/- 0.55, and the mean postoperative visual acuity +/- SEM was significantly increased to 1.87 +/- 0.54 at the last follow-up (P = 0.038). The major cause of recurrent retinal detachment in the long-acting gas tamponade group was nonclosure of the macular hole. For vitrectomized eyes, the major cause was reopening of the macular hole, even with ERM formation and proliferative vitreoretinopathy. There was no obvious correlation between the extent of the detachment or lens status and the reattachment rate.

CONCLUSIONS

The major causes of recurrent retinal detachment in the long-acting gas tamponade and vitrectomized groups were nonclosure of the macular hole and reopening of the macular hole, respectively. Furthermore, a lesser extent of retinal detachment was not associated with a higher anatomical success rate. More aggressive treatment such as silicone oil tamponade may need to be performed to overcome reduced natural adhesion due to posterior staphyloma with marked chorioretinal atrophy. Failure to initiate aggressive treatment can result in an unsatisfactory outcome and repeated surgery.

Surgical management of traumatic macular hole-related retinal detachment

PURPOSE

To investigate the clinical characteristics and surgical outcome of traumatic macular hole-related retinal detachment.

DESIGN

Retrospective, interventional case series.

METHODS

Eight eyes of eight patients with traumatic macular hole-related retinal detachment underwent vitrectomy combined with gas tamponade, either initially or subsequently. Anatomic re-attachment of the retina, closure of traumatic macular hole, and visual outcome were measured.

RESULTS

Successful retinal re-attachment was achieved in seven eyes (87.5%), and the macular hole was successfully closed in all eyes (100%). Improved vision after the surgery was noted in five eyes (62.5%), whereas three eyes (37.5%) displayed no change.

CONCLUSIONS

Vitrectomy combined with gas tamponade appears to give an effective anatomic re-attachment rate for traumatic macular hole-related retinal detachment. The presence of peripheral retinal breaks, vitreous hemorrhage, or the extent of retinal detachment has no discernible significant influence on closure rate of macular hole and retinal re-attachment rate.

MACULAR HOLE DIAMETER AFTER VITRECTOMY FOR MACULAR HOLE AND RETINAL DETACHMENT

PURPOSE

We measured postoperative macular hole (MH) size after vitrectomy for MH and retinal detachment (MHRD) in high myopia and investigated potentially associated factors.

METHODS

Eleven patients (11 eyes) with high myopia (axial length, 25.6-30.8 mm; mean patient age +/- SD, 64.0 +/- 4.31 years) who had retinal attachment without MH closure after vitrectomy for MHRD were included in the study. Postoperative MHs were measured using optical coherence tomography. A horizontal 5.65-mm-long scan of the retina was obtained, and the MH size was measured as the length between the edges of the MH using the retinal thickness mode of the optical coherence tomography system.

RESULTS

The mean postoperative MH size +/- SD was 1,220 +/- 450 microm. Only axial length was significantly associated with postoperative MH size (P < 0.05). There was a tendency for smaller MH sizes to be associated with better postoperative best-corrected visual acuity (P = 0.06).

CONCLUSIONS

Persistent MHs after vitrectomy were enlarged according to axial length elongation in highly myopic eyes. Even if MH closure was not successful, the maximum effort to shorten postoperative MH size led to a better postoperative outcome.

THE MACULAR BUCKLING PROCEDURE IN THE TREATMENT OF RETINAL DETACHMENT IN HIGHLY MYOPIC EYES WITH MACULAR HOLE AND POSTERIOR STAPHYLOMA

PURPOSE

To evaluate the long-term anatomical and functional results of the macular buckling procedure in myopic macular hole with retinal detachment and posterior staphyloma.

METHODS

Twenty-five consecutive highly myopic eyes with retinal detachment, macular hole, and posterior staphyloma, which were operated between February 1983 and April 1992, were retrospectively studied. The last examination was in June 2002. Follow-up of the 25 patients ranged from 10 years to 19 years (mean, 15 years). Macular buckling with an episcleral sponge was the initial and only procedure. In all operated eyes, anchoring of the sponge was away from the posterior pole. Best-corrected visual acuity was evaluated before and after surgery. The axial length of the eyeball was also measured by A-scan ultrasonography before treatment.

RESULTS

Twenty-two of 25 eyes were successfully treated with a single procedure. In the remaining three eyes, retinal reattachment was obtained after a second buckling operation, which was considered necessary due to loosing of the sponge fixation sutures in two cases and the location of the hole beside the buckle in one case. The mean overall visual acuity was improved after treatment.

CONCLUSIONS

The macular buckling procedure with anchoring of the sponge away from the posterior segment provided efficient scleral indentation of long duration for closure of the macular hole and retinal reattachment.

PRIMARY SILICONE OIL TAMPONADE WITHOUT RETINOPEXY IN HIGHLY MYOPIC EYES WITH CENTRAL MACULAR HOLE DETACHMENTS

BACKGROUND

In highly myopic macular hole central retinal detachments, the ideal treatment is still under discussion. In our study, we analyzed anatomic and functional outcomes for eyes undergoing vitrectomy with primary silicone oil filling without central photocoagulation, using the oil as inductor and scaffold for glial closure of the causative macular hole.

