Macula hole surgery: simple or complex?

Bilateral pulmonary emboli following macular hole surgery with postoperative prone positioning

Purpose

To report a rare case of bilateral pulmonary emboli following pars plana vitrectomy with postoperative prone positioning.

Observations

A 60 year-old female presented with a fourmonth history of unilateral distorted vision. Ocular coherence tomography revealed a full thickness macular hole. Two weeks later, the patient underwent a 23-gauge pars plana vitrectomy with internal limiting membrane peeling and 12% perfluoropropane gas tamponade. Postoperatively, she completed two weeks of prone positioning. Five days later, she presented with a two day history of abdominal pain and shortness of breath. Computed tomography angiography revealed bilateral pulmonary emboli. The patient received six months of anticoagulation to prevent further thromboembolic events.

Conclusions

Life threatening blood clots can form due to prolonged immobilization from prone positioning. Patients should be educated to perform light exercise postoperatively to prevent complications of blood stasis.

Five-year nationwide incidence of macular hole requiring surgery in Korea

Background/aims

To estimate the incidence and demographics of macular hole (MH) requiring surgery in Korea.

Methods

Patients who underwent surgery for MH in Korea from 2011 to 2015 with the diagnostic code for MH and the surgical code for vitrectomy were retrospectively identified using the Korean national health claims database. The average incidence rate of MH during the 5-year study period was estimated by applying the direct method of standardisation using the 2015 census data as a reference population.

Results

A total of 7301 patients with MH requiring surgery were identified. The average incidence of MH requiring surgery was 3.14 (95 % CI, 3.07 to 3.21) per 100 000 person-years . The incidence in women (4.29 per 100 000 person-years; 95% CI, 4.17 to 4.40) was significantly higher than that in men (2.00 per 100 000 person-years; 95% CI, 1.92 to 2.07; p<0.001). The incidence rate of MH increased exponentially with increasing age between the ages of 35 years and 69 years and was highest among patients aged 65–69 years. The female-to-male ratio for the incidence of MH was 2.15:1.

Conclusions

This study represents the largest nationwide population-based investigation of the incidence of MH, using a database that covers the entire population of South Korea. MH is the disease of elderly peaked 70 years old and more common in women.

[Prognostic factors for idiopathic macular hole surgery: Report of 107 eyes (Approach by univariate statistical analysis)]

PURPOSE

To identify prognostic factors influencing the success of idiopathic macular hole surgery, including initial visual acuity, hole size and stage, and type of gas used for tamponade.

PATIENTS AND METHODS

Retrospective single-center descriptive analysis of all patients with an idiopathic macular hole operated by the same surgeon, treated in the ophthalmology department of Mulhouse hospital, between January 2004 and July 2014. Patients whose functional and anatomical results could be confounded by the coexistence of other ocular pathologies and patients with secondary macular holes were excluded.

RESULTS

We included and followed 107 eyes of 104 patients for at least 6 months. Initial closure after the first surgery was obtained in 92 eyes (85.98 %), allowing 2 groups to be defined, the cases of success and failure. Initial visual acuity, hole size, stage according to Gass, Gaudric and IVTS classifications, and presence or absence of a PVD, were statistically significant prognostic factors (P<0.05) CONCLUSION: Our univariate statistical analysis identified multiple prognostic factors. These factors may predict success and the choice of surgical technique, including whether to peel the internal limiting membrane, the choice of gas for tamponade, and postoperative positioning.

Re-accumulation of macular pigment after successful macular hole surgery

AIMS

To investigate macular pigment optical density (MPOD) during follow-up of sealed macular holes and to study correlations of MPOD with progressive changes in spectral-domain optical coherence tomography (SD-OCT) and functional results.

METHODS

Consecutive patients (n=18) who had undergone successful vitrectomies for idiopathic macular holes were evaluated postoperatively at 1, 3, 6 and 9 months. At each follow-up visit, MPOD was measured with a modified confocal scanning laser ophthalmoscope and the outer retina evaluated by SD-OCT. The changes of MPOD postoperatively and the relationship of MPOD and SD-OCT findings to best corrected visual acuity were examined.

RESULTS

MPOD did not change significantly throughout follow-up, from 0.49±0.22 (mean±SD) at month 1 to 0.42±0.18 at month 9. There was a tendency towards a significant association between amount of MPOD and recovery of external limiting membrane during follow-up (p=0.068). Best corrected visual acuity increased significantly from 0.24±0.12 before surgery to 0.65±0.25 at month 9. Recovery of the ellipsoid zone determined most of visual acuity improvement (p=0.024). MPOD was not associated with visual acuity changes (p=0.394).

