Comparison of anatomical and visual outcomes of macular hole surgery in patients with high myopia vs. non-high myopia: a case-control study using optical coherence tomography

Lamellar macular hole in highly myopic eyes and insights into its development, evolution, and treatment: a mini-review

Lamellar macular holes (LMHs) are a manifestation of myopic tractional maculopathy (MTM). Owing to the complex and multidirectional traction force in the elongated eyeball, the clinical features, development, evolution, and treatment algorithms of LMH in highly myopic eyes may differ from those of idiopathic LMH or MTM in general. This review aimed to specifically explore the LMHs in highly myopic eyes. Several developmental processes of LMH and their association with macular retinoschisis have been demonstrated, with the tractional component identified in all processes. Epiretinal proliferation was more prevalent and more extensive in LMHs in highly myopic eyes than in idiopathic LMHs. LMHs in highly myopic eyes may remain stable or progress to foveal detachment and full-thickness macular hole with or without retinal detachment. The predictive factors associated with disease progression were summarized to facilitate monitoring and guide surgical intervention. The treatment of LMHs in highly myopic eyes was based on an algorithm for treating myopic tractional maculopathy, including gas tamponade, pars plana vitrectomy, macular buckling, and a combination of vitrectomy and macular buckling. New internal limiting membrane (ILM) manipulation techniques such as fovea-sparing ILM peeling or fovea-sparing ILM peeling combined with ILM flap insertion could reduce the risk of developing iatrogenic full-thickness macular holes postoperatively. Further research should focus on the treatment of LMH in highly myopic eyes.

Inverted flap technique versus internal limiting membrane insertion for macular hole in eyes with extremely high myopia

BACKGROUND

To compare the surgical outcomes of the inverted internal limiting membrane (ILM) flap technique and ILM insertion for macular hole (MH) without retinal detachment in eyes with extremely high myopia.

METHODS

In this retrospective study, we analyzed 22 eyes with an axial length ≥ 30.0 mm that had underwent MH surgery between April 2015 and August 2021. The surgical procedures involved either an inverted ILM flap or ILM insertion. The outcomes were compared between the two techniques. Closure of the MH was confirmed by optical coherence tomography (OCT). The best-corrected visual acuity (BCVA) was measured before and after surgery. Associated complications were documented.

RESULTS

The median of axial length was 30.64 mm (range, 30.0-34.42). The MH closed in 100% (22/22) eyes and did not recur with a median follow-up of 12.5 months. For the inverted ILM flap technique, the median BCVA improved significantly from 0.80 logarithm of the minimum angle of resolution (logMAR) (range, 0.40-2.00) before surgery to 0.70 logMAR (range, 0.09-1.52) after surgery (p = 0.002). In addition, the median of final BCVA was better for the inverted ILM flap than ILM insertion (0.7 logMAR V.S. 1.00 logMAR; p = 0.016).

CONCLUSIONS

In eyes with extremely high myopia, despite comparable effects on MH closure for both ILM insertion and the inverted ILM flap, the later technique achieved significantly better visual outcomes.

Biological ultrathin amniotic membrane flap to close refractory macular holes associated with high myopia

PURPOSE

To propose an ultrathin biological amniotic membrane (btAM) thinner than 10 μm as the graft to treat highly myopic macular holes (MH).

METHODS

This pilot study included 14 patients affected by refractory macular holes associated with high myopia. btAM was used as a bandage covering the holes. The best-corrected visual acuity (BCVA), fundus photography, and optical coherence tomography (OCT) before and after surgery were compared.

RESULTS

The mean MH size was 865.93 ± 371.72 μm and all the MHs achieved anatomical closure. The btAM located centrally and fully on MHs from fundus photography yet no obvious visual masking was complained. The average BCVA 1 month, 3, and 6 months after surgery were 0.95 ± 0.24, 0.92 ± 0.23, 0.92 ± 0.23 logMAR, respectively, improved significantly compared to pre-operative BCVA (1.24 ± 0.42 logMAR, all P < 0.05). Ten out of 14 (71.4%) exhibited 2C closure patterns (formally closed and no bare RPE) on OCT.

CONCLUSION

The btAM thinner showed a favorable anatomical success with less risk of parafoveal atrophy or iatrogenic injuries and shortened the dissolving time.

A three-step approach to close refractory persistent macular holes: a releasing-closing-tapping approach

PURPOSE

The aim of this study was to assess the efficacy and safety of a novel releasing-closing-tapping approach in the treatment of persistent macular holes (PMHs) after initial surgery with internal limiting membrane (ILM) peeling.

METHODS

We retrospectively analyzed patients with PMHs after initial surgery with ILM peeling who were treated with a novel releasing-closing-tapping approach. After repeated pars plana vitrectomy (PPV), the surgeon effectively released the adhesion between the edges and retinal pigment epithelium (RPE) by gently scraping the retinal neuroepithelium. Then, the hole was converted into a transverse slit, and the edges were gently tapped flat so that they attached to the RPE, and no space was left under the edges. Finally, air tamponade was carried out. The primary outcome measures included MH closure and the change in best-corrected visual acuity (BCVA) from preoperatively to postoperatively.

RESULTS

The study included 11 PMH patients with a mean age of 63.82 ± 3.31 years. The mean minimum linear diameter of PMHs was 666.3 ± 208.1 μm, and the mean basal diameter was 1547.2 ± 351.8 μm. MH closure was achieved in 90.9% (10/11) of eyes, with significant improvement of visual acuity from 1.19 ± 0.30 logMAR to 0.65 ± 0.29 logMAR postoperatively.

CONCLUSION

The releasing-closing-tapping approach with repeated PPV is a simple, effective, and safe surgical procedure for refractory PMHs after initial surgery with ILM peeling that can significantly improve the visual outcome and achieve a high surgical success rate.

The effect comparison of ILM flap and traditional ILM peeling in iMH

Purpose

To compare the changes in anatomical structure and visual function after idiopathic macular hole (iMH) treatment with internal limiting membrane (ILM) peeling and inverted ILM flap and determine the value of the inverted ILM flap for the treatment of iMH.

Methods

Forty-nine patients with iMH (49 eyes) were included in this study and followed up for 1 year (12 months) after treatment with inverted ILM flap and ILM peeling respectively. The main foveal parameters assessed included the preoperative minimum diameter (MD), intraoperative residual fragments, and postoperative ELM reconstruction. Visual function was assessed using best-corrected visual acuity.

Results

The hole closure rate was 100% for 49 patients; 15 patients were treated with the inverted ILM flap, and 34 patients underwent ILM peeling. There were no differences between the postoperative best-corrected visual acuities and the rates of ELM reconstruction for the flap and peeling groups with different MDs. In the flap group, ELM reconstruction was associated with the preoperative MD, presence of an ILM flap, and hyperreflective changes in the inner retina 1 month after surgery. In the peeling group, ELM reconstruction was associated with the preoperative MD, intraoperative residual fragments at the hole edge, and hyperreflective changes in the inner retina.

Conclusion

The inverted ILM flap and the ILM Peeling were both able to obtain high closure rate. However, the inverted ILM flap showed no obvious advantages related to anatomical morphology and visual function over ILM peeling.

Proof-of-Concept Analysis of a Deep Learning Model to Conduct Automated Segmentation of OCT Images for Macular Hole Volume

BACKGROUND AND OBJECTIVE

To determine whether an automated artificial intelligence (AI) model could assess macular hole (MH) volume on swept-source optical coherence tomography (OCT) images.

PATIENTS AND METHODS

This was a proof-of-concept consecutive case series. Patients with an idiopathic full-thickness MH undergoing pars plana vitrectomy surgery with 1 year of follow-up were considered for inclusion. MHs were manually graded by a vitreoretinal surgeon from preoperative OCT images to delineate MH volume. This information was used to train a fully three-dimensional convolutional neural network for automatic segmentation. The main outcome was the correlation of manual MH volume to automated volume segmentation.

RESULTS

The correlation between manual and automated MH volume was R² = 0.94 (n = 24). Automated MH volume demonstrated a higher correlation to change in visual acuity from preoperative to the postoperative 1-year time point compared with the minimum linear diameter (volume: R² = 0.53; minimum linear diameter: R² = 0.39).

CONCLUSION

MH automated volume segmentation on OCT imaging demonstrated high correlation to manual MH volume measurements. [Ophthalmic Surg Lasers Imaging Retina. 2022;53(4):208-214.].