METHODS

Eleven patients with central macular hole detachments and myopia ranging from -10.0 to -23.0 diopters underwent vitrectomy and primary silicone oil filling without laser photocoagulation of the central retina. After at least 3 months (mean +/- SD, 5.2 +/- 2.0 months), the oil was removed from all eyes.

RESULTS

In all eyes, the retina was attached by the first postoperative day and remained attached after silicone oil removal until the end of the follow-up period. No severe intra- or postoperative complications were noted. Visual acuity increased in 7 (63.6%) of 11 eyes, remained unchanged in 3 (27.3%) of 11, and deteriorated in 1 (9.1%) of 11.

CONCLUSION

Vitrectomy plus primary silicone oil tamponade without endophotocoagulation is an effective method to treat central macular hole detachments in highly myopic eyes.

EPISCLERAL MACULAR BUCKLING BY SEMIRIGID SHAPED-ROD EXOPLANT FOR RECURRENT RETINAL DETACHMENT WITH MACULAR HOLE IN HIGHLY MYOPIC EYES

PURPOSE

To evaluate the effects of episcleral macular buckling in highly myopic eyes with postvitrectomy recurrent retinal detachment with macular hole.

DESIGN

Interventional case study.

METHODS

Episcleral macular buckling with a shaped-rod silicone plastic exoplant, facilitated by episcleral tissue removal and intraocular pressure reduction, was performed at Tokyo Medical University Hospital for postvitrectomy recurrent retinal detachment due to macular hole in three highly myopic eyes with axial length of >27 mm.

RESULTS

Optical coherence tomography showed successful retinal reattachment after the buckling procedure in all three eyes and closure of the macular hole in two of the three, and visual acuity improved to 20/200, 20/200, and 20/63 from preoperative values of 20/320, 20/250, and 20/320, respectively.

CONCLUSIONS

The anatomic and functional results of the macular buckling procedure used in these three cases were favorable, suggesting that this procedure can provide an effective means of retinal reattachment particularly in cases of retinal detachment recurrence after vitrectomy and therefore warrants further study.

EFFICACY OF INTERNAL LIMITING MEMBRANE REMOVAL FOR RETINAL DETACHMENTS RESULTING FROM A MYOPIC MACULAR HOLE

PURPOSE

To evaluate the efficacy of internal limiting membrane (ILM) or epiretinal membrane removal during pars plana vitrectomy for a retinal detachment resulting from a macular hole in myopic eyes.

METHODS

A retrospective study was conducted in a single institution. Twenty-six highly myopic eyes with a retinal detachment resulting from a macular hole were studied. During pars plana vitrectomy, ILM peeling (ILM-peeled group) was performed on 13 eyes, and the ILM was not removed (ILM-preserved group) in 12 eyes. Main outcome measures were anatomic reattachment, optical coherence tomography-determined macular hole closure, and visual acuity. Follow-up periods were longer than 12 months in all cases.

RESULTS

The anatomic reattachment rate after the initial surgery was significantly higher in the ILM-peeled group (92.3%) than in the ILM-preserved group (50%). The macular holes of 8 (72.7%) of the 11 ILM-peeled and reattached eyes and 2 (50%) of the 4 ILM-preserved and reattached eyes were successfully closed by the initial surgery. No significant difference was found in the postoperative visual acuity and the improvement of visual acuity between the ILM-peeled group and the ILM-preserved group. There was also no significant difference of the postoperative visual acuity and improvement of the visual acuity between the two groups in cases with an initial anatomic success.

CONCLUSION

These results indicate that removal of the ILM contributes to a successful reattachment and is an effective treatment for macular hole and retinal detachment in highly myopic eyes. The authors suggest that the higher success rate after ILM peeling resulted from the release of the traction of the prefoveal vitreous and the epiretinal membrane over the detached retina.

Effect of Internal Limiting Membrane Removal in Treatment of Retinal Detachment Caused by Myopic Macular Hole

The purpose of this study was to evaluate the anatomical outcomes of vitrectomy with internal limiting membrane removal in highly myopic eyes with retinal detachment caused by a macular hole. Nineteen, consecutive, highly myopic eyes with full thickness macular hole with retinal detachment were treated by vitrectomy with internal limiting membrane removal, endolaser photocoagulation on the center of the hole and fluid gas exchange. In five eyes with other peripheral breaks, scleral buckling (3 cases), encircling (1 case) and barrier laser (1 case) were combined. In 15 eyes (79.0%) the macular hole was closed after the initial surgery. In 4 eyes (21%) the macular hole was reopened, but these were successfully treated with fluid gas exchange (1 case) or macular buckling (3 cases). The visual acuity was improved in 15 eyes (79.0%). In conclusion, these results suggest that the removal of the perifoveal internal limiting membrane may be an important adjuvant in the treatment of the myopic macular hole with retinal detachment.

Perfluorocarbon liquid utilization in primary vitrectomy repair of retinal detachment with multiple breaks

PURPOSE

To evaluate the efficacy of pars plana vitrectomy in conjunction with intraoperative perfluoro-n-octane (PFO) use as initial treatment of retinal detachment (RD) with multiple breaks located at various distances from the ora serrata.

