Macular holes

Artificial intelligence in retinal screening using OCT images: A review of the last decade (2013-2023)

BACKGROUND AND OBJECTIVES

Optical coherence tomography (OCT) has ushered in a transformative era in the domain of ophthalmology, offering non-invasive imaging with high resolution for ocular disease detection. OCT, which is frequently used in diagnosing fundamental ocular pathologies, such as glaucoma and age-related macular degeneration (AMD), plays an important role in the widespread adoption of this technology. Apart from glaucoma and AMD, we will also investigate pertinent pathologies, such as epiretinal membrane (ERM), macular hole (MH), macular dystrophy (MD), vitreomacular traction (VMT), diabetic maculopathy (DMP), cystoid macular edema (CME), central serous chorioretinopathy (CSC), diabetic macular edema (DME), diabetic retinopathy (DR), drusen, glaucomatous optic neuropathy (GON), neovascular AMD (nAMD), myopia macular degeneration (MMD) and choroidal neovascularization (CNV) diseases. This comprehensive review examines the role that OCT-derived images play in detecting, characterizing, and monitoring eye diseases.

METHOD

The 2020 PRISMA guideline was used to structure a systematic review of research on various eye conditions using machine learning (ML) or deep learning (DL) techniques. A thorough search across IEEE, PubMed, Web of Science, and Scopus databases yielded 1787 publications, of which 1136 remained after removing duplicates. Subsequent exclusion of conference papers, review papers, and non-open-access articles reduced the selection to 511 articles. Further scrutiny led to the exclusion of 435 more articles due to lower-quality indexing or irrelevance, resulting in 76 journal articles for the review.

RESULTS

During our investigation, we found that a major challenge for ML-based decision support is the abundance of features and the determination of their significance. In contrast, DL-based decision support is characterized by a plug-and-play nature rather than relying on a trial-and-error approach. Furthermore, we observed that pre-trained networks are practical and especially useful when working on complex images such as OCT. Consequently, pre-trained deep networks were frequently utilized for classification tasks. Currently, medical decision support aims to reduce the workload of ophthalmologists and retina specialists during routine tasks. In the future, it might be possible to create continuous learning systems that can predict ocular pathologies by identifying subtle changes in OCT images.

Comparison of stereopsis and foveal microstructure after internal limiting membrane peeling and inverted internal limiting membrane flap techniques in patients with macular hole

PURPOSE

To compare stereopsis and foveal microstructure after internal limiting membrane peeling and inverted internal limiting membrane flap technique in patients with macular hole.

DESIGN

Retrospective observational study.

METHODS

Sixty-six patients with macular hole were included, of whom 41 underwent 25-gauge pars-plana vitrectomy with complete internal limiting membrane peeling (Peeling group) and 25 with the inverted flap technique (Inverted group). We evaluated stereopsis using the Titmus Stereo Test and the TNO stereo test, best-corrected visual acuity, macular hole closure rate, and foveal microstructure with optical coherence tomography before and at 3, 6, and 12 months after surgery.

MAIN OUTCOME MEASURES

Stereopsis and foveal microstructure.

RESULTS

Preoperatively, no difference was observed in the base and minimum diameters of macular hole, Titmus Stereo Test score, TNO stereo test score, and best-corrected visual acuity between the Peeling and Inverted groups. The macular hole closure rate in the Peeling and Inverted groups were 97.6% and 100%, respectively, with no significant difference between groups. At 12 months postoperatively, Titmus Stereo Test score (2.1 ± 0.4 in the peeling and 2.2 ± 0.4 in the inverted groups), TNO stereo test score (2.3 ± 0.4 and 2.2± 0.5), and best-corrected visual acuity (0.20 ± 0.18 and 0.24 ± 0.25) were not significantly different between groups (p = 0.596, 0.332, respectively). The defect of the external limiting membrane was more common in the Inverted group than in the Peeling group at 6 months after surgery (5.4 vs. 28.0%; p < 0.05). No statistically significant inter-group differences were noted in the ellipsoid zone defect ratio throughout the follow-up period.

CONCLUSIONS

There was no difference in postoperative stereopsis nor foveal microstructure between the internal limiting membrane peeling group and the inverted group in patients with macular hole.

Spontaneous Closure of an Idiopathic Full-Thickness Macular Hole: A Literature Review

Purpose:

This work reviews the literature regarding spontaneous closure of idiopathic full-thickness macular holes (FTMHs).

Methods:

Literature on patients with spontaneous idiopathic FTMH closure was reviewed via Ovid MEDLINE, EMBASE, and PubMed through July 16, 2020. A total of 27 of 66 identified articles were included.

Results:

A total of 68 eyes had spontaneous closure. Of the patients, 62.7% were women and the average age was 67.5 years. Visual acuity improved from Snellen 20/78 to 20/33 post closure. The average hole diameter was 176.8 μm; the largest was 350 μm. Most were stage 2 according to Gass and of small size according to International Vitreomacular Traction Study Group (IVTS) staging. The predominant classification system in recent literature is IVTS staging. The average optical coherence tomography–observed closure time was 4.5 months.

Conclusions:

On review, reported spontaneous closure rates of all idiopathic FTMH range from 3% to 15%, and no demographic subgroups are more likely to have closure. Holes ≤250 µm have higher closure rates (22.2%) than those in the range of >250 to 400 µm (13.3%) and ≥400 µm (0%). Closure is associated with favorable visual outcomes, and retinal bridging via glial cells is likely critical to closure. These determinations were based on limited numbers; prospective studies are needed to further ascertain rate, mechanism, and characteristics. IVTS staging provides reliable reporting and insight into whether FTMH can be observed before surgery.

Spectral sensitivity in eyes with macular holes and their fellow eyes

BACKGROUND

This prospective study was undertaken to investigate whether spectral sensitivity can be useful in determining the prognosis of fellow eyes of eyes with macular holes.

METHODS

Spectral sensitivity measurements using a one degree test spot presented at a rate of 1 Hz and 25 Hz on a bright (1000 td) white background were carried out on 10 patients aged between 67 and 74 years (mean age 70.3 +/- 2.6 years). Each patient had a full thickness macular hole in one eye and a normal contralateral fellow eye. The spectral sensitivity measurements were made with eccentric fixation in the eyes with macular holes and with central fixation in the normal fellow eye. A year later, the patient files were reviewed to look at the patient's ocular condition. Another 10 subjects between the ages of 50 and 80 years (mean age 69.5 +/- 4.2 years) were also seen. These control group subjects had visual acuities of 6/9 or better with minimal ocular media changes and no ocular or systemic pathology that could affect colour vision.