CONCLUSIONS

Revisualisation of macular pigment after successful macular hole surgery is not associated with improved visual acuity and may merely be an accompanying sign of the reapposition of the edges of the hole.

Transient increase of retinal nerve fiber layer thickness after macular hole surgery

We studied the changes in the thickness of the retinal nerve fiber layer (RNFL) after surgery for idiopathic macular hole (MH) using spectral-domain optical coherence tomography (SD-OCT). Twenty eyes of 20 consecutive patients who underwent vitrectomy to close a MH were studied. The peripapillary RNFL thickness was measured by SD-OCT before and at 1, 3, and 6 months after surgery. The mean overall thickness, the thickness of the four quadrants, and the thickness of each of the 12 clock hours of the RNFL were analyzed. The mean overall RNFL thickness before surgery was 93.3 ± 9.6 lm,and it increased significantly to 98.7 ± 7.4 lm at 1 month after surgery (P\0.05). The mean overall thickness then returned to the pre-surgery level at three and 6 months. The transient increase of RNFL thickness at 1 month after surgery was statistically significant in the superior, nasal, and inferior quadrants. The increase in the thickness of the nasal quadrants was maintained for up to 6 months. When the thickness of the individual 12 clock hours were analyzed, the transient increase of RNFL thickness at 1 month after surgery was significant at each of the 0–5 o’clock positions. The transient increase in the RNFL thickness after MH surgery may be caused by mild edema of the inner retinal layers caused by the MH surgery.

A comparison of brilliant blue G, trypan blue, and indocyanine green dyes to assist internal limiting membrane peeling during macular hole surgery

PURPOSE

To compare surgical outcomes with three dyes, brilliant blue G (BBG), trypan blue (TB) and indocyanine green (ICG), used to facilitate internal limiting membrane peeling during macular hole surgery.

METHODS

This comparative, interventional cases series consisted of 50 eyes of 50 patients with senile idiopathic macular holes, who underwent vitrectomy with internal limiting membrane peeling using BBG (n = 15), TB (n = 20), or ICG (n = 15). The cases involving use of BBG and TB were enrolled prospectively and concurrently, and the cases using ICG were selected through chart reviews. We compared the intraoperative surgical facilitation with the 3 dyes and the surgical outcomes in terms of macular hole closure and visual improvement at 6 months.

RESULTS

The 3 groups were similar in mean age, sex distribution, preoperative best-corrected visual acuity, and duration of follow-up (P = 0.957, 0.974, 0.939, and 0.5524, respectively). Of the 3 dyes, BBG appeared to provide greatest intraoperative facilitation: most convenient to use and remove, and similar to ICG in terms of internal limiting membrane staining. Six months postoperatively, macular hole closed in 100%, 95%, and 86% eyes (P = 0.48) and visual improvement occurred in 80%, 85%, and 33% eyes (P = 0.005) in BBG, TB, and ICG groups, respectively. The BBG and TB groups also had a better final best-corrected visual acuity than ICG group (P = 0.05) and smaller percentage of visual decline (5% and 6.7% vs. 40% respectively; P = 0.049).

CONCLUSION

Brilliant blue G was comparable with TB in optimizing visual and functional outcomes, while it was similar to ICG in ease of internal limiting membrane peeling.

Long-term outcome of idiopathic macular hole surgery

PURPOSE

To evaluate the role of preoperative macular hole (MH) diameter, cataract surgery, and cystoid macular edema (CME) in the reopening of idiopathic macular hole (IMH) after initially successful surgery.

DESIGN

Multicenter, retrospective, comparative case series.

METHODS

One hundred and thirty patients (135 eyes) with stage 2, 3, or 4 IMH were included after successful IMH repair at Dijon University Hospital or Nancy University Hospital. The eyes were separated into 4 groups according to the lens status: group 1, vitrectomy in pseudophakic eyes; group 2, vitrectomy and cataract extraction as a combined procedure; group 3, vitrectomy followed by cataract extraction; group 4, vitrectomy on eyes that remained phakic. All patients underwent a complete vitrectomy with retinal inner limiting membrane peeling and intraocular gas tamponade. The main outcome measures were IMH closure rate and best-corrected visual acuity.

RESULTS

Mean duration of symptoms was 8.6 +/- 7.6 months. The follow-up was 37 +/- 8.6 months (range, 30 to 67 months). The mean preoperative IMH diameter was 454 +/- 191 mum. No MH reopened during the follow-up after the initial vitreous surgery. Seven cases of CME were observed (1 in groups 1 and 2; 5 in group 3), and cataract surgery was performed in the 53 patients in group 3 with a mean delay of 11.6 months.

CONCLUSIONS

Cataract extraction, CME, or preoperative MH diameter measured by optical coherence tomography were not identified as risk factors for IMH reopening.