Progression of nuclear sclerosis and long-term visual results of vitrectomy with transforming growth factor beta-2 for macular holes

Macular holes: classification, epidemiology, natural history and treatment

BACKGROUND

Macular hole is a retinal disease primarily affecting elderly women. Its overall prevalence in the Danish population is estimated to be 0.14%. The majority of cases are unilateral. The fully developed macular hole evolves through a series of stages starting with an impending hole. About half of impending macular holes regress spontaneously. The remaining half progress to full thickness macular holes. In a patient with a macular hole in one eye, the risk of development of a macular hole in the fellow eye is less than 2% if posterior vitreous detachment is present. If the posterior vitreous is attached, the risk is approximately 15%. If an impending hole is found in the other eye, the risk rises to 50%.

TREATMENT AND OUTCOMES

Macular hole surgery is able to close full thickness macular holes in approximately 90% of cases. Visual acuity of 20/50 or better can be obtained in approximately half of patients with recent onset of symptoms. Complications include retinal detachment, endophthalmitis, late reopening of an initially successfully closed hole and retinal pigment epithelial abnormalities. Retinal detachment should be expected in less than 5% of cases.

Nucleus cryoinversion for extraction of highly complicated cataracts

We describe a technique for cataract extraction in vitrectomized eyes that uses secured removal of the nucleus with no manipulation of the capsular bag. After a large scleral tunnel is prepared and a capsulorhexis created, a 20-gauge retinal cryoprobe enveloped in a plastic or a silicone sleeve is introduced into the anterior chamber. The cryoprobe engages the nucleus by a "freeze-grip" and rotates it 180 degrees so that the nucleus is elevated into the anterior chamber with no force applied to the capsule and the cryoprobe supporting it from below. The cryoprobe is replaced by a vectis under the nucleus and with the help of another instrument from above, the nucleus is removed. Aspiration of cortical material under low-pressure fluid maintenance of the anterior chamber completes removal of the cataract. An intraocular lens is then implanted in the ciliary sulcus for maximum capsule support.

Combining phacoemulsification with vitrectomy for treatment of macular holes

AIM

To describe the results of combined phacoemulsification, insertion of posterior chamber intraocular lens (PCIOL), and pars plana vitrectomy for patients with macular hole.

METHODS

A case series of 89 consecutive patients with macular hole who underwent combined phacoemulsification, insertion of PCIOL, posterior capsulectomy, and pars plana vitrectomy.

RESULTS

80 of 89 patients (89%) had their holes closed with the combined surgery. Four of the nine patients who failed had their holes closed with one further procedure. Of the 89 patients operated on, 61 (65%) had vision of 20/40 or better. Three patients (3%) had Snellen acuity of less than 20/400 postoperatively. Three patients (3%) developed retinal detachments, one with proliferative vitreoretinopathy (PVR). Eight patients (9%) developed CMO. Three patients developed late reopening of their macular holes after remaining closed for 9 months or more.

CONCLUSION

Combined phacoemulsification, insertion of PCIOL, and pars plana vitrectomy surgery can be used to treat macular holes. Combining cataract surgery with vitrectomy surgery may prevent a later second operation for post-vitrectomy cataract formation.

Intraocular lens power calculation after macular hole surgery

A patient had cataract surgery in both eyes after bilateral macular hole repair. In the left eye, the intraocular lens power was calculated using the axial length obtained by biometry. In the right eye, 0.5 mm, the estimated depth of the foveolar crater after stage 3 macular hole repair, was subtracted from the A-scan measurement to obtain the functional axial length. Postoperatively, refraction was +0.25 diopter (D) in the right eye and +1.63 D in the left eye. Biometry after macular hole surgery should be corrected by subtracting the depth of the foveolar crater from the measured axial length.

Phacovitrectomy with internal limiting membrane peeling for idiopathic macular hole

BACKGROUND

Progressive nuclear sclerosis is a known complication of macular hole surgery that hinders patients' recovery to their best visual acuity postoperatively. We report the visual outcome, complications and efficacy of combined phacoemulsification, intraocular lens (IOL) insertion and vitrectomy with internal limiting membrane (ILM) peeling for patients with cataract undergoing macular hole surgery.

METHODS

We reviewed the records of 32 consecutive patients (36 eyes) who underwent phacoemulsification with insertion of a polymethylmethacrylate lens into the capsular bag and pars plana vitrectomy with ILM peeling in one session for repair of idiopathic macular hole. Patients were assessed between February 1998 and August 2001.

RESULTS

The mean age of the patients was 70 (range 52 to 83) years, and 25 (78%) were women. The median duration of the holes before surgery was 8.3 months; in 19 eyes (53%) the duration was 6 months or less. Twenty eyes (56%) had stage 3 holes. The preoperative vision was 20/200 or worse in 29 eyes (80%). The mean grade of nuclear sclerosis was 2.4. The average length of follow-up after surgery was 11 (range 1.5 to 37) months. Primary hole closure was achieved in 28 eyes (78%). In five of the remaining eight cases the patient consented to a second procedure, which was successful in four cases, for a final closure rate of 89%. Postoperatively, the visual acuity improved by 2 lines or more in 22 eyes (61%). Of the 32 eyes with final closure, 11 (34%) attained a visual acuity of 20/40 or better, and 25 (78%) had an acuity of 20/100 or better. The most common complication was posterior capsular opacification (27 eyes [75%]), an expected complication when perfluoropropane or other gases are used for tamponade.

INTERPRETATION

The results are comparable to those with standard macular hole surgery. Combined surgery is reliable and safe; the benefits support its use as a routine procedure for patients with cataract undergoing macular hole repair.

Cataract surgery in patients with retinal disease

Retinal disease and cataracts frequently are associated with one another. Cataract formation can occur following pars plana vitrectomy and pneumatic retinopexy. Conversely, cataract surgery may exacerbate existing retinal disease, such as diabetic retinopathy, macular degeneration, and uveitis. Finally, cataract surgery can lead to retinal disease de novo, such as cystoid macular edema. A review of the medical literature was performed for all articles published between August 1st, 2000 and July 31st, 2001 on the topic of cataract surgery in patients with retinal disease. The authors selected ten articles that were most relevant to the practicing ophthalmologist for inclusion in this review. Topics of interest included age related macular degeneration, retinal detachment, macular hole, diabetic retinopathy, uveitis, and cystoid macular edema.

The role of vitreoretinal surgery in the management of myopic macular hole without retinal detachment

PURPOSE

To evaluate the anatomic and functional outcome of vitreoretinal surgery in eyes with pathologic myopia and macular hole and to determine if surgery improves visual acuity.

METHODS

Twenty-four consecutive highly myopic eyes with full-thickness macular hole without posterior retinal detachment were treated by vitrectomy. Posterior hyaloid dissection, removal of epiretinal and internal limiting membranes (ILM) if thickened, instillation of platelet concentrate, and flushing with 25% sulfur hexafluoride were performed.