RESULTS

The 1 Hz and 25 Hz spectral sensitivities of all patients were reduced for both eyes. Despite the good eye without a macular hole having a VA of 6/6, the spectral sensitivity was similar to that of the eye with the macular hole and markedly reduced visual acuity.

CONCLUSION

The present investigation enabled us to examine the chromatic and achromatic mechanisms by testing spectral sensitivity at 1 Hz and 25 Hz, respectively. The data revealed that both chromatic and achromatic processing could be damaged in the eye with a macular hole. Surprisingly, the spectral sensitivities of both 1 Hz and 25 Hz are equally reduced in the good fellow eye with no macular hole. A one-year follow-up showed that two of the 10 patients (20 per cent) did eventually develop a macular hole in the normal fellow eye. This indicates that there is some subclinical foveal dysfunction in the normal fellow eye, the nature of which is unclear.

Analysis of multiple cytokines in aqueous humor of patients with idiopathic macular hole

Background

Idiopathic macular holes are common ophthalmic manifestations with unknown pathogenesis. Thus far, there has been minimal research regarding the causes of idiopathic macular holes, especially with respect to the underlying immune mechanism. To provide clarity regarding the treatment and prognosis of idiopathic macular holes, specifically regarding the levels of cytokines in affected patients, this study examined and analyzed multiple cytokine levels in aqueous humor from patients with idiopathic macular holes.

Methods

This comparative cross-sectional study included 38 patients in two groups: a cataract control group (n = 17) and an idiopathic macular hole group (n = 21). The levels of 48 cytokines in aqueous humor were detected by multiplex analysis with antibody-coupled magnetic beads. The Kolmogorov–Smirnov test was used to check whether the data were normally distributed; Student’s t-test and the Mann–Whitney U test were used to assess differences in cytokine levels between the two groups. Spearman correlation analysis was used to assess relationships among cytokine levels in the experimental group. Signaling pathways containing cytokines with significantly different expression in the experimental group were identified.

Results

There were significant differences in aqueous humor cytokine levels between patients with idiopathic macular holes and patients in the cataract control group. Notably, hepatocyte growth factor (p = 0.0001), GM-CSF (p = 0.0111), and IFN-γ (p = 0.0120) were significantly upregulated in the experimental group, while TNF-α (p = 0.0032), GRO-α (p < 0.0001), and MIF (p < 0.0001) were significantly downregulated in the experimental group. Furthermore, the GM-CSF level showed significant positive correlations with levels of IL-1 (r = 0.67904, p < 0.001), IL-4 (r = 0.76017, p < 0.001), and IFN-γ (r = 0.59922, p = 0.004097) in the experimental group. Moreover, the levels of nerve growth factor and hepatocyte growth factor showed a significant positive correlation (r = 0.64951, p = 0.001441) in the experimental group.

Conclusions

Patients with idiopathic macular holes showed significant variation in aqueous humor immune response after the onset of hole formation, including the recruitment of immune cells and regulation of cytokine expression. Our findings also suggest that it is not appropriate to use patients with macular holes as the control group in studies of aqueous humor cytokine levels in ophthalmic diseases.

SPONTANEOUS CLOSURE OF SIMULTANEOUS IDIOPATHIC MACULAR HOLES DOCUMENTED BY SPECTRAL-DOMAIN OPTICAL COHERENCE TOMOGRAPHY

PURPOSE

To report a case of spontaneous closure of simultaneous full-thickness macular hole.

METHODS

Case report and literature review.

RESULTS

A 67-year-old woman with small-diameter simultaneous macular holes was observed for a period of 5 months, and progression was documented with spectral-domain optical coherence tomography. Closure of right full-thickness macular hole was evidenced by 1 month and left full-thickness macular hole by 5 months.

CONCLUSION

This case demonstrates possible spontaneous resolution of a condition that is usually treated surgically. A period of observation with serial imaging studies may be advised in cases of small macular holes.

Stereopsis and retinal microstructures following macular hole surgery

The aim of this prospective study was to evaluate the changes in stereopsis in patients who underwent vitrectomy for macular hole (MH) and assess the relationship between stereopsis and retinal microstructures. Fifty-two patients who underwent successful vitrectomy for unilateral MH and 20 control participants were recruited. We examined stereopsis using the Titmus Stereo Test (TST) and TNO stereotest (TNO), optical coherence tomography, and best-corrected visual acuity measurements, preoperatively, and at 3, 6, and 12 months postoperatively. As a result, preoperative and postoperative 3, 6, and 12-month values of stereopsis assessed by TST (log) were 2.7, 2.2, 2.2, and 2.2, respectively. TNO (log) were 2.8, 2.5, 2.4, and 2.4, respectively. Stereopsis in MH after surgery was significantly worse than that in normal participants (p < 0.001). Preoperative TST significantly correlated with MH size and defect length of external limiting membrane (ELM). Postoperative TST demonstrated significant correlation with the preoperative ELM defect length, and postoperative TNO was associated with the preoperative interdigitation zone defect length. Vitrectomy for MH significantly improved stereopsis, although not to normal levels. The ELM defect lengths, which approximately correspond to TST circles, are prognostic factors for postoperative stereopsis by TST. The interdigitation zone defect length, similar in size to the TNO index, is a prognostic factor for postoperative stereopsis by TNO.

Pedicle internal limiting membrane flap technique for very large macular holes: a preliminary report

Background

Conventional vitrectomy technique for macular hole surgery has a good outcome in small and medium macular holes, but for very large macular holes (minimum linear diameter higher than 700 μm) other techniques were developed aiming to achieve greater rates of closure and visual acuity gain. The purpose of this article is to report the anatomical and functional outcomes of four very large macular hole (MH) cases which have undergone vitrectomy with the pedicle internal limiting membrane (ILM) flap technique.

Methods

This is a retrospective series of four patients with large MH who were treated with vitrectomy and the pedicle ILM flap technique. Comprehensive ophthalmologic evaluation was performed before surgery and included ETDRS best-corrected visual acuity (BCVA) and spectral domain optical coherence tomography (SD-OCT) for MH measures: height, minimum linear diameter (MLD) and external base diameter. The particular detail of this technique is related to ILM flap creation. During the peeling, the ILM was not removed completely from the retina but was left attached to the edges of the macular hole and subsequently trimmed with the vitrectomy probe using the scissors mode.

Results

Four patients with very large MH underwent PPV and the pedicle ILM flap technique was used to pursue macular closure. Median preoperative BCVA was 20/400 (range: 20/320 to 20/400) and median postoperative BCVA was 20/200 (range: 20/320 to 20/200). Of the 4 cases reported, 3 obtained anatomical closure (75%), and also presented BCVA improvement after surgery, considering the last follow-up visit of each case. No additional procedures were performed in either case. One patient demonstrated no anatomic and functional improvement.

