Vitreo-retinal relationship and post-operative outcome of macular hole repair in eyes with high myopia

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

Purpose

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

Design

Retrospective study.

Participants

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

Methods

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

Main Outcome Measures

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

Results

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

Conclusions

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

Financial Disclosures

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

Intravitreal gas injection for early persistent macular hole after primary pars plana vitrectomy

Purpose

To report the clinical presentations and outcome of early intravitreal injection (IVI) of octafluoropropane (C₃F₈) for persistent macular holes (MH) after primary pars plana vitrectomy with the internal limiting membrane (ILM) peeling technique.

Methods

Nineteen eyes of 18 patients with persistent MH after vitrectomy underwent intravitreal injection of C₃F₈ between 11 and 21 days after the initial surgery (intravitreal gas injection group). Another nine eyes with a persistent MH without additional IVI C₃F₈ were included (non-intravitreal gas injection group).

Best-corrected visual acuity (BCVA), optical coherence tomography (OCT) features including size and configuration of MH, and time duration between the 2 surgeries were compared between the MH closure and open groups. The closure rate of persistent MHs was compared between the intravitreal gas injection group and non-intravitreal gas injection group.

Results

Twelve of 19 eyes (63%) achieved MH closure after 1 to 3 times IVI C₃F₈. The final BCVA after vitrectomy and IVI gas was significantly better in the MH closure group (P = .005). Nine of 12 patients (75%) in the MH closure group had a visual acuity improvement of more than 2 lines. Original MHs with smaller minimal diameter, higher macular hole index (MHI) and higher tractional hole index (THI); and persistent MHs with smaller minimal diameter, higher THI, and lower diameter hole index (DHI) showed higher MH closure rate. None of the persistent MHs closed in the non-intravitreal gas injection group (0/9 eyes).

Conclusion

Early intravitreal injection of C₃F₈ can be a cost-effective first-line treatment for early persistent MHs after primary surgery, especially in eyes with favorable OCT features.

Comparison of outcomes of idiopathic macular holes treated by vitrectomy with air or silicone oil tamponade based on the hole size

AIM

To compare the efficacy of vitrectomy combined with air or silicone oil in the treatment of idiopathic macular hole (IMH).

METHODS

According to the results of high-definition optical coherence tomography (HD-OCT), 75 cases (75 eyes) of IMH in stage II-IV (Gass stage) in the General Hospital of Chinese PLA from January 2017 to December 2019 were collected for this retrospective study. The best corrected visual acuity (BCVA) and minimum diameter of IMH (MMHD) were measured. Eyes underwent vitrectomy combined with internal limiting membrane peeling operation, and were divided into disinfection air group (30 eyes) and silicone oil group (45 eyes) according to the intraocular tamponade. For MMHD≤400 µm (MMHD1), there were 23 eyes in air group and 16 eyes in silicone oil group. For MMHD2>400 µm (MMHD2), there were 7 eyes in air group and 29 eyes in silicone oil group. One month after surgery, the closure rates of IMH and BCVA were compared and analyzed. According to HD-OCT, the closure shape was graded with A (bridge closure) and B (good closure).

RESULTS

The closure rates of air group and silicone oil group were 86.67% and 95.56% respectively with no significant difference (P>0.05); For MMHD1, those of air group and silicone oil group were 95.65% and 100% respectively with no significant difference (P>0.05); For MMHD2, those of air group and silicone oil group were 57.14% and 93.10% respectively, and those of the silicone oil group were higher than the air group (P<0.05). There was no significant difference in the closure shape grade between MMHD1 air group and silicone oil group (P>0.05). The proportion of Grade B in MMHD2 silicone oil group was higher than that in the air group (P<0.05). BCVA of each group after operation was better than that before operation, and there was no significant difference between air group and silicone oil group. While among them, MMHD1 air group was better than silicone oil group (P<0.05), and there was no significant difference between MMHD2 air group and silicone oil group (P>0.05).

CONCLUSION

For smaller IMH (≤400 µm), the efficacy of vitrectomy combined with air should be considered better than silicone oil; for larger IMH (>400 µm), the efficacy of silicone oil may be better than air.

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.

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.

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.

[Secondary diseases in high myopia]

BACKGROUND

Eyes with high myopia (axial length ≥ 26.5 mm) do not just have a different size. Due to morphological and structural changes there is a considerably increased risk for many different secondary diseases.

OBJECTIVE

Determination of the incidence and mortality in high myopia, discussion of effects and clinical signs, presentation of treatment recommendations and counselling.

MATERIAL AND METHODS

A systematic search of the literature was carried out and a discussion on basic principles and epidemiological investigations is presented.

RESULTS

Findings due to high myopia are not in a closed state but undergo continuous changes. Choroidal neovascularization (adjusted prevalence 2.5-5%), staphyloma, foveoschisis and peripheral retinal degeneration are examples of problems contributing to the increased rate of visual impairment and blindness related to myopia. High myopia is associated with a clearly increased risk of retinal detachment after lens surgery (hazard ratio 6.1) and particularly more frequently in younger people. The associated primary open-angle glaucoma (odds ratio 2.46) is often recognized too late due to relatively low values of intraocular pressure.

CONCLUSION

Understanding of atrophic areas and staphyloma has benefited from recent advances in imaging (e.g. magnetic resonance imaging, optical coherence tomography and wide-field imaging) that complement and explain histological findings. Knowledge of the associated risk profile is of major clinical relevance.