Inverted internal limiting membrane flap technique for retinal detachment due to macular holes in high myopia with axial length ≥ 30 mm

To compare the efficacy of internal limiting membrane (ILM) flap covering to that of ILM flap insertion for the treatment of macular hole retinal detachment (MHRD) in highly myopic eyes with axial length (AL) ≥ 30 mm. We retrospectively analysed the medical records of 48 MHRD patients with high myopia (AL ≥ 30 mm). According to different surgical methods, the patients were divided into a covering group (23 eyes) and an insertion group (25 eyes). The rate of retinal reattachment and MH closure were compared between the two groups, and the related factors affecting the initial anatomical results were analysed. After primary vitrectomy and single silicone oil removal, there were 18 eyes (78.3%) in the covering group, and 20 eyes (80.0%) in the insertion group had retinal reattachment (P = 1.000). Moreover, 16 eyes (69.6%) in the covering group and 17 eyes (68.0%) in the insertion group had their MHs sealed (P = 0.907). The best-corrected visual acuity (BCVA) at 12 months and the improvement in BCVA postoperatively in the two groups were not statistically significant (P = 0.543, 0.955). Logistic regression analysis showed that elongated AL (OR = 1.844, 95% CI 1.037–3.280, P = 0.037) and higher choroidal atrophy (OR = 2.986, 95% CI 1.011–8.821, P = 0.048) were risk factors affecting initial anatomical success. For extremely high-myopia MHRD with AL ≥ 30 mm, ILM flap covering and insertion can both effectively seal the MH and promote retinal reattachment, but the visual function improvement may still be limited. The longer the AL and the higher the choroidal atrophy, the greater is the risk of initial anatomical failure.

LENS CAPSULAR FLAP TRANSPLANTATION AS PRIMARY TREATMENT FOR CLOSURE OF LARGE MACULAR HOLES

PURPOSE

To report the long-term outcomes of lens capsular flap transplantation (LCFT) as initial treatment for large macular holes (MHs).

METHODS

Thirteen consecutive eyes with large MHs who received LCFT as primary treatment were reviewed retrospectively. All enrolled eyes underwent standard 23-gauge vitrectomy, internal limiting membrane peeling, LCFT, and 15% perfluoropropane tamponade. Autologous whole blood was applied in selected eyes to make the LCT intact. A face-down position maintained for 2 weeks postoperatively. Data including demographic information, medical history, anatomical and functional outcomes, and complications were recorded.

RESULTS

The mean preoperative MHs diameter was 979.42 ± 388.28 µm. Eight eyes received autologous LCFT, and the other five eyes received allogenic LCFT. Whole blood was applied in seven eyes. The mean follow-up duration was 19.57 ± 6.24 months (range: 12.0-32.2 months). The macular hole was successfully closed in all cases (13/13). The median best-corrected visual acuity improved from 1.76 (interquartile range, 1.23-1.91) logarithm of the minimum angle of resolution (median Snellen acuity: 20/1,150) preoperatively to 1.16 ± 0.47 logarithm of the minimum angle of resolution (mean Snellen acuity: 20/290) (P < 0.01) at the last visit. No severe complications were noted.

CONCLUSION

Lens capsular flap transplantation may help to improve the closure rate and visual outcomes in large MHs, which could be an alternative method as primary treatment for large MHs.

Three cases of macular hole that occurred in inferior scleral staphyloma associated with tilted disc syndrome: a case series

Background

The objective is to examine the clinical characteristics of three patients with macular hole that occurred in inferior posterior staphyloma associated with tilted disc syndrome.

Case presentations

This study involved three eyes of three Japanese female patients (mean age 76.0 years, range 73–84 years) with macular hole occurring in inferior posterior staphyloma associated with tilted disc syndrome. One of the three eyes was slightly myopic, while the other two eyes were highly myopic. In all three eyes, the macular hole was found to be located in or near the margin of the inferior posterior staphyloma. In one eye, the extent of retinoschisis was rather broad in the margin of the macular hole, and another eye had a history of treatment for choroidal neovascularization. As surgical treatment, the internal limiting membrane in areas surrounding the macular hole was detached after producing artificial posterior vitreous detachment, and a gas tamponade was performed. It was found during surgery that the extensibility of the retina in the margin of the MH was decreased in the three eyes as compared with a usual macular hole. Although the macular hole was successfully closed in all three cases post surgery, the layer structure of the central retina was poorly repaired in all three cases and choroidal neovascularization remained in one case. In all three cases, corrected visual acuity remained at 0.3–0.5 post surgery.

Conclusions

Our findings showed poor improvement of visual acuity in all three cases post surgery, even if closure of the macular hole is achieved, thus suggesting that in cases of macular hole associated with tilted disc syndrome and inferior posterior staphyloma, the presence of macular dysfunction existing prior to the onset of macular hole affects visual prognosis.

Update on surgical management of complex macular holes: a review

Modern surgical interventions effectively treat macular holes (MHs) more than 90%. Current surgical treatment for MHs is pars plana vitrectomy with epiretinal membrane, internal limiting membrane (ILM) peeling, gas endotamponade, and prone posturing postoperatively. However, a small subset of MHs imposes challenges to surgeons and frustrations on patients. A narrative review was performed on the surgical treatment of challenging MHs including large and extra-large MHs, myopic MHs with or without retinal detachment, and chronic and refractory MHs. There are robust data supporting inverted ILM flap as the first-line treatment for large idiopathic MHs and certain secondary MHs including myopic MHs. In addition, several studies had shown that ILM flap manipulations in combination with surgical adjuncts increase surgical success, especially in difficult MHs. Even in eyes with limited ILM, surgical options included autologous retinal graft, human amniotic membrane, and creation of a distal ILM flap that can assist in MH closure even though the functional outcome may be affected by the MH chronicity. Despite relative success anatomically and visually after each technique, most techniques require a long-term study to analyze their safety profile and to establish any morphological changes of the MH plug in the closed MHs.

Factors Associated with Anatomic Failure and Hole Reopening after Macular Hole Surgery

A macular hole (MH), particularly an idiopathic macular hole (IMH), is a common cause of central vision loss. Risk factors for nonidiopathic MH include high myopia, cystoid macular edema, inflammation, and trauma. MH is primarily diagnosed using slit-lamp microscopy and optical coherence tomography (OCT). Half of the patients with stage I MHs are treated conservatively and may show spontaneous resolution. The main treatment methods for MHs currently include vitrectomy and stripping of the internal limiting membrane (ILM). However, in some patients, surgery does not lead to anatomical closure. In this review, we summarize the factors influencing the anatomical closure of MHs and analyze the potential underlying mechanisms.

HUMAN AMNIOTIC MEMBRANE TO CLOSE RECURRENT, HIGH MYOPIC MACULAR HOLES IN PATHOLOGIC MYOPIA WITH AXIAL LENGTH OF ≥30 mm

PURPOSE

To assess the effectiveness of the human amniotic membrane plug for recurrent high myopic macular hole (MH) that already underwent pars plana vitrectomy with internal limiting membrane peeling and gas endotamponade.

METHODS

Sixteen eyes of 16 patients with recurrent high myopic MH were enrolled. A 23-gauge pars plana vitrectomy was performed. Human amniotic membrane plugs were implanted under the neuroretina inside the MH. Twenty percent sulfur hexafluoride or air was used as endotamponades. The patients were instructed to maintain facedown position for 5 days after surgery.

RESULTS

Optical coherence tomography examinations showed that the MHs closed in 15 of the 16 patients (93.75%) 2 weeks after one surgical intervention, and in 100% of patients after second intervention. Mean best-corrected visual acuity improved from 1 logarithm of the minimum angle of resolution (20/200) to 0.67 logarithm of the minimum angle of resolution (20/100) 6 months after surgery. Best-corrected visual acuity remained stable during the 12-month follow-up. One patient had human amniotic membrane plug dislocation after gas absorption that needed a second intervention with new AM plug implantation. No adverse events were reported during the 12-month follow-up.

CONCLUSION

The first case series of recurrent high myopic MH was reported, assessing the effectiveness of the human amniotic membrane plug to close recurrent MHs in pathologic myopia. All the cases were successful with encouraging best-corrected visual acuity recovery.