Conclusion

The present study describes the first Brazilian case series of very large MH treated by the inverted pedicle ILM flap technique. This technique was associated with anatomic and visual improvement in most cases, and represents an alternative therapeutic approach for large macular holes.Trial Registration Project registered in Plataforma Brasil with CAAE number 30163520.0.0000.5440 and approved in ethics committee   from  Ribeirão Preto Medical School Clinics Hospital, University of São Paulo-Ribeirão Preto, São Paulo, Brazil (appreciation number 3.948.426 gave the approval).

Vision-related parameters that affect stereopsis in patients with macular hole

This study evaluated stereopsis and other visual functions in patients with idiopathic macular hole (MH), and sought to identify vision-related parameters that affect stereopsis. In this prospective, consecutive, comparative study, 39 eyes of 39 patients with unilateral idiopathic MH were included. At baseline and at 6 months after MH surgery, we evaluated stereopsis, with the Titmus stereo test (TST) and TNO stereotest (TNO), best-corrected visual acuity (BCVA), letter contrast sensitivity, severity of metamorphopsia, as assessed using M-CHARTS, and extent of aniseikonia, by the new aniseikonia test. Preoperative stereopsis (log) in patients with MH were 2.72 ± 0.53 (range 1.9–4.1) in the TST and 2.82 ± 0.65 (range 1.8–3.9) in the TNO. Preoperative TST was significantly correlated with letter contrast sensitivity (p < 0.05), but not with the other visual functions. TNO showed significant correlation with letter contrast sensitivity (p < 0.05) and aniseikonia (p < 0.005). Preoperative TNO was associated with aniseikonia by multivariate analysis (p < 0.005). MH surgery significantly improved stereopsis, BCVA, letter contrast sensitivity, metamorphopsia, and aniseikonia. Postoperative TST and TNO was significantly associated with BCVA by multivariate analysis. Deterioration of stereopsis in MH patients is associated with contrast sensitivity and the degree of aniseikonia.

Optical Coherence Tomography Morphological Features Following Modified Internal Limiting Membrane Surgical Technique In Traumatic Macular Holes

Objective

To describe the optical coherence tomography (OCT) findings in terms of macular hole closure and ellipsoid zone (EZ) recovery following modified internal limiting membrane (ILM) surgical technique in traumatic macular holes (TMH).

Methods

The study was a retrospective case series that recruited 16 consecutive patients with TMH. Following vitrectomy (PPV), we performed modified ILM surgical technique (IFT) in which ILM peel was stopped at the edges of the hole forming a floating ILM flap. Primary outcome measures were pattern of TMH closure and recovery of EZ. Student’s T-test and Pearson’s correlation coefficient were used for statistical analysis.

Results

The study had 16 eyes of 16 patients. Mean baseline minimum linear diameter (MLD) was 562µ. Mean baseline best-corrected visual acuity (BCVA) was 1.4 logMAR. U-pattern closure occurred in 50% of eyes, V-pattern closure occurred in 31.2% of eyes, whereas W-pattern closure occurred in 18.7% of eyes. Mean BCVA improvement was 5 lines (p 0.02). Failure of recovery of EZ was detected in 75% of eyes. In the present series, neither pre-operative MLD nor time lapse prior to surgery were significant factors in determining the closure pattern of TMH, the grade of EZ recovery or final BCVA.

Conclusion

Modified IFT is effective in promoting macular hole closure and improving visual acuity in patients with TMH. The technique does not promote recovery of EZ.

Coexistence of Peripheral Retinal Diseases with Macular Hole

Objectives:

To investigate the frequency of retinal tear, retinal hole, and lattice degeneration in peripheral retinal examination of patients with macular hole.

Materials and Methods:

The files of patients who underwent pars plana vitrectomy surgery with a diagnosis of macular hole at Eskişehir Osmangazi University Department of Ophthalmology between 2008 and 2018 were retrospectively analyzed. A total of 106 patients with primary macular hole who underwent peripheral retinal examination were included in the study. The frequency of retinal tears, holes, and lattice degeneration associated with macular hole was investigated.

Results:

Peripheral retinal examination of 106 patients who underwent macular hole surgery revealed retinal tear in 3 patients (2.8%), retinal hole in 4 patients (3.8%), and lattice degeneration in 10 patients (9.4%). Retinal hole and lattice degeneration were observed concomitantly in 1 patient.

Conclusion:

This study showed that patients with macular hole have concomitant retinal tears and holes, which are also thought to arise due to vitreoretinal traction, at a frequency similar to that in the general population. This result suggests that both the anterior and posterior vitreous may have different pathologies at the same time related to these diseases.

MECHANISM OF "FLAP CLOSURE" AFTER THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE

PURPOSE

Recent studies described that in approximately 14% to 16% of cases of macular holes treated with the inverted internal limiting membrane flap technique, the hole was closed only by a thin layer of inverted internal limiting membrane-"flap closure." The aim of this article was to describe the functional and anatomical results in flap closure macular holes and also the mechanism of flap closure.

METHODS

A retrospective observational study of 149 eyes of 139 patients treated with vitrectomy using the inverted internal limiting membrane flap technique was reviewed to aggregate eyes with flap closure. Complete ophthalmic examination was performed preoperatively and at 7 days, 1, 3, 6, and 12 months after surgery.

RESULTS

Flap closure (Group 1) was noted in 24 eyes and other closure types in 125 eyes (Group 2). The mean minimal and base diameters of the macular holes in the flap closure group were greater than those in Group 2 (P < 0.001). The mean postoperative best-corrected visual acuity in the flap closure group (20/100) was lower than that in Group 2 (20/50) (P < 0.001).

CONCLUSION

Flap closure probably enables closure of large macular holes with a higher probability of remaining open without the use of the inverted internal limiting membrane flap technique. Foveal architecture continuously improved.

Optical coherence tomography angiography features in patients with idiopathic full-thickness macular hole, before and after surgical treatment

Purpose

To present optical coherence tomography (OCT) angiography features in patients with idiopathic full-thickness macular hole before and after vitrectomy.

Study design

Prospective case series study.

Materials and methods

Patients presenting with an idiopathic full-thickness macular hole (IMH) who underwent posterior vitrectomy with internal limiting membrane peeling and gas tamponade were included in the study. En face OCT and OCT angiography (OCTA) was performed pre- and postoperatively using 3×3 mm scans (Optovue, XR Avanti). Foveal avascular zone (FAZ) area, macular hole size (MHS), central retinal thickness (CRT), macular parafoveal choriocapillary flow area (MCFA), and fovea vessel density (FVDS) were measured and assessed using OCTA. Best-corrected visual acuity (BCVA) was examined before and 3 months after surgery.