RESULTS

Patients' refractive error ranged between -8.0 and -17.5 diopters, and axial length ranged from 27.1 to 31.4 mm. Two epimacular membranes and 10 macular ILM were removed. Ten patients also underwent phacoemulsification and intraocular lens implantation at the same procedure. Mean preoperative best-corrected visual acuity was 20/200. Successful anatomic macular hole closure occurred 6 months postoperatively in 100% of eyes after one (21 eyes, 87.5%) or two surgeries (3 eyes, 12.5%). Visual acuity improved three or more lines in 83.3% of patients. Mean postoperative visual acuity was 20/70. No retinal detachment was observed during the follow-up period, which ranged from 12 to 45 months.

CONCLUSION

Our results suggest that vitreoretinal surgery may effectively manage myopic macular holes, thus improving anatomic and visual outcomes. By closing the hole, vitreoretinal surgery may decrease the risk of posterior retinal detachment in highly myopic eyes.

Duration of vitrectomy and postoperative cataract in the vitrectomy for macular hole study

PURPOSE

To report the association between duration of vitrectomy, as well as other risk factors, and the progression of nuclear sclerosis and posterior subcapsular cataract in the Vitrectomy for Macular Hole Study.

DESIGN

A cohort study nested within a randomized controlled clinical trial.

METHODS

Using a system similar to the Lens Opacities Classification System II, nuclear sclerosis (NS) and posterior subcapsular cataract (PSC) were scored in the vitrectomy and fellow eye of 74 patients at baseline and at 6, 12, and 24 months postoperatively. Age, baseline blood pressure and refractive power, and duration of surgery were evaluated as risk factors for NS or PSC progression and cataract extraction.

RESULTS

The incidence of NS progression in the surgical group of vitrectomy eyes was 81% at 6 months, 98% at 1 year, and 100% at 2 years of follow-up. In contrast, NS progression in the control group of fellow eyes was only 18% at 6 months, 20% at 1 year, and 8% at 2 years. The incidence of PSC progression in the surgical group remained at approximately 11% throughout follow-up, which was not significantly higher than the 3% to 5% incidence in the control group. Vitrectomy was significantly related to progression of NS cataract (P <.001) and cataract extraction (P <.01). No statistically significant differences were found for NS scores, PSC scores, or progression rates between eyes that had less than median surgical duration (60 min.) or more than the median surgical duration. Additionally, no significant differences were found when eyes that experienced 45 minutes or less surgical duration were compared with eyes that endured more than 75 minutes surgical duration. Age, blood pressure, and refractive power were not found to be predictors for NS and PSC progression.

CONCLUSIONS

Although vitrectomy is a risk factor for NS progression, the duration of vitrectomy does not increase the risk.

Phacovitrectomy without prone posture for full thickness macular holes

AIMS

To investigate the role of phacovitrectomy surgery without prone posture for stage 2 and 3 macular holes.

METHODS

A pilot study was performed on 20 patients (20 eyes) having phacoemulsification lens removal and vitrectomy surgery with 20% C(2)F(6) tamponade. Patients were advised to avoid lying on their backs for 10 days following surgery but no other posturing instructions were given. Closure rates and improvement in visual acuity were compared with a group of historical controls in whom phacovitrectomy with gas tamponade and face down posturing was performed.

RESULTS

Anatomical hole closure was noted in 18 of the 20 eyes (90%). 19 eyes (95%) showed an improvement of at least 0.3 logMAR units. This compares favourably with the postured group in which anatomical hole closure was noted in 11 of 13 eyes (85%) and nine of 13 eyes (69%) showed an improvement of at least 0.3 logMAR units.

CONCLUSION

Combined surgery facilitates the use of a large gas bubble. Sufficient tamponade of the hole occurs for closure without prone posturing. Combined surgery prevents patients posturing and returning for cataract surgery.

Assessment of nuclear sclerosis after nonvitrectomizing vitreous surgery

PURPOSE

Nuclear sclerosis develops frequently after successful pars plana vitrectomy. We evaluated changes in the degree of nuclear sclerosis after nonvitrectomizing vitreous surgery for idiopathic epimacular proliferation.

METHODS

Forty-one consecutive patients (41 eyes) underwent removal of idiopathic epimacular proliferation by nonvitrectomizing vitreous surgery and were followed postoperatively for at least 12 months. Visual acuity, refractive error, slit-lamp biomicroscopy, and Scheimpflug photographs were assessed preoperatively and postoperatively to evaluate changes in the degree of lenticular opacification. Quantitative analysis of the nuclear sclerosis was performed by densitometry with Scheimpflug photographs performed on only the last 21 patients. We evaluated these measurements by comparing statistically the preoperative and postoperative difference between both eyes (operative eye minus nonoperative ocular data).

RESULTS

There was no significant difference in the progression of nuclear sclerosis or degree of myopic shift between the operated and fellow eyes during postoperative follow-up (mean +/- SD, 22 +/- 8 months; median, 22 months; range, 12 to 48 months). The average preoperative and postoperative refractive errors in operated eyes were 0.0 +/- 2.4 diopters and 0.1 +/- 2.5 diopters, respectively; the average difference in the refractive errors between both eyes was -0.2 +/- 0.7 diopter preoperatively and -0.2 +/- 0.9 diopter postoperatively (P =.961, paired t test). The average preoperative and postoperative nuclear density values by Scheimpflug photography in 21 operated eyes were, respectively, 72 +/- 18 nuclear density units and 75 +/- 17 nuclear density units; the average difference in nuclear density values between both eyes was -1 +/- 4 nuclear density units preoperatively and 0 +/- 6 nuclear density units postoperatively (P =.631, paired t test).

CONCLUSION

Progression of nuclear sclerotic cataract based on changes in refractive error and Scheimpflug photography was not observed after nonvitrectomizing vitreous surgery.

Surgical management of macular holes: a report by the American Academy of Ophthalmology

OBJECTIVE

The document describes macular hole surgery and examines the available evidence to address questions about the efficacy of the procedure for different stages of macular hole, complications during and after surgery, and modifications to the technique.

METHODS

A literature search conducted for the years 1968 to 2000 retrieved over 400 citations that matched the search criteria. This information was reviewed by panel members and a methodologist, and it was evaluated for the quality of the evidence presented.

RESULTS

There are three multicenter, controlled, randomized trials that constitute Level I evidence and compare the value of surgery versus observation for macular hole. There are three multicenter, controlled, randomized trials studying the use of adjuvant therapy in macular hole repair. Postoperative vision of 20/40 or better has been reported in 22% to 49% of patients in randomized trials. The risks of surgical complications include retinal detachment (3%), endophthalmitis (<1%), cataract (>75%), and late reopening the hole (2% to 10%).