Flap technique-assisted surgeries for advanced retinitis pigmentosa complicated with macular hole: a case report and literature review

Background

Full-thickness macular hole (FTMH) is a rare complication in retinitis pigmentosa (RP) patients and may increase intraoperative challenges. Furthermore, lens capsular flap transplantation and inverted internal limiting membrane (ILM) flap were reported to close complicated FTMH successfully. Here, we present a case of bilateral advanced RP complicated by a FTMH treated with a novel lens capsular flap transplantation and inverted internal limiting membrane flap.

Case presentation

A 46-year-old presented to our hospital with a complaint of progressively blurred vision and metamorphopsia in both eyes. Spectral-domain optical coherence tomography revealed a FTMH with retinoschisis in the right eye and another FTMH in the left eye. ILM peeling with inverted ILM flap technique was performed on the right eye and ILM peeling with anterior lens capsular flap technique was performed on the left eye. Post-operative follow-up showed successful closure of the FTMH and improved vision in both eyes.

Conclusions

In our present case, flap-assisted techniques for retinitis pigmentosa with macular hole result in excellent visual and anatomic outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-02082-3.

Progress in the use of plasma rich in growth factors in ophthalmology: from ocular surface to ocular fundus

Introduction: The use of blood derivatives and especially Plasma rich in growth factors (PRGF), for regenerative purposes has been a common trend along the last decades in the field of oral surgery, dermatology, orthopedics, and more recently in ophthalmology.Areas covered: PRGF is a type of platelet-rich plasma that is being explored for the treatment of ocular injuries. The present review article highlights 50 ophthalmology-related publications about the application of PRGF in the treatment of acute and chronic pathologies in ophthalmology as well as most relevant challenges and future prospects.Expert opinion: PRGF technology provides a wide range of formulations that can be used therapeutically in many different acute and chronic ocular pathologies. In addition to eye drops enriched with autologous growth factors, PRGF enables the preparation of both immunologically safe and fibrin-based formulations. Recent advances in the field have promoted PRGF storage for 12 months under freezing conditions, its daily use for 7 days at room temperature and the freeze-dried formulation. The thermally treated immunosafe formulation has shown promising clinical results for the treatment of several diseases such as Sjögren syndrome, graft versus host disease or cicatrizing conjunctivitis. In addition, several fibrin formulations have been preclinically evaluated and clinically incorporated as an adjuvant to ocular surface or glaucoma surgeries, dermal fat graft procedures, limbal stem cell expansion and retinal surgeries. The present review explores the latest scientific and clinical data, current challenges, and main prospects of this technology for the treatment of several ocular injuries.

Current management strategies for atypical macular holes

This review evaluates the current surgical management options for refractory and atypical macular holes (MH) and proposes a treatment paradigm for approaching complex cases. A review of literature was performed to deliver a thorough discussion of the epidemiology and pathophysiology of MH as well as the historic evolution of surgical management strategies. With this context established, an update on recent surgical advances for management of large, chronic, and highly myopic MH is provided. New small MH may be adequately treated with pars plana vitrectomy, while those ≥300 μm should undergo internal limiting membrane (ILM) peel. For MH ≥400 μm with risk factors for failure, primary intervention should involve creation of an ILM flap and various methods of flap creation are discussed. For very large MH ≥700 μm or in refractory cases, autologous retinal transplants and other recently proposed procedures should be considered. While typical MHs enjoy high initial surgical success rates, atypical and refractory MH require additional intraoperative and postoperative considerations to maximize surgical success and optimize vision. With many techniques at the surgeon's disposal, patient selection becomes critical to improving outcomes.

Changes in each retinal layer and ellipsoid zone recovery after full-thickness macular hole surgery

To analyze the changes in each retinal layer and the recovery of the ellipsoid zone (EZ) after full-thickness macular hole (FTMH) surgery. Patients who underwent surgery for FTMH were included. Spectral-domain optical coherence tomography (SD-OCT) was performed preoperatively and postoperatively at 1, 3, 6, 9, and 12 months. A total of 32 eyes were enrolled. Ganglion cell layer, inner plexiform layer, and inner nuclear layer showed significant reductions over time after surgery (P = 0.020, P = 0.001, and P = 0.001, respectively), but were significantly thicker than those of fellow eyes at 12 months postoperatively. The average recovery duration of the external limiting membrane (ELM), outer nuclear layer (ONL), and EZ was 1.5, 2.1, and 6.1 months, respectively. Baseline best-corrected visual acuity (BCVA) (P = 0.003), minimum linear diameter (MLD) (P = 0.025), recovery of EZ (P = 0.008), and IRL thickness (P < 0.001) were significant factors associated with changes in the BCVA. Additionally, axial length (P < 0.001), MLD (P = 0.020), and IRL thickness (P = 0.001) showed significant results associated with EZ recovery. The IRL gradually became thinner after FTMH surgery but was still thicker than that of the fellow eye at 12 months postoperatively. The recovery of ELM and ONL may be a prerequisite for the EZ recovery. The BCVA change was affected by baseline BCVA, MLD, recovery of EZ, and IRL thickness. Additionally, axial length, MLD, and IRL thickness were significantly associated with EZ recovery.

INTRAOPERATIVE AND POSTOPERATIVE MONITORING OF AUTOLOGOUS NEUROSENSORY RETINAL FLAP TRANSPLANTATION FOR A REFRACTORY MACULAR HOLE ASSOCIATED WITH HIGH MYOPIA

PURPOSE

To describe the intraoperative and postoperative morphological and functional outcomes after autologous neurosensory retinal flap transplantation (ART) for a high myopia-related refractory macular hole (MH).

METHODS

This prospective interventional study enrolled five eyes of five patients (age range 54-84 years) with highly myopic refractory MHs who underwent ART. All cases were evaluated with intraoperative optical coherence tomography and postoperative optical coherence tomography, optical coherence tomography angiography, and microperimetry for at least 6 months postoperatively.

RESULTS

Intraoperatively, the MH was covered by an ART flap with a persistent small subretinal space that was filled with the ART flap after 4 days to 6 days. Optical coherence tomography discriminated the original from the transplanted retina. The mean basal diameter of the original MH decreased from 1,504 ± 684 µm preoperatively to 1,111 ± 356 µm postoperatively. The best-corrected visual acuity improved in two cases, was stable in two cases, and deteriorated in one case. Microperimetry demonstrated no obvious postoperative changes in the fixation points and the absolute scotoma corresponding to the base of MHs with chorioretinal atrophy. In two eyes, choroidal neovascularization developed beneath the transplanted retinas.

CONCLUSION

Transplanted tissue was in a fixed position by 1 week postoperatively with a decreased diameter of the original MH. Postoperative fixation points were on the original retina at the MH edge. Because choroidal neovascularization may develop, detailed monitoring is required.

Long-Term Outcomes of Macular Hole Repair with Triamcinolone Acetonide Visualization

Purpose

To evaluate the long-term anatomic and visual outcomes of macular hole (MH) repair utilizing triamcinolone acetonide (TA) visualization of the internal limiting membrane (ILM) treated at a tertiary care retina practice.

Methods

Retrospective chart review of eyes undergoing MH repair with ILM peel utilizing TA visualization followed by gas tamponade and facedown positioning between 2014 and 2020. Pre- and post-operative visual acuity (VA), IOP, and anatomic closure based on optical coherence tomography were documented.

Results

Seventy-eight eyes were followed for 2.3±0.2 years after primary repair with anatomic closure in 73 (94%) eyes at their final visit and excluding eyes with pathologic myopia, 97%, and for stage 2 and small MHs, 100%. In all eyes, VA significantly improved from 0.97±0.04 (Snellen: 20/187) to 0.66±0.06 (20/91) logMAR (p < 0.0001). There were 16 eyes with 4 years of follow-up, 10 (63%) eyes achieving a VA ≥20/30 at that follow-up visit. Stage 2 and 3 MHs had significantly greater improvements in VA than Stage 4 MHs, −0.46 ± 0.06 versus −0.11 ± 0.11 logMAR (p = 0.021). Of the 13 (17%) eyes with recurrent MHs, 6 (46%) had pathologic myopia and 8 (61.5%) had associated cystoid macular edema. Cataract progression was reported in 52 (96%) phakic eyes and 2 eyes required Ahmed valve placement for management of pre-existing glaucoma.

Conclusion

Long-term results of MH repair with TA for ILM visualization demonstrate that it is safe and effective. Visual acuity continued to improve throughout the follow-up. Pre-existing glaucoma may progress and recurrence is associated with pathologic myopia and macular edema.