Results

Twenty-eight eyes of 28 patients were included in the study. The mean age of patient group was 68.28 years. The hole was closed in all eyes after the initial surgery. OCTA showed enlargement of FAZ and increased CRT in foveal area. Mean preoperative FAZ area was 0.39±0.07 mm². En face images of the middle retina showed a range of preoperative cystic patterns surrounding the hole. BCVA was improved from 0.1±0.11 preoperatively to 0.42±0.17 postoperatively. Mean FAZ area was reduced to 0.24±0.07 mm² postoperatively with resolution of macular hole and adjacent cystic areas. Mean CRT was reduced from 396±62.6 µm pre-operatively to 272±30.7 µm postoperatively. After vitrectomy, the parafoveal choriocapillary flow area and FVDS of IMH eyes increased compared with the preoperative measurements.

Conclusion

Quantitative evaluation of vascular and morphological changes following IMH surgery using OCTA shows the potential for recovery due to vascular and neuronal plasticity. OCTA showing vascular changes and their quantitative characteristics might be a useful tool for the assessment of macular holes before and after surgical treatment.

Clinical outcomes with large macular holes using the tiled transplantation internal limiting membrane pedicle flap technique

AIM

To report the surgical technique and efficacy of the tiled transplantation internal limiting membrane (ILM) pedicle flap technique after vitrectomy for 33 patients with large macular hole (MH).

METHODS

This study was a prospective noncontrolled interventional study. All patients were treated by vitrectomy, the tiled transplantation ILM pedicle flap and gas tamponade. All patients underwent visual acuity measurements and optical coherence tomography (OCT), during preoperative and the follow-up visits postoperative.

RESULTS

Two high-myopic patient had flap dislocation during surgery. The thorough closure of MH following the tiled transplantation ILM pedicle flap technique was ultimately achieved in 31 patients observed by OCT imaging (93.94%) 1wk after surgery. Visual acuity improved from 1.51±0.31 (logMAR) preoperative to 0.92±0.30 6mo after surgery (P=0.000). There were no significant changes in OCT finding during the follow-up period from 1mo to 6mo after surgery.

CONCLUSION

The tiled transplantation ILM pedicle flap technique provides bridge for retinal gliosis to achieve successful closures of the large MHs, and the microenvironment of this technique is more similar to the normal physiological conditions.

A Combination of Surgical Techniques to Repair a Giant Traumatic Macular Hole

A 38-year-old man with a traumatic full-thickness macular hole (FTMH) presented to our eye casualty department with a sudden deterioration of his right eye vision to hand movements over the past one week. The suspected traumatic FTMH was present since he was 13 years old from a direct impact of a golf ball in his right eye and his best-corrected visual acuity (BCVA) has always remained at 1/60 Snellen vision. On examination, he had a very large FTMH measuring 1635 µm with central foveal retinal detachment. Pars plana vitrectomy combined with large inverted internal limiting membrane (ILM) peel flap, 5000 Cs silicone oil tamponade, and autologous platelets implantation was performed. Follow-up visits revealed that the FTMH was closed under silicone oil. The silicone oil was removed six months after the surgery and the FTMH remained close with the retina remaining attached. His BCVA was restored to his previous baseline level of 1/60 Snellen vision. With the advent of multiple techniques to repair FTMH such as the ILM flaps, we have combined this technique with older proven techniques such as silicone oil tamponade and autologous platelets implantation to close the giant traumatic FTMH. This case study demonstrates that combining techniques can help close a FMTH that is otherwise deemed impossible in the past.

Mechanical Evaluation of Retinal Damage Associated With Blunt Craniomaxillofacial Trauma: A Simulation Analysis

PURPOSE

To evaluate retinal damage as the result of craniomaxillofacial trauma and explain its pathogenic mechanism using finite element (FE) simulation.

METHODS

Computed tomography (CT) images of an adult man were obtained to construct a FE skull model. A FE skin model was built to cover the outer surface of the skull model. A previously validated FE right eye model was symmetrically copied to create a FE left eye model, and both eye models were assembled to the skull model. An orbital fat model was developed to fill the space between the eye models and the skull model. Simulations of a ball-shaped object striking the frontal bone, temporal bone, brow, and cheekbones were performed, and the resulting absorption of the impact energy, intraocular pressure (IOP), and strains on the macula and ora serrata were analyzed to evaluate retinal injuries.

RESULTS

Strain was concentrated in the macular regions (0.18 in average) of both eyes when the frontal bone was struck. The peak strain on the macula of the struck-side eye was higher than that of the other eye (>100%) when the temporal bone was struck, whereas there was little difference (<10%) between the two eyes when the brow and cheekbones were struck. Correlation analysis showed that the retinal strain time histories were highly correlated with the IOP time histories (r > 0.8 and P = 0.000 in all simulation cases).

CONCLUSIONS

The risk of retinal damage is variable in craniomaxillofacial trauma depending on the struck region, and the damage is highly related to IOP variation caused by indirect blunt eye trauma.

TRANSLATIONAL RELEVANCE

This finite element eye model allows us to evaluate and understand the indirect ocular injury mechanisms in craniomaxillofacial trauma for better clinical diagnosis and treatment.

Surgical Management of Idiopathic Macular Holes

Idiopathic macular holes have long been considered to be a stable, untreatable condition with little or no chance of spontaneous visual improvement. Within the last few years, surgical intervention has been developed for the management of idiopathic Stage 3 and Stage 4 holes. With pars plana vitrectomy surgery, at least 50% of patients will experience a 2 or more line improvement in visual acuity, and 25% of patients will improve to 20/40 or better. Since the natural history of idiopathic macular holes is extremely poor, all patients with Stage 3 or 4 lesions should be seriously considered for vitreous surgery.

Comparison of inverted flap and subretinal aspiration technique in full-thickness macular hole surgery: a randomized controlled study

PURPOSE

To compare the inverted flap and the subretinal aspiration technique for full-thickness macular hole (FTMH) surgery.

METHODS

Forty consecutive eyes with a stage IV FTMH were randomly assigned into 2 treatment groups. After core vitrectomy and perimacular internal limiting membrane (ILM) peeling, in group A, the subretinal remnant macular fluid was aspirated with a 41-G cannula after the air-fluid exchange procedure, while in group B, the technique of an inverted ILM flap was completed. Differences in postoperative best-corrected visual acuity (BCVA) and occurrence of intraoperative or postoperative complications between the 2 groups were evaluated.