CONCLUSIONS

The evidence does not support surgery for patients with stage 1 holes. Level I evidence supports surgery for stage 2 holes to prevent progression to later stages of the disease and further visual loss. Level I evidence shows that surgery improves the vision in a majority of patients with stage 3 and stage 4 holes. There is no strong evidence that adjuvant therapy used at the time of surgery results in improved surgical outcomes. Patient inconvenience, patient preference, and quality of life issues have not been studied.

Surgery for idiopathic macular holes associated with extensive subretinal fluid

PURPOSE

To study the baseline characteristics and outcomes of surgery for idiopathic macular holes associated with localized macular detachment.

METHODS

In this case-control study, eight consecutive patients with idiopathic macular hole associated with localized macular detachment (cases) and 30 randomly selected patients with idiopathic macular hole not associated with macular detachment underwent macular hole surgery.

RESULTS

The mean age (62.1 versus 68.2 years; P = 0.086), mean refractive error (-0.13 versus +0.23 diopters; P = 0.68), average duration of symptoms (5.9 versus 4.6 months; P = 0.47), and macular hole stage (P = 0.43) were similar in the cases and controls. The baseline visual acuity ranged from 20/50-20/80 (1 [13%] versus 1 [3%]) to 20/100-20/200 (2 [25%] versus 24 [80.0%]) to < 20/200 (5 [63%] versus 5 [17%]) (P = 0.10). Single-operation anatomic success was achieved in 2 (25%) cases and 24 (80%) controls (P = 0.007). Visual acuity 3 months after the last macular hole surgery was worse in cases compared to controls: > or = 20/40 in 0 versus 6 (20%), 20/50-20/80 in 1 (13%) versus 13 (43%), 20/100-20/200 in 4 (50%) versus 10 (33%), and < 20/200 in 3 (38%) versus 1 (3%) (P = 0.003). The mean improvement in visual acuity was 0.2 logMAR units in cases versus 0.4 logMAR units in controls (P = 0.054).

CONCLUSIONS

Surgical outcomes for idiopathic macular hole associated with a localized macular detachment compare poorly with the outcomes for macular hole not associated with extensive surrounding subretinal fluid.

Posterior subcapsular and nuclear cataract after vitrectomy

PURPOSE

To examine the morphological changes in the postvitrectomy lens and to monitor the development of these changes over time.

SETTING

Oxford Eye Hospital, Oxford, United Kingdom.

METHODS

In this prospective study, 33 consecutive phakic patients having pars plana vitrectomy were recruited. Cataract development was quantified by clinical grading and digital Scheimpflug image analysis. Slitlamp biomicroscopy and photography were used to document the morphological appearance. The main outcome measures were the incidence, morphology, and development of posterior subcapsular and nuclear cataract.

RESULTS

A characteristic, transient posterior subcapsular cataract (PSC) was present in 89% (17 of 19) of tamponade patients within 24 hours of surgery. Of the patients who had vitrectomy without tamponade, 9% (1 of 11) developed similar changes. Nuclear opacity developed in 61% (11 of 18) of tamponade patients and in 50% (3 of 6) of nontamponade patients. A longer term retrospective review of the same patients' case notes revealed nuclear cataract in 67% (12 of 18) of tamponade cases and 30% (3 of 10) of nontamponade cases. Eighteen percent (2 of 11) of nontamponade cases and 67% (14 of 21) of tamponade cases had cataract surgery after a 10.7 month and a 12.4 month follow-up, respectively.

CONCLUSIONS

Vitrectomy and tamponade produced a characteristic transient PSC in the immediate postoperative period. Disruption of fluid balance in the region of the posterior lens was suggested by the morphological appearance. The acute changes resolved but were followed by accelerated nuclear opacification.

Effect of infusion air pressure on visual field defects after macular hole surgery

PURPOSE

A defect in the visual field is one of the serious complications of macular hole surgery. We investigated the relationship between the occurrence of visual field defect and the location of infusion cannula and air pressure during fluid-air exchange.

METHODS

We studied 100 eyes from 90 patients with macular holes. All patients underwent preoperative and postoperative visual field testing. Vitreous surgery was performed in a standard three-port fashion, with surgically induced posterior vitreous detachment, fluid-air exchange, and sulfur hexafluoride gas injection. We analyzed differences in surgical methods in three groups. In group A, the infusion cannula was placed inferotemporally, and the air pressure was set at 50 mm Hg. In group B, the infusion cannula was placed inferonasally, and the air pressure was set at 50 mm Hg. In group C, the infusion cannula was placed inferotemporally, and the air pressure was set at 30 mm Hg.

RESULTS

Eighteen eyes (18%) showed visual field defects after vitrectomy. The defect was always located contralateral to the infusion cannula. There was no statistically significant difference in the incidence of visual field defects in groups A and B. Decreased air pressure reduced the occurrence of visual field defects significantly (24% in group A versus 4% in group C, P = .011).

CONCLUSIONS

The location of the visual field defect correlated with the location of the infusion cannula. The incidence of this visual field defect was influenced strongly by the infusion air pressure. The visual field defect may be caused by the mechanical damage of air infusion.

The macular hole: report of an Australian surgical series and meta-analysis of the literature

PURPOSE

To report an Australian series of macular hole surgery by pars plana vitrectomy and fluid-gas exchange, and to identify factors influencing the outcome of the surgery through meta-analysis of the literature.

METHODS

Fifty-six consecutive cases of macular hole were treated by pars plana vitrectomy, fluid-gas exchange and face-down positioning for at least 7 days, and prospectively followed for 3-12 months. Thirty-six reports of macular hole surgery were reviewed. A meta-analysis on the pre- and postoperative parameters was performed on 389 cases, in which case-specific data-points were available.

RESULTS

In the current series, anatomical closure was achieved in all (100%) of 16 stage 2, and in 35 (87.5%) of 40 stage 3 or 4 macular holes. At least 2 logMAR lines of improvement in visual acuity were seen in 10 (62.5%) stage 2 and 20 (50.0%) stage 3 or 4 holes. Postoperative visual acuity was 6/12 or better in 10 (62.5%) stage 2 and 17 (42.5%) stage 3 or 4 holes. In both the current series and the meta-analysis, favourable surgical outcomes were associated with stage 2 macular holes, better preoperative visual acuity, and shorter preoperative duration. Adjuvant use was associated with a higher rate of anatomical closure but there was no clear benefit in terms of postoperative visual acuity.

CONCLUSION

Our experience and the results of the meta-analysis suggest that macular hole surgery should be offered as early as possible once full-thickness neuroretinal defect occurs.

Surgical treatment of macular holes with multiple recurrences

PURPOSE

To evaluate the results of a third macular hole surgery in eyes with recurrent macular holes and two prior macular hole surgeries.

DESIGN

Retrospective consecutive noncomparative case series.

PARTICIPANTS

Sixteen eyes of sixteen patients with two prior macular hole surgeries with recurrent macular hole.

INTERVENTION

A third vitreous surgery was performed in each eye using a long-acting gas bubble.

MAIN OUTCOME MEASURE

Closure of the macular hole and change in visual acuity.