Anatomical and Functional Outcomes in Eyes with Idiopathic Macular Holes that Underwent Surgery Using the Inverted Internal Limiting Membrane (ILM) Flap Technique Versus the Conventional ILM Peeling Technique

INTRODUCTION

To evaluate the anatomical and functional outcomes of the inverted internal limiting membrane (ILM) flap technique (IFT) in macular holes (MHs), especially in MHs with a macular hole index (MHI) < 0.5.

METHODS

This was a retrospective comparative study. Patients with idiopathic MHs who underwent either the IFT or conventional ILM peeling (CP) were investigated. The main outcomes included the MH closure rate, best corrected visual acuity (BCVA), and recovery rates of the external limiting membrane (ELM) and ellipsoid zone (EZ) at 1, 3, and 6 months postoperatively.

RESULTS

Forty-eight eyes of 48 patients who underwent the IFT (n = 29, Group A) or CP (n = 19, Group B) were included. The mean minimal diameter was 522.00 ± 208.08 µm. The closure rate was 100.0% in Group A and 94.7% in Group B (P = 0.396). The mean BCVA and EZ and ELM recovery rates improved significantly in both groups postoperatively. No significant differences in BCVA or the EZ or ELM recovery rates were found between the two groups. Of the 39 eyes whose MHI was < 0.5, 25 underwent the IFT, and 14 underwent CP. Comparing the results of the closure rate, BCVA and recovery rates of the EZ and ELM between groups were similar to those in 48 eyes.

CONCLUSION

Both the IFT and CP can achieve a high closure rate, with no significant difference in ordinary idiopathic MHs. The IFT does not seem to achieve better anatomical and functional outcomes than CP. The IFT should be used conservatively in ordinary non-refractory MH surgery.

LONG-TERM SURGICAL OUTCOMES OF LENS CAPSULAR FLAP TRANSPLANTATION IN THE MANAGEMENT OF REFRACTORY MACULAR HOLE

PURPOSE

To report long-term surgical outcomes of autologous and allogenic lens capsular flap transplantation (LCFT) in refractory macular hole (MH) treatment.

METHODS

Fifty consecutive eyes with refractory MH who received LCFT were reviewed retrospectively. Twelve eyes underwent autologous LCFT (LCF obtained from the same eye in 7 eyes and the fellow eye in 5 eyes) and 38 eyes with allogenic LCFT. All eyes underwent complete vitrectomy, internal limiting membrane peeling if not peeled, LCF transplantation, and 15% perfluoropropane tamponade. Simultaneous autologus whole-blood application was applied in 31 eyes to reduce LCF dislocation. The patients maintained a facedown position for 2 weeks postoperatively. Demographic information, functional results, and structural changes were evaluated.

RESULTS

The mean preoperative MH diameter was 1,102.00 µm ± 561.63 µm. The mean follow-up duration was 18.50 months ± 6.05 months (range, 12.0-38.9 months). The MH was completely closed in 48 eyes (96.00%) (18 eyes receiving autologous LCFT and 30 receiving allogenic LCFT). There are no differences of age, previous MH surgery times, MH diameter, preoperative and postoperative best-corrected visual acuity, and closure rate between the subgroups. The median visual acuity improved from 1.78 (interquartile range, 1.28-1.85) logarithm of the minimum angle of resolution (median Snellen acuity: 20/1,200) preoperatively to 1.00 (interquartile range, 0.90-1.70) logarithm of the minimum angle of resolution (median Snellen acuity: 20/200) (P < 0.01) in all patients.

CONCLUSION

Both autologous and allogenic LCFT application may provide anatomical and visual improvements in refractory MH cases. Blood application can be applied in selected cases to reduce LCF dislocation. LCFT can be performed as first-line treatment for refractory MHs.

Inverted ILM Flap Technique in Idiopathic Full-Thickness Macular Hole Surgery: Functional Outcomes and Their Correlation with Morphologic Findings

Objectives

The inverted internal limiting membrane (ILM) flap technique has been shown to increase the success rate in large full-thickness macular holes (FTMHs) and in FTMHs associated with high myopia. The aim of our study was to confirm the efficacy and safety of inverted ILM flap technique in idiopathic FTMHs independent of their dimensions and to assess functional outcomes and their correlation to morphologic findings.

Methods

Sixteen consecutive patients affected by idiopathic FTMH were enrolled in this prospective study. The preoperative mean (±SD) diameter of the FTMH was 422 (±106) µm. All patients underwent vitrectomy and ILM peeling with inverted ILM flap. At 1-, 3-, and 6-month postoperative visits, visual acuity measurement, indirect ophthalmoscopy, and microperimetry were performed, and the foveal contour and the integrity of the ellipsoid zone (EZ) and external limiting membrane (ELM) were investigated using spectral domain optical coherence tomography (SD-OCT).

Results

At six months postoperatively, 15 out of 16 (93.75%) patients obtained FTMH closure. The mean best corrected visual acuity (BCVA) improved from 1.1 LogMAR to 0.3 LogMAR, and the mean retinal sensitivity (MS) improved from 7.2 to 23.4 dB. ELM defects were evident in 1 out of 16 (6.25%) eyes, and EZ defects were detected in 2 out of 16 (12,50%) eyes. A statistically significant relationship was observed between BCVA, MS, and EZ reconstitution at each follow-up visit.

Conclusions

Results confirm that the inverted ILM flap technique is a safe and effective option for FTMH treatment and show a strong correlation between higher BCVAs and MSs and EZ reconstitution after surgery.

Autologous full-thickness retinal transplant for refractory large macular holes

Background

Despite the constant refinement of techniques and surgical aids, extremely large and refractory macular holes continue to have poor surgical outcomes with the current standard of care. The objective of the present study is to assess the anatomical and functional outcomes, as well as the structural change through time, of the optical coherence tomography of patients with refractory macular holes treated with a full-thickness autologous retinal transplant.

Methods

Prospective, case series. We include patients with a clinical diagnosis of refractory macular holes with a minimum diameter of at least 500 µm. All the patients had a comprehensive ophthalmological examination, which included a best-corrected visual acuity assessment, fundus examination, and optical coherence analysis. All the patients underwent a 23-gauge pars plana vitrectomy with a full-thickness retinal transplant and silicone oil tamponade (5000 cs<). Follow-up was done at 1, 3, 6, and 12 months. Statistical analysis was done with a test for repeated measurements and Bonferroni correction, with an alpha value of 0.05 for statistical significance and a Mann-Whitney U test for nonparametric continuous variables.

Results

We enrolled 13 eyes from 13 patients (mean age: 67.15 years) with refractory macular holes, with a mean base diameter of 1615.38 ± 689.19 µm and a minimum diameter of 964.08 ± 709.77 µm. The closure rate after 12 months of follow-up was 76.92%. Six patients with a closed macular hole at the end of the follow-up had complete recovery of the myoid/ellipsoid layer. The remaining showed a 44.9% reduction of the initial gap. Most patients formed a pseudofovea and normalization of the internal retinal layers. Despite a positive trend toward visual recovery (p = 0.034), after the correction of the alpha value, the change lost its statistical significance. During follow-up, one patient developed mild proliferative vitreoretinopathy and epiretinal membrane without anatomical or functional consequences.

Conclusions

An autologous full-thickness retinal transplant may improve the anatomical and structural outcome of patients with refractory macular holes. The full safety profile of this new technique is still unknown. More studies are needed in order to assess functional changes through time.

Pre- and post-operative differences between genders in idiopathic macular holes

BACKGROUND

To compare idiopathic macular holes (IMHs) between male and female before and after surgery.

METHODS

Patients with IMHs of stage 3 and stage 4 who underwent 23-gauge vitrectomy were retrospectively enrolled. Pre-operative clinical features like age of onset, and best-corrected visual acuity (BCVA) were reviewed. Optical coherence tomography parameters including minimum linear diameter (MLD), central macular thickness and some other indexes were measured and calculated. Main surgical outcomes included the primary closure rate, the highest BCVA during follow-up, and the recovery duration. All the metrics mentioned above were compared between genders with appropriate statistical methods.

RESULTS

A total of 298 eyes from 280 patients (male: 51; female: 229) were enrolled. Compared with men, women demonstrated a significantly higher ratio of stage3/stage4 (P = 0.045), larger horizontal MLD (P = 0.009), but similar surgical outcomes except for a relatively longer recovery duration (P = 0.024). For stage 3 IMHs, women exhibited significantly younger age of onset (P = 0.023), larger MLD (P = 0.003), and smaller height of the hole (P = 0.029). However, for stage 4 IMHs, all the pre- and post-operative metrics showed no differences between genders.