RESULTS

All FTMHs were closed after the first surgery with no intraoperative or postoperative complications. In group A, 16 patients (80%) showed improvement of BCVA and 4 (20%) showed stabilization. In group B, 12 patients (60%) had improved BCVA, while 6 (30%) remained stable and 2 (10%) worsened. Postoperative BCVA for group A was significantly better than for group B (p = 0.022).

CONCLUSIONS

The surgical techniques had similar rates of closure of FTMH, although BCVA outcomes were significantly better in the subretinal aspiration group.

Pars Plana Vitrectomy with Internal Limiting Membrane Peeling in Traumatic Macular Hole: 14% Perfluoropropane (C3F8) versus Silicone Oil Tamponade

Purpose

To evaluate the outcome of 23 G PPV and ILM peeling with 14% C₃F₈ compared with silicone oil tamponade in cases of TMHs without spontaneous closure.

Methods

A retrospective comparative study included 33 eyes with TMHs; 7 eyes healed spontaneously, and the remaining 26 eyes have been treated with PPV and ILM peeling. Silicone oil was used as a tamponade for children or adults who refused to adopt face-down position (10 cases). In all other cases (16 cases), 14% C₃F₈ was used. These cases were followed up for 6 months postoperatively.

Results

26 cases (22 males and 4 females) were reviewed, including 10 cases treated with silicone oil and 16 cases treated with 14% C₃F₈. Patients' age ranged from 9 to 54 years. The success rate was 90% in the silicone-filled (9/10) and 94% in the gas-filled (15/16) eyes. At 6 months, the mean BCVA was 0.3 ± 0.25 in the silicone group and 0.2 ± 0.13 in the gas group (p < 0.05).

Conclusions

Cases of TMHs should be observed for spontaneous closure. PPV with ILM peeling should be conducted for nonclosing cases. Gas and silicone oil tamponades are equally successful in anatomical and visual outcomes. This trial is registered with CTRI/2017/06/008765.

miRNAs in the vitreous humor of patients affected by idiopathic epiretinal membrane and macular hole

Purpose

The aim of the present study was to assess the expression of miRNAs in the Vitreous Humor (VH) of patients with Macular Hole (MH) and Epiretinal Membrane (ERM) compared to a control group.

Methods

In this prospective, comparative study, 2-ml of VH was extracted from the core of the vitreous chamber in consecutive patients who underwent standard vitrectomy for ERM and MH. RNA was extracted and TaqMan^® Low Density Arrays (TLDAs) were used to profile the transcriptome of 754 miRNAs. Results were validated by single TaqMan^® assays. Finally, we created a biological network of differentially expressed miRNA targets and their nearest neighbors.

Results

Overall 10 eyes with MH, 16 eyes with idiopathic ERM and 6 controls were enrolled in the study. Profiling data identified 5 miRNAs differentially expressed in patients affected by MH and ERM with respect to controls. Four were downregulated (miR-19b, miR-24, miR-155, miR-451) and 1 was downregulated (miR-29a); TaqMan^® assays of the VH of patients affected by MH and ERM, with respect to controls, showed that the most differentially expressed were miR-19b (FC -9.13, p:<0.00004), mir-24 (FC -7.52, p:<0.004) and miR-142-3p (FC -5.32, p:<0.011). Our network data showed that deregulation of differentially expressed miRNAs induces an alteration of several pathways associated with genes involved in both MH and ERM.

Conclusion

The present study suggests that disregulation of miR-19b, miR-24 and miR-142-3p, might be related to the alterations that characterize patients affected by MH and ERM.

Effectiveness of combined macular buckle under direct vision and vitrectomy with ILM peeling in refractory macular hole retinal detachment with extreme high axial myopia: a 24-month comparative study

Purpose

To evaluate the efficacy of a combined macular buckle under direct vision and 23-gauge pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling in refractory macular hole retinal detachment (MHRD) with extreme high axial myopia.

Design

Prospective, randomised controlled study.

Participants

The study included 98 eyes of 98 patients of MHRD with extreme high axial (>30 mm) myopia.

Intervention

Patients were randomly assigned to undergo PPV with ILM peeling (group 1, n=52) or PPV with ILM peeling combined with macular buckle under direct vision (group 2, n=46).

Main outcome measures

Complete ocular examination included best-corrected visual acuity (BCVA) (LogMAR), applanation tonometry, optical biometry, slit-lamp biomicroscopy, colour fundus photography, ultrasound examination and optical coherence tomography at baseline and every follow-up visit.

Results

Initial retinal reattachment rate was significantly higher in group 2 than in group 1 at 12-month postoperatively (χ² test, p=0.020). Macular hole closure rate in group 2 was significantly higher than that in group 1 at 3, 12, 18 and 24 months postoperatively (Fisher's exact test, p<0.05). In initial retinal reattachment cases, the mean BCVA decreased significantly in group 2 than in group 1 at 3 months postoperatively (Wilcoxon matched pairs signed rank test, p=0.036), and had increased significantly in group 2 than in group 1 since 6 months postoperatively (Wilcoxon matched pairs signed rank test, p<0.05). Mean axial lengths in group 2 were significantly shorter than that of group 1 at each follow-up time point (Wilcoxon matched pairs signed rank test, p<0.05).

Conclusions

Combined macular buckle under direct vision and PPV with ILM peeling is more effective in treatment of MHRD with extreme high axial (>30 mm) myopia.

Sulfur hexafluoride (SF6) versus perfluoropropane (C3F8) tamponade and short term face-down position for macular hole repair: a randomized prospective study

Background

To compare early visual and anatomical outcomes after either sulfur hexafluoride (SF₆) or perfluoropropane (C₃F₈) tamponade for macular hole repair.

Methods

147 eyes affected by primary full-thickness macular hole underwent pars plana vitrectomy with dye assisted removal of the internal limiting membrane and gas tamponade. Prone position was prescribed for 48 h after surgery. All patients were divided into 3 groups depending on the size of the hole: small (<250 µm), medium (>250–<400 µm) or large (>400 µm). Eyes within the same group randomly received either SF₆ (70 eyes) or C₃F₈ (77 eyes). A complete ophthalmic evaluation, including best corrected visual acuity and anatomic status of the macular holes, was conducted preoperatively, at 1 week and 1 month after surgery. Macular hole volume was calculated using optical coherence tomography scans. The Wilcoxon Signed Ranks Test, the Mann–Whitney Test, the Spearman’s rank-order correlation coefficient and the study of variance for repeated measures were used for statistical analysis.

Results

Mean best-corrected visual acuity improved from 0.92 logMAR to 0.28 logMAR (P < 0.001). A reduction of the dimensions of macular holes was observed in all cases, with a total repair of 90 % (63/70 eyes) in the SF₆ group and 91 % in the C₃F₈ group (70/77 eyes). There was a negative correlation between the initial minor diameter, the volume of the hole and the rate of anatomic success.