RESULTS

The macular hole was closed in 12 of 16 eyes (75%) at 3 months after the third surgery. Visual acuity improved 2 or more Snellen lines in 9 of 16 eyes (56%), and 5 of 16 eyes (31%) achieved 20/40 or better vision. Six eyes (37.5%) had cataract surgery after the third macular hole surgery, and visual acuity results were similar in eyes with or without cataract surgery. Successful closure of the macular hole improved the visual acuity from 20/80 -1 to 20/50 +1 (P < 0.001). Eyes in which one of the previous surgeries had been temporarily successful in closing the macular hole improved from a mean of 20/80 to 20/40 (P = 0.003). Eyes in which both prior macular hole surgeries had been primary failures had minimal benefit with a preoperative visual acuity of 20/100 +1 and a postoperative visual acuity of 20/100 +2 (P = 0.67).

CONCLUSIONS

Repeat macular hole surgery should be considered in eyes with recurrent macular holes and two prior surgeries when the macular hole was temporarily closed by at least one of the two previous surgeries. Successful closure of a macular hole in such cases usually results in significant visual acuity improvement.

Surgery for full-thickness macular holes with short-duration prone posturing: results of a pilot study

PURPOSE

To see whether surgical success and complication rates in surgery for full-thickness macular holes (FTMH) followed by 5 days prone posturing are comparable to those obtained with longer posturing regimes recorded in the literature.

METHODS

A pilot study was carried out of pars plana vitrectomy, autologous platelet adjunct and 16% C2F6 tamponade followed by 5 days prone posturing in 38 eyes of 34 patients with idiopathic FTMH. A follow-up postal questionnaire was used to assess patients' perception of posturing and outcome.

RESULTS

Fifty-three per cent of eyes gained 2 or more lines of Snellen acuity. Twenty-four per cent of patients with symptom duration of 12 months or less (29 patients) achieved a visual acuity of 6/12. Fifty-eight per cent of patients achieved N8 or better near vision. The only significant predictor of post-operative Snellen acuity was the stage of the hole (p = 0.02). Eighty-six per cent of questionnaire respondents felt that surgery had improved their quality of life. Eighty-seven per cent of all patients reported a reduction in, or elimination of, metamorphopsia. Fifty-four per cent of patients described posturing for 5 days as difficult or very difficult. Five patients admitted to posturing for less than 12 h a day, but all stated that they had postured for the full 5 days. Cataract was the commonest complication observed in this series (42% of patients have had or been listed for cataract surgery).

CONCLUSIONS

Five days of prone posturing following vitrectomy for FTMH with autologous plaletet concentrate and C2F6 tamponade afforded success and complication rates comparable to those in published studies with longer posturing times.

Update on current surgical management of idiopathic macular holes

Idiopathic macular holes were generally considered an untreatable condition until 1991 when the first papers reported successful closure of macular holes and visual improvement using pars plana vitrectomy, peeling of the cortical vitreous and face-down positioning. Since that time, the original pathogenesis theory has been refined as well as surgical methods and techniques. Currently, macular hole surgery is considered the most successful vitreoretinal surgery, with a greatly improved prognosis for patients. This article will review the general characteristics of macular holes and the clinical trials and outcomes that have led to the latest techniques in idiopathic macular hole surgery.

Visual and anatomical results of surgery for long standing macular holes

AIMS

To determine the visual and anatomical outcome of surgery for long standing idiopathic macular holes.

METHODS

A retrospective review of 24 eyes of all 22 patients who underwent surgery for idiopathic full thickness macular holes (FTMH) symptomatic for between 1 and 3 years. Postoperative follow up was for 6 months. Preoperative and postoperative visual acuities were recorded as well as the presence of anatomical closure of the hole.

RESULTS

The mean duration of symptoms was 18.21 (SD 5.42) months). Anatomical closure of the FTMH was achieved in 17 (70.8%) of the eyes at 6 months. The logMAR acuity of the group where closure was achieved improved by a mean of 0.31, equivalent to a change of Snellen acuity from 6/60 to 6/29. Where the hole remained open the acuity deteriorated by a mean logMAR of 0.11 lines, equivalent to a change of Snellen acuity from 6/60 to 5/60. Anatomical closure of the hole was associated with a significantly improved acuity over non-closure (p<0.001). The degree of visual improvement was independent of the preoperative visual acuity (Spearman correlation coefficient 0.03, p=0.888), though preoperative acuity was related to the final acuity (Spearman correlation coefficient 0.701, p<0.001). Over the study period, six patients required cataract surgery, one patient developed secondary glaucoma, and one a retinal detachment.

CONCLUSIONS

Vitrectomy with intraocular gas tamponade and postoperative posturing is a well tolerated and effective intervention for long standing macular holes. Anatomical closure of the macular hole is associated with a significant improvement in visual acuity.

Optical coherence tomography of successfully repaired idiopathic macular holes

PURPOSE

To present the cross-sectional retinal imaging results of optical coherence tomography in eyes with successfully repaired idiopathic macular hole and their relevance to visual recovery.

METHODS

We studied 33 eyes with successful repair of an idiopathic macular hole through vitrectomy and fluid-gas exchange from 32 patients (11 men and 21 women) with ages ranging from 48 to 78 years, with a median age of 66 years. Preoperative conditions in eyes with primary surgery disclosed nine eyes with stage 2, 14 eyes with stage 3, and four eyes with stage 4 macular hole. An additional six eyes underwent a second surgery because the previous surgery was unsuccessful. Measurement of best-corrected visual acuity, slit-lamp biomicroscopy with fundus contact lens, fundus photographs, and optical coherence tomographic examination were performed between 6 and 9 months after surgery in 29 eyes and between 15 and 36 months after surgery in four eyes.

RESULTS

Optical coherence tomographic images of the repaired macular holes were categorized into three patterns. U-type (normal foveal contour; 13 eyes) showed mildly to moderately backscattering layers with a smooth circular surface covering retinal pigment epithelium and choriocapillaris layers. In eyes with V-type (steep foveal contour; 13 eyes), the retinal pigment epithelium and choriocapillaris layers were covered with moderately backscattering layers with a notch. W-type (foveal defect of neurosensory retina; seven eyes) showed abruptly or gradually terminating sensory retinal layers to expose the surface of the retinal pigment epithelium and choriocapillaris layers. Postoperative acuity was well correlated with these patterns of optical coherence tomographic images.

CONCLUSION

Assessment of successfully repaired idiopathic macular holes with optical coherence tomographic images provides a useful correlation with postoperative visual recovery.

Nonvitrectomizing vitreous surgery: a strategy to prevent postoperative nuclear sclerosis

OBJECTIVE

The development or progression of postoperative nuclear sclerosis is the most common complication of successful vitrectomy in elderly patients. The authors treated idiopathic epimacular proliferation (EMP) with nonvitrectomizing vitreous surgery in an attempt to prevent postoperative nuclear sclerosis.

DESIGN

Prospective, nonrandomized, comparative case series.