CONCLUSIONS

Female IMHs seem to demonstrate an earlier age of onset and larger size of hole, especially in IMHs of stage 3. However, these differences, which may owe to normal gender-related variations, have limited influence on the surgical outcomes.

Comparisons of surgical outcomes after epiretinal membrane peeling in the myopic eyes with long to that with normal axial length

PURPOSE

To compare the outcomes of vitrectomy with removal of an idiopathic epiretinal membrane (ERM) in the myopic eyes with long axial length (AL) to that in the eyes with normal AL.

METHODS

This was a retrospective, observational, case-control study. Fifty-six eyes of 56 patients with an idiopathic ERM were studied. Twenty-eight of these eyes had an axial length longer than 26.0 mm (Group A), and the other 28 eyes had axial lengths < 26.0 mm (Group B). The age and visual acuity of the two groups were not significantly different. All subjects were treated by vitrectomy and peeling of the ERM with a 25- or 27-gauge system. The postoperative best-corrected visual acuity (BCVA) and optical coherence tomographic findings were determined at 3 and 6 months postoperatively.

RESULTS

The mean BCVA improved from 0.35 ± 0.25 to 0.15 ± 0.25 logMAR units in the eyes with the long AL and from 0.35 ± 0.25 to 0.10 ± 0.21 logMAR units in the eyes with normal AL at 6 months postoperatively (both P < 0.001). The postoperative BCVA was not significantly different between the two groups at 6 months (P = 0.221). The central macula was thinner in the eyes of Group A than Group B (P < 0.001). The restorations of the ellipsoid zone and the external limiting membrane were observed in both groups, but the interdigitation zone was less frequently restored in Group A (P < 0.001).

CONCLUSIONS

Vitrectomy with the removal of the epiretinal membrane is effective in attaining a good BCVA even in the myopic eyes with long AL.

Parafoveal atrophy after human amniotic membrane graft for macular hole in patients with high myopia

Purpose

To report the surgical outcome and postoperative hypopigmented change around fovea among patients with high myopia who received human amniotic membrane (hAM) graft transplantation for macular hole (MH).

Method

This retrospective, interventional case series included 10 eyes of 10 consecutive patients (5 (50%) male) with high myopia (axial length over 26.5 mm) who received hAM graft to treat persisted or chronic MH with or without retinal detachment in two hospitals. Postoperative parafoveal atrophy was identified with colour fundus picture and structure optical coherent tomography. Baseline characteristics and short-term visual outcome were analysed.

Results

The preoperative mean (±SD) axial length and MH diameter were 29.9 (±1.8) mm and 881.8 (±438.5) μm, respectively. After hAM transplantation, seven (70%) eyes had complete MH closure and the mean best-corrected visual acuity (BCVA) improved from 1.26 (±0.48) logarithm of minimal angle of resolution (logMAR) before operation to 1.11 (±0.44) logMAR on the last visit (p=0.074). Patchy atrophy-like depigmentation developed around the MH lesion in four (40.0%) eyes as early as in the first month after surgery. None of them had visual worsening. In terms of demographics, axial length, MH size, ocular history, preoperative BCVA and postoperative BCVA, there was no significant difference between those with and without the parafoveal atrophy. No graft rejection and inflammation happened during the follow-up.

Conclusion

Parafovea atrophy, a rare complication in the conventional MH surgery, was observed in 40% of eyes with highly myopic MH after hAM graft transplantation. The pathogenesis and long-term consequence need further investigations.

Comparison between Cryopreserved and Dehydrated Human Amniotic Membrane Graft in Treating Challenging Cases with Macular Hole and Macular Hole Retinal Detachment

Purpose

To evaluate the surgical outcomes of cryopreserved and dehydrated human amniotic membrane (hAM) graft transplantation for macular hole (MH) and macular hole retinal detachment (MHRD) repair.

Materials and Methods

This retrospective, interventional case series was conducted in two hospitals. Two types of hAM grafts, namely, the dehydrated form (AmnioGen, HCT Regenerative, Taiwan) and the cryopreserved form (AmnioGraft, Bio-Tissue, Miami, FL), were consecutively used in MH surgeries. Anatomical and functional outcomes between the 2 types of hAM grafts were compared.

Results

Seventeen patients (mean age: 62.1 ± 10.0 years, 9 (52.9%) males) were enrolled. Of them, 11 patients had persistent MH, 3 had MH without prior surgery, and 3 had MHRD. A cryopreserved hAM graft was used in 10 patients, and a dehydrated hAM graft was used in 8 patients. One patient used a cryopreserved hAM in the first MH surgery and a dehydrated hAM in the second surgery for extramacular hole with retinal detachment. After a 6-month follow-up, 13 (76.5%) patients had sealed MHs. The average visual acuity (VA) of cases with sealed MHs improved from 1.38 ± 0.62 to 1.12 ± 0.47 logMAR (p=0.03). In the other 4 cases with persistent MH, 3 had graft dislocation and 1 had a reopened MH with graft contraction. There were no significant differences in closure rate (80.00% vs. 71.43%, p=0.68) or VA improvement (0.19 ± 0.37 logMAR vs. 0.15 ± 0.41 logMAR, p=0.85) between the 2 kinds of hAM graft.

Conclusion

This preliminary case series showed that both cryopreserved hAM and dehydrated hAM are feasible alternative grafts for either persistent or recurrent MH. Both approaches have similar anatomical and functional outcomes.

ANATOMICAL AND VISUAL OUTCOMES OF INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE VERSUS INTERNAL LIMITING MEMBRANE PEELING IN MYOPIC MACULAR HOLE WITHOUT RETINAL DETACHMENT: A Preliminary Retrospective Study

PURPOSE

To compare the results of vitrectomy with internal limiting membrane (ILM) peeling and inverted ILM flap for treating myopic macular hole without retinal detachment.

METHODS

Twenty-eight eyes of 28 patients undergoing vitrectomy with either ILM peeling (n = 16) or inverted ILM flap technique (n = 12) were included. Outcomes were myopic macular hole closure by optical coherence tomography and visual acuity at 6 months and at the end of follow-up.

RESULTS

Closure of myopic macular hole was achieved in 13 eyes (81.2%) of the ILM peeling group and in 11 eyes (91.7%) of the inverted ILM flap group. The median length of follow-up was 18 months in the peeling group and 10.3 in the inverted group. There were not statistically significant differences between restoration of the external limiting membrane, external limiting membrane and ellipsoid zone, and none of both layers between the two groups. The median best-corrected visual acuity (logarithm of minimal angle of resolution) at the end of follow-up was 0.25 (20/35 Snellen) in the peeling group and 0.4 (20/50) in the inverted group (P = 0.027).

CONCLUSION

Both techniques were associated with high closure rates of myopic macular hole but the small sample size and the retrospective design prevents any claims of superiority of one technique over the other.

Autologous Platelet-Rich Fibrin in the Treatment of Refractory Macular Holes

Purpose

To describe a novel method for the treatment of refractory macular holes.

Methods

Two case reports on the use of autologous platelet rich fibrin (PRF), followed by sulfur hexafluoride gas tamponade to facilitate closure of refractory macular holes.

Results

Macular holes were succesfully closed within a week in both cases. Best corrected Snellen visual acuities improved from counting fingers to 0.16 in the first case, and from 0.05 to 0.2 in the second case. No complication occurred during or after the procedures.

Conclusion

The use of autologous PRF seems to be a safe and effective alternative method for the treatment of refractory macular holes. Further experience and studies are required to assess the value of autologous PRF in the management of challenging macular hole cases of different etiologies. To the best of our knowledge, this is the first use of autologous PRF in the treatment of macular holes.

AUTOLOGOUS LENS CAPSULAR FLAP TRANSPLANTATION COMBINED WITH AUTOLOGOUS BLOOD APPLICATION IN THE MANAGEMENT OF REFRACTORY MACULAR HOLE

PURPOSE

To report results of lens capsular flap transplantation (LCFT) and autologous whole blood application in refractory macular hole (MH) treatment.

METHODS

Seven phakic and three aphakic eyes with persistent MH after standard surgery with internal limiting membrane peeling were studied. Lens capsule flap was acquired from the same eye in eight cases (seven phakic and one aphakic). The fellow eye was used in two aphakic eyes without sufficient lens capsule. The fellow eye underwent simultaneous phacoemulsification. All eyes underwent complete vitrectomy, LCFT into the MH, whole blood application, and 15% perfluoropropane (C3F8) tamponade. The patients were instructed to maintain a face-down or prone position for two weeks postoperatively. Structural and functional changes were evaluated.