Conclusions

Short-term anatomical and visual outcomes were similar in eyes treated with either SF₆ or C₃F₈, independently of the stage of the macular hole. The initial volume and the minor diameter of the hole may be considered as valid tools for predicting surgical success. Age and gender did not appear to have influenced the prognosis.

Full-Thickness Macular Hole Secondary to High-Power Handheld Blue Laser: Natural History and Management Outcomes

PURPOSE

To report the natural history and management outcomes of full-thickness macular hole (MH) caused by momentary exposure to a high-power handheld blue laser device and highlight the dangers of such easily available devices.

DESIGN

Retrospective consecutive case series.

METHODS

A chart review of all patients presenting with full-thickness MH from exposure to blue-light high-powered lasers from January 2012 to May 2014 at 2 institutions was performed. Evaluation included a full ophthalmic examination, fundus photography, macular spectral-domain optical coherence tomography, and fundus fluorescein angiography. The main and secondary outcomes were MH closure and final visual acuity, respectively.

RESULTS

There were 17 eyes of 17 patients with full-thickness MH. Best-corrected Snellen visual acuity (BCVA) at presentation ranged from 20/30 to 2/200 (mean: 20/210). The MH minimum diameter ranged from 168 μm to 620 μm (mean: 351 μm). Fourteen eyes underwent pars plana vitrectomy, internal limiting membrane peeling, and gas or silicone oil tamponade. Eleven of the 14 (78.6%) operated eyes had complete closure of the macular hole. Of the 3 unoperated eyes, only 1 eye with the smallest macular hole (minimum diameter: 168 μm) closed spontaneously with observation. Final BCVA in all cases had a mean of 20/62 (range: 20/20-4/200).

CONCLUSION

Full-thickness MH can result from momentary exposure to high-power handheld laser devices. While spontaneous closure may occur in rare cases, most cases require early surgical intervention. Vitrectomy may be successful in closing the macular hole with visual acuity improvement in most of the cases.

Evaluation of macular retinal ganglion cell-inner plexiform layer thickness after vitrectomy with internal limiting membrane peeling for idiopathic macular holes

PURPOSE

To evaluate macular retinal ganglion cell-inner plexiform layer (GCIPL) thickness changes after Brilliant Blue G-assisted internal limiting membrane peeling for idiopathic macular hole repair using a high-resolution spectral-domain optical coherence tomography (SD-OCT).

METHODS

32 eyes from 32 patients with idiopathic macular holes who underwent vitrectomy with internal limiting membrane peeling between January 2011 and July 2012 were retrospectively analyzed. GCIPL thickness was measured before surgery, and at one month and at six months after surgery. Values obtained from automated and semimanual SD-OCT segmentation analysis were compared (Cirrus HD-OCT, Carl Zeiss Meditec, Dublin, CA).

RESULTS

No significant differences were found between average GCIPL thickness values between preoperative and postoperative analysis. However, statistical significant differences were found in GCIPL thickness at the temporal macular quadrants at six months after surgery. Quality measurement analysis performed by automated segmentation revealed a significant number of segmentation errors. Semimanual segmentation slightly improved the quality of the results.

CONCLUSION

SD-OCT analysis of GCIPL thickness found a significant reduction at the temporal macular quadrants at 6 months after Brilliant Blue G-assisted internal limiting membrane peeling for idiopathic macular hole.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Ocular trauma. Blunt ocular trauma]

Ocular traumas represent a major public health problem with poorly understood ramifications at both the individual and community levels. Any of the ocular structures can be damaged in the case of closed globe injury. These lesions, often multiple, may appear immediately or in a delayed fashion. Classifications have been developed recently in order to better inform the patient of the visual prognosis. However, significant efforts are still needed, on the one hand, to assess and develop new therapies, and on the other hand, to implement effective policies to prevent ocular trauma.

Comparative study between a standard 25-gauge vitrectomy system and a new ultrahigh-speed 25-gauge system with duty cycle control in the treatment of various vitreoretinal diseases

AIM

To compare a standard 25-gauge vitrectomy system with a new ultrahigh-speed (UHS) 25-gauge system with duty cycle control for pars plana vitrectomy.

METHODS

In this prospective, controlled clinical trial, 120 patients (divided into 2 groups of 60 patients) underwent a 3-port pars plana vitrectomy for the treatment of epiretinal membranes, macular holes, retinal detachment, and complications of diabetic retinopathy. Evaluations were performed preoperatively, intraoperatively, on the first 3 postoperative days, and at 1 week, 1 month, and 3 months. Main outcome measures were vitrectomy time, induction of posterior vitreous detachment, and intra- and postoperative complications. Vitrectomy time included retinal manipulation, but did not include wound opening and closure.

RESULTS

The duration of surgery was significantly different between the groups. Patients in the new UHS 25-gauge group had a significantly shorter duration of vitrectomy time (P < 0.0001). Mean overall vitrectomy time was 1,583.7 ± 875.4 seconds (26 minutes) in the standard 25-gauge group and 1,106.3 ± 575.9 seconds (18 minutes) in the UHS 25-gauge group. Twenty-nine patients (48.3%) in the standard group and 27 patients (45.0%) in the UHS group experienced induction of posterior vitreous detachment. Thirteen patients (21.7%) in the standard 25-gauge group and 1 patient (1.7%) in the new UHS group had intraoperative iatrogenic retinal breaks.

CONCLUSION

The new-generation UHS 25-gauge system may provide a new paradigm of high-flow, smaller-diameter instrumentation, thus increasing the efficiency of the small-gauge technique and the safety of the surgery.

Macular hole formation in fellow eyes with a perifoveal posterior vitreous detachment of patients with a unilateral macular hole

PURPOSE

To estimate the rate of macular hole formation in fellow eyes with a perifoveal posterior vitreous detachment (PVD) and early stage 1 intrafoveal lesions in patients with a unilateral idiopathic full-thickness macular hole (MH) using optical coherence tomography (OCT).

DESIGN

Retrospective observational case series.

METHODS

Fellow eyes of consecutive patients with a unilateral full-thickness MH were examined on OCT. A subset of fellow eyes with a perifoveal PVD had been followed to investigate the rates of macular hole formation in fellow eyes with early stage 1 intrafoveal lesions.

RESULTS

Of 176 patients with a unilateral full-thickness MH, 42 fellow eyes (42 patients) with a perifoveal PVD were identified. During follow-up, a foveolar detachment was seen in 16 eyes, and 4 eyes had a foveal pseudocyst alone. In the 16 eyes with a foveolar detachment, 9 eyes had concurrent inner foveal splits. Within another 2 years of follow-up, OCT showed that 5 of 16 fellow eyes (31%) with a foveolar detachment developed a second full-thickness MH and 5 of 9 fellow eyes with a foveolar detachment and inner foveal splits developed a second full-thickness MH. Two of 4 eyes with a foveal pseudocyst alone developed vitreofoveal separation without hole formation. The remaining 2 eyes with a foveal pseudocyst alone remained stable at the last follow-up visit.