PARTICIPANTS

The authors surgically removed membranes from the sensory retina in 21 eyes of 21 patients with EMP.

INTERVENTION

Neither intravitreal infusion nor vitrectomy of any kind was performed during the procedure. The peeled membrane was left floating in the vitreous cavity in 11 (group 1) eyes and removed in 10 eyes (group 2). Nonoperated fellow eyes served as controls.

MAIN OUTCOME MEASURES

Visual acuity, slit-lamp and/or Scheimpflug photography, and refractometry were performed pre- and postoperatively to evaluate changes in the degree of lenticular opacity.

RESULTS

There was no difference in the rate of development or progression of nuclear sclerosis or the degree of myopic shift between operated and control eyes during the postoperative follow-up period (mean, 9.7 months). No serious complications were noted. There was no difference in postoperative course between patients in the two operative groups.

CONCLUSIONS

Although interpretation of the results of this study is limited due to its small size and short follow-up, nonvitrectomizing vitreous surgery seems to decrease the postoperative development or progression of nuclear sclerosis in patients with idiopathic EMP.

Phacoemulsification in eyes with past pars plana vitrectomy: case-control study

PURPOSE

To determine intraoperative and postoperative complications and outcomes of phacoemulsification of cataract in eyes that had previous pars plana vitrectomy.

SETTING

University-based anterior segment disease referral practice.

METHODS

This was a retrospective case-control study of a surgical series of 52 consecutive postvitrectomy cataract extractions statistically compared with control eyes from the same practice.

RESULTS

Cataract extraction followed vitrectomy by 2 months to 6 years (mean 19 months). Cataracts with a posterior subcapsular component were seen more frequently in postvitrectomy eyes (58% versus 25% in control eyes). Cataract extraction after pars plana vitrectomy was often more challenging than in control eyes. Challenges included unstable posterior capsules, loose zonules, and posterior capsule plaque. Postoperative posterior capsule opacification (PCO) was more common in study than in control eyes (51% versus 21%; P = .002), especially if expandable gas or silicone oil had been used at vitrectomy. Visual acuity improved in 87% of study eyes, with 46% achieving a visual acuity of 20/40 or better. In study eyes in which the indication for vitrectomy was macular hole or epiretinal membrane, nuclear sclerosis was the most common cataract type, no intraoperative complications occurred, the PCO rate was low (13%), and visual acuity was better (73% 20/40 or better) than in the other study eyes.

CONCLUSION

Phacoemulsification after pars plana vitrectomy can be performed with a low complication rate and with good visual results, although limited by underlying retinal disease. Posterior capsule opacification requiring neodymium: YAG capsulotomy was common in this series.

Prevention of visual field defect after macular hole surgery by passing air used for fluid-air exchange through water

PURPOSE

To evaluate the effect on peripheral visual field defects occurring after macular hole surgery of passing air that is used for fluid-air exchange through water before infusion to the eye.

METHODS

We used Goldmann perimetry to measure the visual fields of patients who underwent vitrectomy to manage idiopathic full-thickness macular holes using either room air or humidified air for fluid-air exchange. We retrospectively studied visual fields measured in 39 patients (group 1) who underwent vitrectomy without humidification of air and prospectively studied visual fields measured in 33 patients (group 2) who consecutively underwent vitrectomy with humidified air for fluid-air exchange.

RESULTS

In group 1, nine patients (23%) had peripheral visual field defects, most often located in the inferior or inferotemporal quadrant. No patients (0%) in group 2 had a visual field defect after vitrectomy. The difference between groups 1 and 2 in the proportion of patients with visual field defects after vitrectomy was statistically significant (P = .003).

CONCLUSIONS

Passing air used for fluid-air exchange through water seems to prevent visual field defects after vitrectomy for macular hole surgery. Visual field defects that occur after room air is used may result from desiccation of the retina by room air.

Treatment of reopened macular hole after vitrectomy by laser and outpatient fluid-gas exchange

OBJECTIVE

This study aimed to assess a new nonsurgical treatment for patients who have previously undergone vitrectomy for macular hole with either persistent or reopened holes.

DESIGN

A prospective, noncomparative, consecutive case series.

PARTICIPANTS

Fifteen patients (15 eyes) were studied.

INTERVENTION

Patients were treated by an outpatient method consisting of laser photocoagulation to the foveal pigment epithelium followed by fluid-gas exchange with 20% perfluoropropane gas and prone positioning. Patients without known allergy were treated with two doses of oral Diamox (250 mg) and ciprofloxacin (500 mg).

MAIN OUTCOME MEASURES

Visual acuity, intraocular pressure, anatomic status of the macular hole, and cataract were the principal outcome measures studied.

RESULTS

Thirteen of 15 macular holes were closed successfully with 1 or more procedures. All patients with macular hole closure achieved two lines or greater of vision improvement on Snellen testing. Three patients (20%) achieved 20/40 and nine (60%) achieved 20/80 or better. Three patients required more than one procedure. Four patients developed mild transient ocular hypertension.

CONCLUSIONS

The combination of office-based outpatient fluid-gas exchange and laser appears to be a safe and cost-effective alternative to repeat surgery in selected patients with persistent or reopened macular holes after vitrectomy, in whom there are no visible epiretinal membranes, or in whom return to the operating room is undesirable for medical or personal reasons.

Comparison of recombinant transforming growth factor-beta-2 and placebo as an adjunctive agent for macular hole surgery

OBJECTIVE

This study aimed to compare the visual and anatomic results of macular hole surgery in eyes treated with recombinant transforming growth factor-beta-2 (TGF-beta2) or placebo.

DESIGN

The design was a prospective, multicenter, randomized, double-masked, placebo-controlled clinical study.

PARTICIPANTS

One hundred thirty eyes with idiopathic macular holes of 1 year or less and a refracted Early Treatment Diabetic Retinopathy Study visual acuity of 20/80 or worse were treated with 1.1 microg recombinant TGF-beta2 or placebo to the macular hole after fluid-gas exchange.

INTERVENTION

The effect of recombinant TGF-beta2 as an adjunctive agent for macular hole surgery was evaluated.

MAIN OUTCOME MEASURES

Closure of the macular hole and change in visual acuity at 3 months were measured.

RESULTS

The 3-month visits were completed for 120 eyes. The macular hole was closed at 3 months in 35 (61.4%) of 57 eyes treated with placebo and 49 (77.8%) of 63 eyes treated with recombinant TGF-beta2 (P = 0.08). The mean visual acuity gain was +6.4 letters in eyes receiving placebo and +8.9 letters in eyes treated with recombinant TGF-beta2 (P = 0.27). Visual acuity improved 2 or more lines in 23 (40.4%) of 57 eyes treated with placebo and 30 (47.6%) of 63 eyes treated with recombinant TGF-beta2 (P = 0.42). Intraocular pressure elevation greater than 30 mmHg was more common 2 weeks after surgery in eyes treated with recombinant TGF-beta2 (P < 0.001).