METHODS

Twenty-two consecutive eyes (15 phakic, 2 aphakic, and 5 pseudophakic) presenting with RD with multiple breaks and tears underwent primary pars plana vitrectomy, PFO retinal reattachment, transcleral cryopexy or endolaser treatment of breaks, PFO/air exchange, and final injection of 18% perfluoropropane (C3F8). Scleral buckles were not used. The mean follow-up period was 29 months.

RESULTS

Temporary PFO utilization attached the posterior retina and facilitated the safe removal of vitreous at its base and around the retinal tears. Intraoperative complications included new breaks (3 eyes), enlargement of breaks (2 eyes), and a small bubble of subretinal PFO (1 eye). Postoperatively, the retina remained attached during follow-up in 19 eyes. Cataract developed or progressed in 13 phakic eyes.

CONCLUSIONS

Pars plana vitrectomy in conjunction with intraoperative PFO utilization is effective as initial treatment of RDs with multiple breaks. The main limitation of this technique is the postoperative progressive cataract formation in phakic eyes.

Optical coherence tomographic findings of macular holes and retinal detachment after vitrectomy in highly myopic eyes

PURPOSE

Macular holes cause retinal detachments in highly myopic eyes. Because degenerative macular changes often coexist, biomicroscopic evaluation of macular hole status after retinal reattachment is sometimes difficult. We studied macular holes with retinal detachment after vitrectomy using optical coherence tomography and evaluated the anatomic status of the hole and factors associated with anatomic success.

DESIGN

Retrospective, nonrandomized, comparative study.

PATIENTS

Sixteen eyes that underwent vitrectomy for retinal detachment associated with a macular hole were included. Internal limiting membrane peeling with indocyanine green was performed in 14 eyes; the epiretinal membrane was peeled with a diamond-dusted membrane scraper alone in two eyes. All retinas reattached postoperatively. The follow-up period at the optical coherence tomography examination was at least 6 months.

METHODS

Optical coherence tomography was performed vertically and horizontally, and the presence of a persistent macular hole was determined. Other information was obtained from patient records.

RESULTS

The macular holes closed in seven of 16 eyes (44%). Age, sex, axial length, preoperative best-corrected visual acuity, duration of symptoms, preoperative refractive error, and the preoperative area of the retinal detachment were not significantly correlated with hole closure. Improved postoperative best-corrected visual acuity (P <.05) was significantly associated with macular hole closure, and more frequent visual improvement (P =.06) was of borderline significance.

CONCLUSIONS

The success rate was lower than those obtained in eyes without myopia or in myopic macular holes without retinal detachments. Macular hole closure may predict improved visual outcome for patients with retinal detachment and macular holes. Optical coherence tomography detects persistent macular holes in highly myopic eyes with retinal detachment.

Surgical management of retinal detachment associated with myopic macular hole: anatomic and functional status of the macula

PURPOSE

To evaluate the postoperative status of the macula after vitreous surgery with internal limiting membrane removal for macular hole related retinal detachment in patients with severe myopia.

DESIGN

Interventional case series.

METHODS

We prospectively examined 10 eyes with retinal detachment associated with a myopic macular hole from 10 consecutive patients, and performed pars plana vitrectomy with internal limiting membrane peeling. Macular buckling was performed in one eye during the initial treatment and in three eyes during subsequent operations. The main outcome measures were the anatomic reattachment rate and the postoperative status of the macular hole. We examined the macular area pre- and postoperatively with slit-lamp biomicroscopy and with a scanning laser ophthalmoscope. Cross-sectional imaging of the macular area was conducted with optical coherence tomography.

RESULTS

Successful retinal reattachment was achieved in seven eyes (70%) after the initial surgery and in three eyes (30%) after additional procedures. Visual acuity remained unchanged in two eyes (20%), and improved by two or more logarithmic units of minimum angle of resolution (logMAR) measurement in eight eyes (80%). The macular hole was anatomically closed in only one eye (10%). Postoperative enlargement of the macular hole was observed in seven eyes.

CONCLUSIONS

In highly myopic eyes with macular hole related retinal detachment, closure of the macular hole is difficult to attain despite the complete relief of tangential traction by internal limiting membrane peeling. Results indicate the presence of a possible imbalance between the retina and the choroid-sclera complex associated with axial elongation and posterior staphyloma in highly myopic eyes.

Pathologic myopia: where are we now?

PURPOSE

To describe current concepts and available treatments for pathologic myopia.

DESIGN

Review of experimental and clinical studies.

METHODS

The demography, natural history, medical and surgical treatments for choroidal neovascular membrane, vitreoretinal interface disorders and future strategies for pathologic myopia are reviewed.

RESULTS

Several medical and surgical modalities are currently available to treat various complications of pathologic myopia. Macular translocation appears to stabilize or improve visual function in many eyes with choroidal neovascularization.

CONCLUSION

Newer strategies are emerging to better ameliorate or prevent the complications of pathologic myopia.