CONCLUSIONS

Fellow eyes with a foveolar detachment and a perifoveal PVD may be at high risk, and fellow eyes with a foveolar detachment and inner foveal splits might be at higher risk for progression to macular hole formation.

Correlation of microperimetry with fundus autofluorescence and spectral-domain optical coherence tomography in repaired macular holes

PURPOSE

To investigate the correlation of microperimetry with fundus autofluorescence (FAF), spectral-domain optical coherence tomography (SD-OCT), and visual acuity (VA) in order to better characterize visual outcomes after successful macular hole (MH) surgery.

DESIGN

Cross-sectional case series.

METHODS

Postoperative VA, microperimetry, FAF, and SD-OCT images from 23 eyes of 23 patients who underwent successful MH surgery were obtained. FAF images were examined using the Heidelberg retina angiograph 2, and foveal structure and macular sensitivity were evaluated with SD-OCT and microperimetry. The mean retinal sensitivities within the central 9 degrees (microperimetry, mean), the retinal sensitivity of the foveal center (microperimetry, center), and the difference between the values obtained for the foveal center or mean of study and fellow eyes (microperimetry, centerdiff and microperimetry, meandiff, respectively) were measured with microperimetry.

RESULTS

Microperimetry (mean) was well correlated with microperimetry (center) in both study and fellow eyes. Poor postoperative VA was correlated with large microperimetry (meandiff). Following successful MH surgery, FAF of all eyes decreased markedly. There was a positive correlation between microperimetry (centerdiff) and degree of FAF of study eyes. However, a decrease in FAF after MH surgery was not correlated well with either degree of defect in the junction between photoreceptor inner and outer segment (IS/OS) or central retinal thickness on SD-OCT.

CONCLUSIONS

The amount of remaining FAF is related to macular sensitivity as measured by microperimetry after successful MH surgery. Function of photoreceptors and retinal pigment epithelium as well as integrity can be estimated by measuring the decrease in FAF after successful MH surgery. Moreover, functional correlation with microperimetry provides both morphologic and functional information on repaired MHs.

A study of macular hole formation by serial spectral optical coherence tomography

BACKGROUND

The purpose of this paper is to evaluate changes of the vitreoretinal interface in fellow eyes of eyes with a macular hole and to study early stages of macular hole formation by spectral optical coherence tomography (SOCT).

METHODS

A prospective study of 131 consecutive patients with history of macular hole. Serial SOCT examinations were performed on the fellow eyes four times during a 6-month observation period. Progression of foveal changes and formation of macular hole in the fellow eyes were studied.

RESULTS

Seven distinct abnormalities in the foveal region were noted in 70 of the fellow eyes (53.4%). Additionally in 18 patients (13.6%) other defects typical for the older population were noted. Gradual evolution to full-thickness macular holes during the 6-month observation period was noted in five eyes. One of these eyes had a previously detected cyst, and four eyes had elevation of the photoreceptor layer.

CONCLUSIONS

The high prevalence of macular abnormalities in the fellow eyes particularly epiretinal membranes and vitreous traction with schizis as well as the evolution of these abnormalities over time suggest that diseases of the vitreomacular interface may have similar pathogenesis. Macular hole formation often starts as a triangular elevation of the photoreceptor layer. In some cases, a cyst in the inner retinal layers can be an early step in macular hole formation.

Retinal breaks associated with the induction of posterior vitreous detachment

PURPOSE

To evaluate the correlation between the incidence of vitrectomy-related retinal breaks and the induction of a posterior vitreous detachment (PVD).

DESIGN

Retrospective, nonrandomized comparative study.

METHODS

Three hundred and eleven eyes of 311 patients who underwent pars plana vitrectomy for the treatment of epiretinal membrane (ERM) or macular hole (MH) were reviewed. We identified the incidence of retinal breaks, the number of eyes requiring induction of PVD during operation, and the possible associated factors for retinal break in the 2 groups.

RESULTS

The incidence of retinal breaks related to the operation was 6.9% (12/174 eyes) in the ERM group and 14.6% (20/137 eyes) in the MH group (P = .02). Induction of PVD was carried out in 28 eyes (16.0%) of the ERM group and in 105 eyes (76.6%) of the MH group (P = .01). Intraoperative or postoperative retinal breaks, or both, in the ERM group were detected in 9 (32.1%) of 28 eyes with induction of PVD and in 3 (2.1%) of 146 eyes without induction of PVD (P = .006). A similar trend also was observed in the MH group; retinal breaks related to the operation were detected in 19 (12.7%) of 105 eyes with induction of PVD and in 1 (3.1%) of the 32 eyes without induction of PVD (P = .008).

CONCLUSIONS

Induction of PVD during vitrectomy results in a significantly higher incidence of intraoperative or postoperative retinal breaks, or both. Caution should be exercised after the induction of PVD to identify all retinal breaks so they can be treated.

Clinical and cost-effectiveness of internal limiting membrane peeling for patients with idiopathic full thickness macular hole. Protocol for a randomised controlled trial: FILMS (Full-thickness Macular Hole and Internal Limiting Membrane Peeling Study)

BACKGROUND

A full-thickness macular hole (FTMH) is a common retinal condition associated with impaired vision. Randomised controlled trials (RCTs) have demonstrated that surgery, by means of pars plana vitrectomy and post-operative intraocular tamponade with gas, is effective for stage 2, 3 and 4 FTMH. Internal limiting membrane (ILM) peeling has been introduced as an additional surgical manoeuvre to increase the success of the surgery; i.e. increase rates of hole closure and visual improvement. However, little robust evidence exists supporting the superiority of ILM peeling compared with no-peeling techniques. The purpose of FILMS (Full-Thickness Macular Hole and Internal Limiting Membrane Peeling Study) is to determine whether ILM peeling improves the visual function, the anatomical closure of FTMH, and the quality of life of patients affected by this disorder, and the cost-effectiveness of the surgery.

METHODS/DESIGN

Patients with stage 2-3 idiopathic FTMH of less or equal than 18 months duration (based on symptoms reported by the participant) and with a visual acuity

DISCUSSION

FILMS will provide high quality evidence on the role of ILM peeling in FTMH surgery.

TRIAL REGISTRATION

This trial is registered with Current Controlled Trials ISRCTN number 33175422 and Clinical Trials.gov identifier NCT00286507.