CONCLUSIONS

Recombinant TGF-beta2 resulted in a similar proportion of successful closure of macular holes as placebo. There was no statistically significant visual acuity benefit with the use of recombinant TGF-beta2 for the treatment of macular holes.

Pearls in the management of submacular hematoma

Subretinal hemorrhage (SRH), complicated by choroidal neovascularization such as age-related macular degeneration, often reduces central vision in middle-aged patients. Although the visual results of SRH removal by surgery seem to have improved recently, the efficacy has not yet been confirmed in a prospective, controlled fashion. Therefore, it cannot be stated with certainty that surgery for SRH is more beneficial than the natural course of the disease. However, we believe surgery is beneficial in selected patients. Herein, we describe our technique for the surgical removal of SRH. The development of safer, more effective techniques should further improve patient outcomes.

Macular hole

A macular hole is a full-thickness defect of retinal tissue involving the anatomic fovea, thereby affecting central visual acuity. Macular holes have been associated with myriad ocular conditions and originally were described in the setting of trauma. The pathogenesis of idiopathic, age-related macular holes remains unclear despite a litany of theories. Recently, Gass has described an updated biomicroscopic classification of macular holes and postulated that tangential vitreous traction may play a role. Cellular components surrounding the rim of macular holes may also contribute tangential traction forces and elevate the rim. Pseudomacular holes may be mistaken for macular hole lesions, despite careful clinical examination. Careful biomicroscopic examination with a contact lens and use of the Watzke and laser aiming beam tests help to ensure accurate diagnosis. Newer imaging technology, such as optical coherence tomography, helps distinguish true macular holes from pseudoholes and may provide additional insight into the pathogenesis of this condition. Surgical management with or without pharmacosurgical adjuncts can improve vision in select cases. The most common surgical complication is progressive lens opacification in phakic patients.

Pearls in the management of macular holes

We studied the efficacy of removing the retinal pigment epithelium (RPE) from the base of the macular hole to treat 124 eyes of 118 patients with stage 2 (n = 38), stage 3 (n = 52), or stage 4 (n = 34) macular hole. The patients ranged in age from 42 to 81 years (mean = 66.7 years), and the duration of symptoms preoperatively ranged from 1 to 140 months (average = 16.8 months). During vitrectomy for the macular hole, the RPE at the base of the hole was gently aspirated with either a silicone-tipped extrusion needle or a blunt-tipped 27-gauge needle. The follow-up period averaged 18.6 months (range = 3 to 48 months). The holes resolved in 112 (90%) of the 124 eyes after one surgical procedure. In 107 eyes with a follow-up period of 6 months or longer, 91 (85.0%) showed improved visual acuity of at least 2 lines of Snellen equivalent. The final visual acuity was 20/25 or better in 34 (31.8%) and 20/40 or better in 80 (74.8%) of the 107 eyes. A complication peculiar to RPE removal is the hypertrophy of the RPE. This complication was observed in 15 (14.0%) of the 107 eyes that were followed for 6 months or longer. From these results, I conclude that RPE removal will improve the anatomical and the visual results in selected macular hole cases.

Phacoemulsification and lens implantation after pars plana vitrectomy

OBJECTIVE

This study aimed to describe the intraoperative and postoperative complications and visual acuity outcomes of patients undergoing Kelman phacoemulsification (KPE) and intraocular lens (IOL) implantation after pars plana vitrectomy (PPV).

DESIGN

The study design was a retrospective review of a consecutive surgical series.

PARTICIPANTS

Forty-four eyes of 43 patients who underwent surgery at the Jules Stein Eye Institute, Los Angeles, California, or Advanced Vision Care, West Hills, California, were studied.

INTERVENTION

Office records, referring retina specialists' records, and operative reports were reviewed for demographic information, indications for PPV, preoperative cataract severity, unplanned intraoperative events and complications, early and late postoperative complications, and postoperative visual acuities.

MAIN OUTCOME MEASURES

Complications and postoperative visual acuities were measured.

RESULTS

The mean interval from PPV to KPE was 20 months. The mean interval from KPE to final examination was 19 months. Primary indications for PPV included development of a macular epiretinal membrane, macular hole, proliferative diabetic retinopathy, retinal detachment, vitreous abscess, and vitreous hemorrhage. The degree of nuclear sclerosis in postvitrectomy eyes was greater than that in typical cataract eyes (P = 0.00002). The most common intraoperative problem was the discovery of a posterior capsule plaque. In a few cases, surgery was made difficult by unusual fluctuations in anterior chamber depth and lens zonule instability. The most common early postoperative complication was corneal edema; the most common late complication was the need for neodymium:YAG (Nd:YAG) laser posterior capsulotomy. An IOL was implanted in every eye. There were no retinal detachments. Median visual acuity improved from 20/125 before cataract surgery to 20/40 6 weeks after surgery to 20/30 on final examination. Visual acuity of 20/40 or better was achieved by 63.6% of eyes at 6 weeks and by 72.7% of eyes by final examination.

CONCLUSIONS

Kelman phacoemulsification and IOL implantation can be performed safely after PPV. Intraoperative and postoperative complications are uncommon. Pre-existing posterior segment pathology limits the ultimate improvement in visual acuity, but substantial gains in visual acuity are realized by most patients.

Incidence of idiopathic full-thickness macular holes in fellow eyes. A 5-year prospective natural history study

PURPOSE

This study aimed to determine the incidence of idiopathic full-thickness macular hole (FTMH) in normal fellow eyes and to evaluate the role of electrodiagnostic and psychophysical tests in identifying eyes at risk.

PATIENTS AND METHODS

A prospective longitudinal natural history study of a cohort of patients with unilateral holes and normal, asymptomatic fellow eyes without posterior vitreous detachment was conducted. Subjects underwent baseline examination, pattern reversal electroretinography, electro-oculography (EOG), and color contrast sensitivity (CCS) testing for protan, deutan, and tritan thresholds and were recalled for clinical examination at 18 months and 5 years.

RESULTS

At baseline, 114 patients were examined. Eighty were available for review at 18 months, of whom 6 had full-thickness macular holes develop in the fellow eye. At 5 years, 67 of the remaining 74 patients who had not developed holes at 18 months were re-examined and a further 5 were found to have holes develop in the fellow eye. A posterior vitreous detachment without hole formation had developed in 20 fellow eyes at 5 years. Although mean pattern reversal electroretinography and EOG responses were within normal limits in affected and fellow eyes at baseline, mean CCS protan, deutan, and tritan thresholds were elevated significantly in affected eyes at baseline (P = 0.0001). Unaffected fellow eyes showed normal mean protan and deutan thresholds, but significantly elevated mean tritan thresholds (P = 0.01) at baseline. Mean tritan CCS loss was, however, similar in fellow eyes in which holes later developed and in fellow eyes in which holes did not.