RESULTS

The mean preoperative MH diameter was 1,472.78 ± 736.88 μm. The MH was completely closed in nine eyes: eight eyes receiving same-eye LCFT and one receiving fellow-eye LCFT. In the other fellow-eye LCFT recipient, the MH was partially closed. Visual acuity improved from 1.84 ± 0.49 logarithm of the minimum angle of resolution (median Snellen acuity: 20/1,750, range: 20/4,000-20/125) preoperatively to 1.34 ± 0.59 logarithm of the minimum angle of resolution (median Snellen acuity: 20/450, range: 20/4,000-20/63) postoperatively (P = 0.009).

CONCLUSION

Lens capsular flap transplantation and autologous whole blood application may improve anatomical and visual outcomes in refractory MH cases. The lens equator and fellow eye may be promising sources of LCF.

Treatment of recurrent myopic macular hole using membrane of plasma rich in growth factors

Purpose

To describe the case of a patient with a recurrent large myopic macular hole (MH), who was successfully treated with a plasma rich in growth factors (PRGF) membrane.

Case Report

A 71-year-old patient presented a myopic MH in his right eye. One month later, pars plana vitrectomy with internal limiting membrane (ILM) peeling was performed, achieving closure of the MH. Three months later a recurrence was observed (700 µm) without visual acuity (VA) improvement. A new surgery was carried out placing an autologous PRGF-membrane into the MH, and performing a fluid-gas exchange at the end of the surgery. After two months of follow-up, the MH was completely closed, obtaining the anatomic recovery of the foveal depression, and improving the VA to 0.1. No adverse reactions were associated with the use of PRGF and there were no new recurrences of the MH in a follow-up period of six months.

Conclusion

The use of PRGF-membrane can be used as adjunctive therapy in the surgical repair of recurrent large myopic MHs, thus improving anatomic and visual outcomes.

Comparison of Anatomical and Visual Outcomes between Idiopathic and Myopic Macular Holes Using the Internal Limiting Membrane or Inverted Internal Limiting Membrane Flap Technique

Purpose

To compare the results of vitrectomy with those of internal limiting membrane (ILM) peeling or inverted ILM flap for treating myopic or idiopathic macular hole.

Methods

Thirty-nine eyes of 39 patients undergoing vitrectomy with ILM peeling for macular hole (25 idiopathic and 14 myopic) and 27 eyes of 27 patients undergoing vitrectomy with inverted ILM flap (15 idiopathic and 12 myopic) were included. Outcome measures were macular hole closure by optical coherence tomography and visual acuity at 6 months.

Results

Closure was achieved in 25 (100%) idiopathic and 12 (86%) myopic macular holes in the ILM peeling group and in 14 (93%) idiopathic and 11 (91.77%) macular holes in the inverted ILM flap group. There were no statistically significant differences in restoration of the external limiting membrane and ellipsoid zone between the groups. Median best-corrected visual acuity (logarithm of minimal angle of resolution) at the end of follow-up was 0.22 (20/32 Snellen) in idiopathic and 0.4 (20/50) in myopic (P=0.042) patients in the ILM peeling group and 0.4 (20/50) in idiopathic and 0.4 (20/50) in myopic (P=0.652) patients in the inverted ILM flap group.

Conclusion

Both techniques were associated with high closure rates in myopic and idiopathic macular holes, with somewhat better visual outcomes in idiopathic cases. The small sample size may have provided insufficient power to support the superiority of one technique over the other in the two groups.

SURGICAL OUTCOMES IN EYES WITH EXTREMELY HIGH MYOPIA FOR MACULAR HOLE WITHOUT RETINAL DETACHMENT

PURPOSE

The authors evaluated surgical outcomes in eyes with extremely high myopia for macular hole (MH) without retinal detachment.

METHODS

In this retrospective study, 14 eyes with axial lengths of ≥30.0 mm underwent vitrectomy and internal limiting membrane (ILM) peeling with or without inverted ILM flap insertion for MH without retinal detachment (October 2009-June 2016). Outcome measures were MH closure confirmed by optical coherence tomography, best-corrected visual acuity, and complications.

RESULTS

The mean axial length was 30.69 ± 0.76 mm. The overall final closure rate was 85.7% (12/14 eyes); the mean follow-up was 17.29 (±20.20) months. Primary anatomical MH closure after 1 operation was achieved in three of eight eyes (37.5%) without an inverted ILM flap and was achieved in six of six eyes (100%) with inverted ILM flap insertion (P = 0.031). There was no reopening of MH during follow-up. Mean visual acuity improved significantly from 1.10 ± 0.43 logarithm of the minimum angle of resolution (Snellen equivalent, 20/254) to 0.84 ± 0.50 logarithm of the minimum angle of resolution (Snellen equivalent, 20/138) (P = 0.046; 2-tailed, paired t-test). Only 1 eye developed an MH-associated retinal detachment 4.5 years after previously failed MH surgery; reattachment was achieved after a second operation.

CONCLUSION

Patients with extremely high myopia obtained anatomical and functional improvements from MH surgery; inverted ILM flap insertion achieved significantly higher primary success rates in MH closure.

The Role of Single-Layered Flap in Temporal Inverted Internal Limiting Membrane Flap Technique for Macular Holes: Pros and Cons

Purpose

To assess the safety and effectiveness of the single-layered inverted internal limiting membrane (ILM) flap technique for treating chronic, large, or highly myopic macular holes (MHs).

Methods

The medical records of 20 eyes of 20 consecutive Japanese patients with large MHs (n=6) (minimal diameter, >400 μm), chronic MHs (n=2) (symptom duration, >24 months), MHs in high myopia (n=11) (axial length, >26 mm), and MHs in a patient unable to maintain prone positioning postoperatively (n=1) were reviewed retrospectively. All patients underwent 25-gauge pars plana vitrectomy and the temporal inverted ILM flap technique. A semicircular ILM notch was made temporally two disc diameters from the MH using a 25-gauge knife, and the ILM was peeled temporally to create a semicircular ILM flap using a 25-gauge forceps. The single-layered ILM flap was inverted in a nasal direction to cover the MH. When an epiretinal membrane (ERM) was present, it was peeled before the ILM flap was inverted.

Results

The MHs closed successfully in all (100%) eyes postoperatively. In the MHs associated with an ERM, after hole closure, gradual foveal deformation occurred in both the area from which the ILM was not peeled and the ILM flap inverted side.

Conclusions

The single-layered inverted ILM flap technique, a simple surgery to treat MHs, provides scaffolding for retinal gliosis and may facilitate bridge formation between the walls of the MH under the flap. Considering the 100% success rate of MH closure, this technique seems to be effective and safe for treating chronic, large, or highly myopic MHs and MHs in patients unable to maintain postoperative prone positioning. In the MHs associated with ERMs, gradual foveal deformation was observed after ERM peeling. Further studies are needed to minimize surgical complications and understand the mechanism of this technique. This trial is registered with UMIN000035091.

Inverted ILM Flap for the Treatment of Myopic Macular Holes: Healing Processes and Morphological Changes in Comparison with Complete ILM Removal

Purpose

To investigate the microstructural changes after successful myopic macular hole (MMH) surgery, comparing inverted ILM flap and complete ILM removal techniques, and their association with visual function.

Methods

Spectral-domain optical coherence tomography (SD-OCT) was used to evaluate both external limiting membrane (ELM) and ellipsoid zone (EZ) recovery in 40 eyes of 39 patients who underwent pars plana vitrectomy with either inverted internal limiting membrane flap technique (n=27) or complete ILM removal (n=13) to achieve MH closure. The association between ELM and EZ recovery and visual acuity was also investigated. The patients were followed up at 1 year.

Results

ELM and EZ was recovered in 72% and 62% of cases, respectively, regardless of the surgical techniques 1 year after surgery. A strong positive association between the ELM and EZ recovery and the mean BCVA was found: regardless of the surgical technique, this was statistically significant at each time point (p < 0.05). None of the baseline variables were found to act as predictive factors for either ELM or EZ.

Conclusion

The inverted ILM flap technique did not affect the MMH healing processes compared to complete ILM removal. Thus, the presence of the ILM plug did not interfere with the restoration of both ELM and EZ, which correlated with functional recovery.