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Grants

• HERU1 Chief Scientist Office
• HERU2 Chief Scientist Office
• HSRU1 Chief Scientist Office

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Affiliation(s)

Noemi Lois Ophthalmology Department, Grampian University Hospitals-NHS Trust, Aberdeen, AB25 2ZN, UK
Jennifer Burr Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
John Norrie Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
Luke Vale Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
Jonathan Cook Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
Alison McDonald Health Services Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD, UK
the Full-thickness macular hole and Internal Limiting Membrane peeling Study (FILMS) Group

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Collaborators

Hatem Atta, Charles Boachie, John Forrester, Karon McEwing, Laura Duncan, Ayyakkawnv Manivannan, Gladys McPherson, Laura Ternent, Alison Farrow, Andrew Dick, Richard Haynes, Cherry Daly, Gillian Bennerson, Stephen Neilson, Dara Kilmartin, Catherine Cleary, Tarik Saddik, John Ellis, Stan Keys, Jim Talbot, Ian Pearce, Carl Groenewald, David Wong, Henrich Heimann, Valerie Tompkin, Ronnie Jackson, C K Patel, Charles Cottriall, Lynda Lindsell, Anne Bolton, David Steel, Sarah Muir, Anita Murphy, Terri Ainsley, Stephen Beatty, Asif Orakzai, Ayman Saeed, Muhammad Irfan Khan, Adrian Gran,

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Combined phacovitrectomy for macular hole: long-term results

BACKGROUND AND OBJECTIVE

To present the long-term results of patients undergoing combined phacovitrectomy surgery for idiopathic macular hole at a single center.

PATIENTS AND METHODS

A retrospective review of the records for 57 eyes of 53 consecutive patients who underwent combined phacovitrectomy for idiopathic macular hole during an 18-month period was completed at the Southampton Eye Unit.

RESULTS

In 45 of 57 eyes (78.9%), the macular hole closed after one surgical procedure. Forty-seven patients had a follow-up period of more than 12 months (mean = 22.1 months). In this group, the mean visual acuity (standard deviation) improved by 0.37 (+/- 0.46) logarithm of the minimum angle of resolution units. Thirty-two (68%) cases had improved visual acuity of 2 or more Snellen lines. Hole closure rate at the final follow-up examination was 87.2%.

CONCLUSION

Combining phacoemulsification and vitrectomy for an idiopathic macular hole has many benefits. It is a safe procedure and produces long-term results that are comparable to previously published series.

Optical coherence tomography characteristics of full-thickness traumatic macular holes

PURPOSE

The objective of this paper is to describe the optical coherence tomography (OCT) characteristics of patients with full-thickness traumatic macular hole (TMH) and to correlate them with biomicroscopy findings.

METHODS

Twelve eyes of ten consecutive patients with full-thickness TMH participated in this observational retrospective multicentre study. Patients underwent biomicroscopic fundus examination, colour fundus photography, and OCT.

RESULTS

Traumatic macular hole was documented with OCT in five women and five men. Mean (range) time between trauma and macular hole (MH) diagnosis was 8.1 (1-24) months. The shape of TMHs was round in 11 (91.7%) eyes. The posterior vitreous was completely detached in six (50%) eyes, and with an operculum in one (8.3%) eye. The common findings seen on OCT were: (1) full-thickness loss of retinal tissue through the hole with sharp edges, perpendicular to the retinal pigment epithelium in five (41.7%) eyes; (2) TMH with an operculum totally detached from the hole's edge in two (16.7%) eyes; (3) presence of epiretinal membrane around of the hole in three (25%) eyes; and (4) presence of abnormalities of the surrounding retina in all (100%) eyes. The OCT characteristics correlated well with biomicroscopic findings, and these characteristics may be predictive for final visual acuity (VA) in TMHs. Only one of the TMHs closed spontaneously in our series.

CONCLUSION

Optical coherence tomography complements biomicroscopy in the evaluation of full-thickness TMHs.

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

BACKGROUND AND OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Tamoxifen therapy conveys increased risk of developing a macular hole

PURPOSE

To determine etiological factors in the development of, as well as anatomic success rate and visual outcome of a large consecutive series of macular hole surgeries.

METHODS

Retrospective analysis of 300 consecutive cases of macular hole surgery by a single surgeon (RDB) between 1999 and 2003. Patients' medical and surgical histories were recorded and analysed for factors involved in aetiology and visual outcome.

RESULTS

There were 8 (4.12%) women, on tamoxifen in the study, two of these women had bilateral macular holes. When this study prevalence of tamoxifen therapy (4.12%) was compared to the estimated percentage of women in the same age group in the Australian population on tamoxifen (0.82%), a statistically significant difference (p value 0.0001) was found. Analysis of the number of bilateral holes in the tamoxifen group compared to the non-tamoxifen group was suggestive of an increased incidence of bilateral holes but not to a significantly significant degree.

CONCLUSION

Whilst no published reports link tamoxifen and macular holes, this may be due to the low incidence of the condition. Our study demonstrates a strong link between tamoxifen use and macular holes. Patients being commenced on tamoxifen should be advised of possible ocular complications and receive prompt ophthalmic review if symptoms develop.

Internal Limiting Membrane Removal during Macular Hole Surgery

PURPOSE

To evaluate the effect of internal limiting membrane (ILM) peeling and other variables in hole closure and functional success rate after idiopathic macular hole surgery.

DESIGN

Retrospective, multicenter, observational study.

METHODS

The records of 1627 patients operated on for idiopathic macular hole were collected retrospectively from 28 surgeons. All patients underwent a single pars plana vitrectomy and were divided into 2 groups: with and without ILM peeling. Preoperative, intraoperative, and postoperative variables were evaluated.

RESULTS

The overall rate of macular hole closure was 94.1% in the ILM peeling group and 89.0% in the no ILM peeling group (P<0.001). The probability of achieving hole closure after surgery is 2.59 times higher if the ILM is peeled (95% confidence interval [CI], 1.71-3.92; P<0.001), 3.12 times higher for holes lasting less than 6 months (95% CI, 1.70-5.71; P<0.001), 4.94 (95% CI, 2.39-10.20) for stage 2 holes, and 2.34 (95% CI, 1.55-3.53) for stage 3 holes than that of patients with a stage 4 hole (P<0.001).

CONCLUSIONS

Internal limiting membrane peeling seems to improve hole closure for stage 3 and 4 holes and for long-lasting holes. Higher-stage macular holes and longer duration of symptoms are risk factors for surgical failure. In patients obtaining hole closure, there is no difference in functional results between pseudophakic peeled and not peeled patients, whereas in phakic patients, a better functional result in not peeled patients was seen.