CONCLUSIONS

The Kaplan-Meier estimated risk of fellow eye involvement is 15.6% (range, 8.4%-22.3%; P = 0.05) at 5 years. Although electrodiagnostic and psychophysical testing was not predictive of fellow eye involvement, tritan CCS loss at baseline, in apparently normal fellow eyes, may indicate subclinical foveal dysfunction, the nature of which is unclear.

Glaucoma after macular hole surgery

OBJECTIVE

The study aimed to report incidence and to assess risk factors of postoperative glaucoma in patients with stage 3 idiopathic macular hole treated with pars plana vitrectomy, removal of posterior hyaloid membrane, and perfluoropropane gas tamponade.

DESIGN

The author performed a retrospective chart review and statistical analysis of risk factors of postoperative glaucoma by using chi-square statistics, Fisher's exact test, and logistic regression.

PARTICIPANTS

Forty consecutive patients with stage 3 idiopathic macular hole who were operated on between January 1994 and December 1995 were studied.

INTERVENTION

A pars plana vitrectomy, removal of posterior hyaloid membrane, and 14% perfluoropropane gas tamponade were done to all patients.

MAIN OUTCOME MEASURES

Preoperative and postoperative intraocular pressure measurements were performed.

RESULTS

Twenty-one (52%) of 40 patients experienced transient intraocular pressure elevation to more than 30 mmHg. Nine (22%) had pressure elevation within 2 to 4 hours, 6 (15%) in 24 hours, and 6 (15%) in 1 week after surgery. Three patients, including one with a history of preoperative ocular hypertension, required extended topical antiglaucoma medication. Factors of age, race, gender, lens status, preoperative intraocular pressure (all preoperative intraocular pressure were 25 mmHg or less), and success in closure of macular hole were not to any statistically significant degree associated with postoperative pressure elevation.

CONCLUSION

Glaucoma is a significant complication after stage 3 macular hole surgery even without adjunctive therapy. Usually happening within the first postoperative week, elevation of intraocular pressure in most cases is transient and can be controlled by medication. However, extended medication might become necessary in some cases.

Surgical management of macular holes: results using gas tamponade alone, or in combination with autologous platelet concentrate, or transforming growth factor beta 2

BACKGROUND

Vitrectomy and gas tamponade has become a recognised technique for the treatment of macular holes. In an attempt to improve the anatomic and visual success of the procedure, various adjunctive therapies--cytokines, serum, and platelets--have been employed. A consecutive series of 85 eyes which underwent macular hole surgery using gas tamponade alone, or gas tamponade with either the cytokine transforming growth factor beta 2 (TGF-beta 2) or autologous platelet concentrate is reported.

METHODS

Twenty eyes had vitrectomy and 20% SF6 gas tamponade; 15 had vitrectomy, 20% SF6 gas, and TGF-beta 2; 50 had vitrectomy, 16% C3F8 gas tamponade, and 0.1 ml of autologous platelet concentrate prepared during the procedure.

RESULTS

Anatomic success occurred in 86% of eyes, with 96% of the platelet treated group achieving closure of the macular hole. Visual acuity improved by two lines or more in 65% of the SF6 only group, 33% of those treated with TGF-beta 2 and in 74% of the platelet treated group. In the platelet treated group 40% achieved 6/12 or better and 62% achieved 6/18 or better. The best visual results were obtained in stage 2 holes.

CONCLUSION

Vitrectomy for macular holes is often of benefit and patients may recover good visual acuity, especially early in the disease process. The procedure has a number of serious complications, and the postoperative posturing requirement is difficult. Patients need to be informed of such concerns before surgery.

Long-term visual outcomes in patients with successful macular hole surgery

OBJECTIVE

The purpose of the study is to determine the long-term visual outcomes in patients undergoing successful macular hole surgery.

DESIGN

A consecutive series of eyes with an anatomically successful macular hole surgical result and at least 1 year postoperative follow-up information was identified and studied. Preoperative and postoperative visual acuities were measured in accordance with the Early Treatment Diabetic Retinopathy Study protocol.

MAIN OUTCOME MEASURES

Visual acuity, improvement of visual acuity, and rate of final visual greater than or equal to 20/40 were measured.

RESULTS

The median visual acuity increased from 20/125 before surgery to 20/50 1 year after surgery (93 eyes) and to 20/30 at 36 months after surgery (68 eyes). The trend for improvement in visual acuity after 1 year after surgery was statistically significant. The postoperative visual acuity was greater than or equal to 20/40 in 15 (17%) eyes at 3 months and 53 (78%) at 36 months. Before surgery, 12 (13%) eyes were pseudophakic, and 77 (83%) were pseudophakic at 36 months. Median visual acuity in the fellow eye was 20/32 at baseline and 20/32 at 36 months. The visual acuity in the study eye was better than in the fellow eye in 36 (39%) patients at 36 months after surgery.

CONCLUSIONS

Visual acuity in patients after anatomically successful macular hole surgery continues to improve even beyond 1 year after surgery. Although substantial improvement occurs soon after cataract extraction, further improvement in visual acuity continues for 2 years thereafter.

Combined macular hole and cataract surgery

PURPOSE

Cataract often develops after macular hole surgery, necessitating cataract surgery. We report a combination of macular hole surgery and cataract surgery on four eyes of four patients.

METHODS

Four eyes of four patients had a full-thickness stage III or IV macular hole and some degree of cataract. Combined cataract surgery with intraocular lens implant and macular hole surgery was associated with intravitreal perfluoropropane at 15% concentration and with face-down positioning for 21 days.

RESULTS

After combined cataract and macular hole surgery, the rim of subretinal fluid resolved successfully in four eyes of four patients. Twelve months after surgery, the macular hole reopened in one eye in association with the new onset of macular pucker. Best-corrected visual acuities ranged from 20/25 to 20/100 12 months after surgery, while preoperative visual acuities with best correction were 20/70 to 20/200.

CONCLUSIONS

In selected cases, a combination of cataract surgery with intraocular lens implant and macular hole surgery offers advantages. This combined approach warrants consideration.

Lens clarity after lens-sparing vitrectomy in a pediatric population

PURPOSE

The purpose of the study is to assess lens clarity after pediatric lens-sparing vitrectomy.

METHODS

The study offers a retrospective analysis of 85 eyes of 77 pediatric patients who underwent lens-sparing vitrectomy for tractional retinal detachment or opaque media, and who were observed for 10 to 55 months.

RESULTS

A total of 57 eyes maintained clear lenses at last follow-up examination. Cataract was found in 13 (15%) of the 85 eyes. Fifteen eyes (18%) had undergone lens removal as part of reoperation for progressive ocular disease.

CONCLUSION

Sixty-seven percent of pediatric lenses remained clear after lens-sparing vitrectomy.

Visual acuity and macular hole size after unsuccessful macular hole closure

PURPOSE

To evaluate the visual acuity, change in macular hole size, and change in subretinal fluid cuff size after unsuccessful macular hole closure.