Inverted internal limiting membrane (ILM) flap technique for macular hole closure: patient selection and special considerations

This paper reviews the current status of the newer inverted internal limiting membrane flap technique for macular hole surgery. It gives an overview of the importance of patient selection and special considerations along with variations in technique. It discusses the pathophysiology and how the technique has been an important addition in the armamentarium of vitreoretinal surgeons to attain better anatomical as well as functional results in challenging situations.

Macular Hole Surgery Using Gas Tamponade-An Outcome from the Oslo Retrospective Cross-Sectional Study

Purpose: The study aims to determine the anatomical success and functional outcome of pars plana vitrectomy (PPV) for macular holes (MH) performed at a single study center using a consistent procedure of internal limiting membrane (ILM) peeling, SF6 tamponade and 3 days face-down positioning. Methods: A retrospective cross-sectional study involving eyes with MHs which underwent 23- or 25-gauge PPV with or without phacoemulsification and all undergoing a 20% SF6 gas tamponade, follow-up to 6 months postoperatively were included at the Department of Ophthalmology, Oslo University Hospital and University of Oslo, Oslo, Norway (12-month study period between 1 January and 31 December 2015) Pre- and post-operative Best-Corrected Visual Acuity (BCVA) assessment, comprehensive eye examination and intraocular pressure (IOP) measurement. as well as Optical Coherence Tomography to determine the diameter of the MH and its closure were all carried out. Results: 198 consecutive eyes operated for MH (age: 69.4 ± 7.6 years; 1.6:1 female:male ratio) were included; 35.7%/48.6% had symptoms from 3-6/6-48 months; 5.1% had high-grade myopia, 21.5% focal VMT <1500 µm with or without epiretinal membrane (ERM), and 74.0%/26.0% had phakic/pseudophakic status. Primary closure of the MH occurred in 93.3% of the patients. Lens status and length of symptoms showed no significant correlation with closure of the MH. The pre-operative logMAR visual acuity: 0.8 ± 0.3 (median: 0.7; interquartile range (IQR): 0.5-0.8; range: 0.3-1.7), improved significantly post-operatively: 0.4 ± 0.3 (median: 0.3; interquartile range (IQR): 0.1-0.5; range: -0.02-1.2). BCVA improvement of <0.2, 0.2-0.4 and >0.4 was present in 28.3%, 27.3% and 44.4% of the treated patients. No significant median differences could be detected between the duration of the pre-operative symptoms and the pre-/post-operative visual acuity. Increased IOP was measured in 2.6% of the cases day after surgery. Conclusions: Our study found visual outcome not to be dependent upon the length of symptoms in MH patients treated by PPV all undergoing ILM peeling, SF₆ tamponade and face-down positioning. The large diameter MH was not a limiting factor to achieve improved post-operative BCVA.

Management of refractory macular hole with blood and gas-assisted autologous neurosensory retinal free flap transplantation: a case report

Background

Macular hole (MH) may become refractory if the hole does not close after multiple surgeries. We provide a modified surgical technique for refractory MH repair with neurosensory retinal free flap transplantation.

Case presentation

To treat a 68-year-old female patient with refractory MH after multiple surgeries, we harvested a neurosensory retinal free flap with a 2-MH diameter area. A drop of whole blood was placed within the MH as an adhesive to fix the neurosensory retinal free flap at the MH under gas tamponade. Two months after surgery, optical coherence tomography (OCT) revealed closure of the MH. The flap was visible on OCT and had filled the MH without overlapping the neurosensory retina. The patient’s best-corrected visual acuity (BCVA) improved from 20/500 preoperatively to 20/50 at 2 months postoperatively.

Conclusions

Using whole blood as an adhesive to aid in the fixation of an autologous neurosensory retinal free flap under gas tamponade provides another option for patients with refractory MH due to multiple prior surgeries.

Electronic supplementary material

The online version of this article (10.1186/s12886-018-0909-9) contains supplementary material, which is available to authorized users.

Treatment of refractory giant macular hole by vitrectomy with internal limiting membrane transplantation and autologous blood

AIM

To investigate the effect of internal limiting membrane transplantation and autologous blood on treating refractory giant macular hole.

METHODS

Thirty-seven eyes with giant macular hole of the smallest hole diameter >700 µm, the maximum diameter of the substrate >1000 µm and hole formation factor <0.6 underwent surgical treatment. The patients were randomly divided into two groups. Nineteen eyes with surgical flip of the internal limiting membrane in group A, 18 eyes with internal limiting membrane transplantation in group B who underwent the tamponade of internal limiting membrane into the hole, autologous plasma was used to seal the hole. The patients were followed up for 3mo, optical coherence tomography and best corrected visual acuity (BCVA) were recorded before and after operation, and the results were statistically analyzed.

RESULTS

At 3mo after operation, BCVA of the two groups was significantly improved compared with that before operation (t_A=4.192, t_B=4.374, P<0.05). But there was no significant difference in visual acuity between the two groups (χ²=0.128, P>0.05). At 3mo after operation, the closure rate of group A was 68.4%, and 100% in group B. (χ²=5.628, P<0.05). The defect diameter of inner segment/outer segment at 3mo after the operation was significantly lower than that before operation (t_A=12.287, t_B=15.481, P<0.05), and the difference was statistically significant (t=2.552, P<0.05).

CONCLUSION

Internal limiting membrane transplantation combined with autologous whole blood can improve the postoperative closure rate of the refractory large aperture, and can effectively improve the postoperative visual acuity.

A Review of Surgical Outcomes and Advances for Macular Holes

The surgical outcomes of macular holes (MHs) have improved greatly in recent years. The closure rate is as high as 90-100%, but the outcomes of some special types of MHs remain unsatisfactory. Internal limiting membrane (ILM) peeling dramatically improves the anatomic success rate, but recent studies have found that it could also cause mechanical and subclinical traumatic changes to the retina. Dyes are widely used, and apart from indocyanine green (ICG), the toxicities of other dyes require further research. Face-down posturing is necessary for MHs larger than 400 μm, and the duration of this posture is determined by the type of tamponade and the case. The ellipsoid zone has been shown to be highly correlated with visual outcome and recovery. New surgical methods include the inverted ILM flap technique and the ILM abrasion technique. However, they require further research to determine their effectiveness.

Autologous neurosensory retinal free patch transplantation for persistent full-thickness macular hole

PURPOSE

To evaluate anatomical and functional outcomes after autologous neurosensory retinal free patch (ANRFP) transplantation for persistent idiopathic full-thickness macular hole (iFTMH).

METHODS

A 65-year-old woman with persistent macular hole in her right eye after previous 27-gauge pars plana vitrectomy with internal limiting membrane peeling and long-acting gas tamponade underwent ANRFP transplantation. Before surgery, best corrected visual acuity in her right eye was 20/800. Optical coherence tomography (OCT) showed a 715-micron-diameter FTMH. To treat the persistent FTMH, a small autologous neurosensory retinal patch was transplanted and placed inside the macular hole under perfluorocarbon liquids (PFCL). PFCL-air exchange was performed, and long-acting gas tamponade was carried out. Clinical features of the macular area, visual acuity (VA), fundus autofluorescence, microperimetry and OCT were recorded during the 10-month follow-up.

RESULTS

The macular hole appeared successfully closed with retinal patch stable and well plugged into the hole during the whole follow-up. VA improved to 20/100 and microperimetry revealed an increase in mean retinal sensitivity from 14.7 dB at 1 month to 15.6 dB at 10 months postoperatively. OCT showed a well-distinguishable retinal patch into the hole 1 month after surgery and a completely integrated retinal patch between the retinal layers 10 months postoperatively. No intra- and postoperative complications were noticed.

CONCLUSIONS

ANRFP transplantation may represent an innovative technique for persistent iFTMH treatment.

Cellular Characterization of OCT and Outer Retinal Bands Using Specific Immunohistochemistry Markers and Clinical Implications

PURPOSE

OCT has been a technological breakthrough in the diagnosis, treatment, and follow-up of many ocular diseases, especially retinal and neuro-ophthalmologic pathologic conditions. Until now, several controversies have arisen over the specific cell types that the bands observed in the OCT represent, especially over the 4 outer retinal bands.

DESIGN

To correlate the 4 outer hyperreflective bands observed in the OCT with the histologic structures using human retinal sections and immunocytochemistry at the fovea level.

PARTICIPANTS

Eyes from human donors.