METHODS

Forty-two consecutive eyes with macular hole and unsuccessful surgery for macular hole were studied. Preoperative and postoperative best-corrected visual acuities were tested according to the Early Treatment Diabetic Retinopathy Study (ETDRS) protocol, and changes were compared. Preoperative and postoperative fundus photographs were analyzed on a photograph documenter for changes in diameter of the macular hole and surrounding subretinal fluid cuff.

RESULTS

Mean visual acuity decreased from 20/133 preoperatively to 20/154 postoperatively (mean loss, 0.79 ETDRS line). Mean diameter of the macular hole enlarged 22%; mean diameter of the visible surrounding subretinal fluid cuff enlarged 36%. A decrease in best-corrected visual acuity postoperatively was correlated with better preoperative visual acuity, earlier macular hole stage, and shorter duration. Enlargement in the diameter of the macular hole and fluid cuff did not correlate with better preoperative best-corrected visual acuity, earlier macular hole stage, or shorter duration. In 23 eyes that had failed previous surgery, macular hole surgery was anatomically successful in 17 (65%) (mean improvement, 3.7 ETDRS lines; mean best-corrected final visual acuity, 20/74).

CONCLUSION

After macular hole surgery, anatomically unsuccessful closure of the hole correlates with small enlargements in the diameter of the macular hole and its surrounding subretinal fluid cuff, and with a slight decrease in visual acuity. Macular hole closure after repeat surgery improves visual acuity outcome in the majority of retreated eyes.

Clinicopathologic correlation of an untreated macular hole and a macular hole treated by vitrectomy, transforming growth factor-beta 2, and gas tamponade

PURPOSE

To study the clinicopathologic features of an untreated macular hole in the right eye and a macular hole in the left eye treated by vitrectomy, application of transforming growth factor-beta 2, and gas tamponade.

METHODS

The patient, a 73-year-old man with bilateral macular holes, was studied clinically before and after surgical treatment of the macular hole in his left eye. The patient's eyes were obtained postmortem and serially step-sectioned through the macula and optic nerve head for electron microscopy.

RESULTS

Examination of 1-micron thick plastic-embedded sections through the macula of the right eye disclosed a 0.6-mm macular hole with rounded gliotic margins, a thin epiretinal membrane, and parafoveal cystic changes. Examination of 1-micron thick plastic-embedded sections through the macula of the left eye disclosed a 0.25-mm defect in the fovea, which was bridged by glial cells. The glial cells were continuous with a thin hypocellular epiretinal membrane without contraction features on both sides of the defect. The ultrastructural features of the glial cells were consistent with Mueller cells.

CONCLUSIONS

Treatment of a macular hole with vitrectomy, transforming growth factor-beta 2, and gas tamponade was followed by complete closure of the macular hole by Mueller cell proliferation.

Visual field defects after macular hole surgery

PURPOSE

To describe a group of patients with dense visual field defects following macular hole surgery.

METHODS

Nine (7%) of 125 patients reviewed noted onset of dense visual field defects following uncomplicated vitrectomy with gas-fluid exchange for the treatment of macular hole. Patient records were reviewed to investigate the etiology of these defects.

RESULTS

Eight (89%) of nine eyes that had surgery for macular hole developed dense, wedge-shaped visual field defects in the temporal periphery. One eye had an inferonasal wedge-shaped defect extending to fixation. Seven (78%) of nine eyes had generalized or focal narrowing of the retinal arteriole extending into the area of retina corresponding to the visual field defect, and five (56%) of nine eyes developed mild to moderate segmental nasal optic disk pallor. Postoperative fluorescein angiography disclosed one eye with delayed filling of the retinal arteriole extending into the area of retina corresponding to the visual field defect. Vitrectomy specimens showed no evidence of nerve fiber layer or internal limiting membrane in eight (89%) of nine eyes.

CONCLUSIONS

Visual field defects can occur following vitrectomy and gas-fluid exchange for macular hole. The most common visual field defect is dense and wedge-shaped and involves the temporal visual field. Although unclear, the etiology may involve trauma to the peripapillary retinal vasculature or nerve fiber layer during elevation of the posterior hyaloid or during aspiration at the time of air-fluid exchange, followed by compression and occlusion of the retinal peripapillary vessels during gas tamponade.

Vitrectomy, fluid-gas exchange and transforming growth factor--beta-2 for the treatment of traumatic macular holes

PURPOSE

To evaluate whether vitreous surgery is successful in closing full-thickness traumatic macular holes and whether there is subsequent improvement in visual acuity.

METHODS

Twelve eyes from 12 consecutive patients with traumatic macular holes underwent vitrectomy, fluid-gas exchange and instillation of bovine or recombinant transforming growth factor (TGF)-beta-2. Three of four eyes underwent repeat vitrectomy with TGF-beta-2 after the initial procedure failed to close the macular hole.

RESULTS

Eleven (92%) of 12 eyes had closure of the macular hole. Follow-up ranged from 3 to 33 months. Visual acuity improved by 2 or more lines in 8 (67%) of 12 eyes. Six (50%) of 12 eyes improved to 20/40 or better. All 3 eyes that underwent reoperation had successful closure of the macular hole and achieved 2 or more lines of visual improvement.

CONCLUSION

Treatment of full-thickness traumatic macular holes with vitrectomy, fluid-gas exchange, and TGF-beta-2 may result in successful anatomic closure and visual improvement.

Nuclear sclerotic cataract after vitrectomy in patients younger than 50 years of age

PURPOSE

To evaluate the occurrence of cataract formation after pars plana vitrectomy and gas-fluid exchange in patients younger than 50 years of age.

METHODS

Twenty-eight patients younger than 50 years of age with bilaterally symmetric crystalline lenses underwent pars plana vitrectomy and gas-fluid exchange in one eye. Postoperatively, lens photographs were used to assess any asymmetry between the surgical and nonsurgical eye. Lens photographs were graded by three independent masked observers using the Lens Opacities Classification System III (LOCS III). Significant cataract progression was defined as either cataract extraction in the surgical eye or a greater than a 0.9 LOCS III unit difference in lens opacity between the surgical and nonsurgical eye. Results were compared with 28 patients older than 50 years of age who had undergone identical surgery.

RESULTS

In only 7% of patients younger than 50 years of age (mean age, 36.5 years; range, 16-47 years) did significant lens opacity develop in the surgical eye compared with the nonsurgical eye during the follow-up period (mean follow-up, 25.4 months; range, 12-43 months). Of patients older than 50 years of age (mean age, 68.2 years; range, 51-85 years), 79% developed significant lens opacity in the surgical eye compared with the nonsurgical eye during the follow-up period (mean follow-up 27.3 months; range, 12-49 months). The difference in cataract progression between patients younger than 50 years of age and patients older than 50 years of age was statistically significant (P < 0.0000001).

CONCLUSION

Pars plana vitrectomy with gas-fluid exchange is minimally cataractogenic within the first few years in patients younger than 50 years of age.