METHODS

Vertical cryosections of human retinas were immunostained with antibodies specific for cones photoreceptors, bipolar cells, mitochondria, Müller cells, and retinal pigment epithelium (RPE) cells and were visualized using confocal microscopy.

MAIN OUTCOME MEASURES

Morphological correlation between histology and OCT at the fovea level.

RESULTS

Triple immunolabeling allowed distinguishing between cells types and different cell compartments. Immunostaining with guanine nucleotide-binding protein β 3 (GNB3) and cellular retinaldehyde-binding protein (CRALBP) antibodies showed all retinal layers at the foveola, especially the separation between the outer nuclear layer and the Henle fiber layer. CRALBP and cytochrome C (Cyt C) immunolabeling revealed that hyperreflective bands 1 and 2, observed in the OCT, correspond to the outer limiting membrane and the cone ellipsoids, respectively, separated by the cone myoids. CRALBP, cytochrome C, and GNB3 showed that the RPE interdigitations extend along the entire external segment of the cones, we do not believe them to be the structure responsible for forming the third band. However, the identification of small fragments of cone outer segments within the RPE led us to characterize the third band as the cone phagosomes located in the top of the RPE. Finally, we propose that the fourth band corresponds to the accumulation of mitochondria at the basal portion of the RPE, as identified by cytochrome C immunoreactivity, and that the hyporeflective band between bands 3 and 4 corresponds to the RPE nuclei and melanosomes zone.

CONCLUSIONS

This study proposes a new interpretation of the outer retinal bands that leads to a more accurate interpretation of OCT images, providing information about the health of cones and their relationship with the RPE, and could help to form a better understanding of retinal disease diagnosis and prognosis.

LENS CAPSULAR FLAP TRANSPLANTATION IN THE MANAGEMENT OF REFRACTORY MACULAR HOLE FROM MULTIPLE ETIOLOGIES

PURPOSE

To report the clinical results of lens capsular flap transplantation in refractory macular hole (MH).

METHODS

This retrospective, interventional, consecutive case series included 20 eyes with persistent MH after previous standard MH surgery. All eyes underwent vitrectomy, lens anterior or posterior capsule transplantation into the MH, gas tamponade, and a 1-week postoperative head down. Structural and functional changes were evaluated.

RESULTS

The predisposing conditions to surgical failure included high myopia with MH and retinal detachment in four eyes, MH after myopic foveoschisis surgery in one eye, high myopia with a large MH in one eye, proliferative diabetic retinopathy with MH in three eyes, MH with severe retinal detachment in one eye, retinal detachment with concurrent peripheral breaks and MH in one eye, and large or chronic MH in nine eyes. Macular hole was closed in all the 10 eyes receiving anterior capsular flap transplantation. In the 10 eyes with posterior capsular flap transplantation, MH was closed in 5, partially closed in 3, and not closed in 2. Visual acuity in logarithm of minimal angle of resolution improved from 1.53 ± 0.39 preoperatively to 1.07 ± 0.35 postoperatively.

CONCLUSION

Lens capsular flap transplantation may close the MH and improve visual outcome in the majority cases of refractory MH.

Short-Term Results of Platelet-Rich Plasma as Adjuvant to 23-G Vitrectomy in the Treatment of High Myopic Macular Holes

Purpose

To investigate the short-term safety and efficacy of autologous platelet-rich plasma (a-PRP) as adjuvant to pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling in the treatment of highly myopic macular holes (MH).

Methods

This was a prospective, nonrandomized interventional case series. Patients with MH associated with high myopia, with or without previous PPV, were included. All patients underwent 23-G PPV with the use of a-PRP. Anatomical and functional results of surgery were recorded.

Results

We included 7 eyes of 6 patients with highly myopic MH. Primary anatomical success was achieved in 7 out of 7 eyes. Mean best-corrected visual acuity improved by more than 1 line from baseline (0.66 ± 0.36 LogMAR) to final visit (0.52 ± 0.25 logMAR), but with no statistically significant difference (p = 0.246, Wilcoxon test). No surgical-related complications were noticed.

Conclusions

The use of a-PRP as adjuvant to PPV with ILM peeling is effective in the treatment of highly myopic MH. This approach may represent a valid alternative to the inverted ILM flap technique, with comparable visual and anatomical results and the advantage of a simpler procedure. Further studies are necessary to confirm its usefulness in the management of high myopic MH.

Rates of Reoperation and Retinal Detachment after Macular Hole Surgery

PURPOSE

To evaluate rates of reoperation and retinal detachment (RD) after macular hole surgery.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Patients in the insurance claim-based MarketScan databases from 2007 through 2013 with a record of macular hole surgery.

METHODS

Patients with macular hole surgery were identified. Cases of definite (the same eye was coded both times) and presumed (the eye laterality was not coded) macular hole reoperations within 2, 3, and 12 months were queried. In addition, cases of postoperative RD within 2, 3, and 12 months were captured.

MAIN OUTCOME MEASURES

Rates of macular hole reoperation and postoperative RD, including subgroup analysis based on presence or absence of internal limiting membrane (ILM) peeling.

RESULTS

Records of 23465 macular hole surgeries among 20 764 patients were analyzed. Among presumed reoperations, the rates of reoperation were 4.3% (4.1% after ILM peeling and 5.0% after no ILM peeling; P = 0.01) within 2 months of surgery, 5.5% (5.3% after ILM peeling and 6.2% after no ILM peeling; P = 0.03) within 3 months of surgery, and 9.5% (9.0% after ILM peeling and 11.0% after no ILM peeling; P = 0.01) within 12 months of surgery. The rates for definite reoperations were 1.3% (1.2% after ILM peeling and 1.8% after no ILM peeling; P = 0.04) at 2 months, 1.7% (1.6% after ILM peeling and 2.5% after no ILM peeling; P = 0.004) at 3 months, and 4.1% (3.3% after ILM peeling and 7.5% after no ILM peeling; P < 0.001) at 12 months. The cumulative rate of postoperative RD was 1.81±0.09% to 2.18±0.5% after 2 months, 2.27±0.10% to 3.18±0.67% after 3 months, and 3.92±0.16% to 5.70±1.1% after 12 months. Internal limiting membrane peeling was associated negatively with postoperative RD at 2 months (2.3% vs. 1.7%; P = 0.007), 3 months (2.8% vs. 2.1%; P = 0.004), and 12 months (4.7% vs. 3.3%; P < 0.001).

CONCLUSIONS

In this sample, reoperations for macular hole were performed at low rates. Internal limiting membrane peeling was associated with lower rates of reoperation and RD.

Postoperative anatomical and functional outcomes of different stages of high myopia macular hole

Background

Recently it was suggested that high myopia macular holes (HMMH) and macular holes accompanied by retinal detachment occur in the advanced stages of myopia traction maculopathy (MTM), while macular retinoschisis, shallow retinal detachment without holes, and lamellar macular holes occur in the early stages of MTM. Complete vitreous cortex removal associated with internal limiting membrane peeling is now widely used to treat HMMH. However, it remains uncertain at what HMMH stage patients would benefit most from surgical intervention. Our study was aimed to evaluate the postoperative anatomical changes and functional outcomes of high myopia macular holes (HMMH).

Methods

Patients were retrospectively collected between March 2009 and August 2011. Before and 1st, 3rd, and 9th month after 23G pars plana vitrectomy, all patients underwent a complete ophthalmologic examination, spectral domain optical coherence tomography (SD-OCT) and MP-1. At each follow-up, best-corrected visual acuity (BCVA), photoreceptor inner and outer segments (IS/OS) defects, and retinal sensitivity (RS) were investigated. According to different preoperative macular hole morphologies, patients were divided into three groups: Group 1, macular hole with epiretinal membrane (ERM) traction and macular retinoschisis; Group 2, full-thickness macular hole (FTMH); Group 3, FTMH with subretinal fluid.

Results

43 eyes from 43 patients met the inclusion criteria. The mean age was 60 years. BCVA and RS were significantly improved after vitrectomy; the mean IS/OS defect was significantly reduced. At 9 postoperative months, 11 of 43 (25.6 %) eyes achieved IS/OS junction integrity; 9 of these 11 (81.8 %) eyes belonged to Group 1, 2 (18.2 %) belonged to Group 2.

Conclusions

Pars plana vitrectomy combined with ILM peeling and gas tamponade results in limited functional outcomes in patients with HMMH. The appearance of subretinal fluid indicates a worse prognosis for surgical intervention.