Preoperative and postoperative features of macular holes on en face imaging and optical coherence tomography angiography

Artificial Intelligence, Digital Imaging, and Robotics Technologies for Surgical Vitreoretinal Diseases

OBJECTIVE

To review recent technological advancement in imaging, surgical visualization, robotics technology, and the use of artificial intelligence in surgical vitreoretinal (VR) diseases.

BACKGROUND

Technological advancements in imaging enhance both preoperative and intraoperative management of surgical VR diseases. Widefield imaging in fundal photography and OCT can improve assessment of peripheral retinal disorders such as retinal detachments, degeneration, and tumors. OCT angiography provides a rapid and noninvasive imaging of the retinal and choroidal vasculature. Surgical visualization has also improved with intraoperative OCT providing a detailed real-time assessment of retinal layers to guide surgical decisions. Heads-up display and head-mounted display utilize 3-dimensional technology to provide surgeons with enhanced visual guidance and improved ergonomics during surgery. Intraocular robotics technology allows for greater surgical precision and is shown to be useful in retinal vein cannulation and subretinal drug delivery. In addition, deep learning techniques leverage on diverse data including widefield retinal photography and OCT for better predictive accuracy in classification, segmentation, and prognostication of many surgical VR diseases.

CONCLUSION

This review article summarized the latest updates in these areas and highlights the importance of continuous innovation and improvement in technology within the field. These advancements have the potential to reshape management of surgical VR diseases in the very near future and to ultimately improve patient care.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

[Multimodal topographically oriented approach to the study of full-thickness macular holes]

PURPOSE

This article studies the relationship between structural changes according to the findings of optical coherence tomography (OCT) and OCT angiography (OCTA), microperimetry (MP), multifocal electroretinography (mfERG) parameters in topographically corresponding areas of the macular region in idiopathic full-thickness macular holes (FTMH).

MATERIAL AND METHODS

OCT, OCTA, MP and mfERG were performed in 14 eyes with FTMH stages I-IV according to Gass. In 13 points at a distance of 0-2.5°, 2.5-5.0°, and 5.0-10.0° from the fixation point, the light sensitivity (LS), amplitude and latency of the P1 component were compared with the size of the hole, the area of cystic changes (CC) at the level of the inner nuclear layer (INL) and the outer plexiform layer and Henle fiber layer complex (OPL+HFL), vessel density in the superficial and deep capillary plexus (SCP and DCP).

RESULTS

LS and P1 component amplitude were significantly reduced at a distance of up to 5.0° from the fixation point. LS correlates with the apical and basal diameter of the hole (R> -0.53), the area of CC in the INL (R> -0.62) and the OPL+HFL complex (R> -0.55), the density of vessels in the SCP at a distance of up to 2.5° from the fixation point (R>0.51) and in the DCP at a distance of up to 5° from the fixation point (R>0.49). The P1 amplitude correlates with the basal diameter of the hole (R= -0.38), the area of CC in the INL and the OPL+HFL complex (R> -0.33) and vessel density in the SCP (R=0.37) at a distance of up to 2.5° from the fixation point, as well as vessel density in the DCP at a distance of up to 5° from the fixation point (R=0.47). Vessel density in the DCP is significantly lower in the presence of CC in the retina (p<0.001).

CONCLUSION

In FTMH, there is a relationship between bioelectrical activity and LS, and structural disorders, capillary perfusion in different layers of the retina. A multimodal topographically oriented approach allows studying the relationship between structural and functional parameters in individual points of the retina and can be used in monitoring of FTMH after surgical treatment.

Effect of perfluoropropane (C3F8) versus sulfurhexafluoride (SF6) tamponades on the retinal microvasculature after macular hole surgery

PURPOSE

To determine the effects of C3F8 and SF6 gasses by using optical coherence tomography angiography (OCTA) in patients with surgically closed idiopathic full-thickness macular holes (FTMH).

METHODS

A prospective, comparative study, in which 38 eyes of 38 patients with an idiopathic FTMH were studied. Twenty patients were randomized to the C3F8 group and 18 patients to the SF6 group. All patients underwent pars plana vitrectomy, internal limiting membrane peeling with 14 % C3F8 or 20 % SF6 gasses. The superficial capillary plexus (SCP) and deep capillary plexus (DCP) vessel densities (VD), foveal avascular zone (FAZ) area in SCP, the choriocapillaris flow area; and subfoveal choroidal thickness (SFCT) were examined at preoperative and postoperative first- and third-month controls using OCTA.

RESULTS

When the changes in the FAZ, SFCT, SCP and DCP VDs were compared, no significant differences were found between the groups (p>0.05 for all). It was determined that the 1-mm radius flow area increases in the C3F8 group at the first and third months after the surgery were significantly higher than in the SF6 group (p<0.05). A significant gain was observed in the BCVA values compared to their preoperative values for both groups; however any differences between the C3F8 and SF6 groups in terms of BCVA were not detected in this study.

CONCLUSION

This is the first report to compare the effects of C3F8 and SF6 gasses on idiopathic FTMH surgery by using OCTA. C3F8 and SF6 gasses may have similar effect on the remodeling process of vascular tissues.

Perifoveal Microvascular Changes following Internal Limiting Membrane Peeling Surgery for Epiretinal Membrane and Macular Hole

INTRODUCTION

The aim of the study was to evaluate perifoveal microvasculature changes following pars plana vitrectomy with internal limiting membrane peeling for the epiretinal membrane (ERM) and macular hole (MH).

METHODS

This retrospective study included 59 eyes from 59 patients. Subjects were divided into two groups: an ERM group (n = 43) and an MH group (n = 16) based on the initial diagnosis. Swept-source optical coherence tomography angiography (SS-OCTA) was performed in the macular area, pre- and postoperatively. Perifoveal microvascular changes were calculated using MATLAB from the 6 × 6 mm SS-OCTA images, excluding the foveal avascular zone. Pre- and postoperative perifoveal vessel densities (pfVDs) were separately analyzed in six sectors (superior, superotemporal, inferotemporal, inferior, inferonasal, and superonasal) in the superficial capillary plexus (SCP) and deep capillary plexus (DCP). The baseline characteristics and other clinical factors were compared between the ERM and MH groups.

RESULTS

The postoperative best-corrected visual acuity significantly improved in both groups (p < 0.05). One year after surgery, the pfVD in the SCP of the ERM group significantly decreased in the inferotemporal sector (p = 0.049). The postoperative pfVD in the DCP of the MH group significantly decreased in temporal sectors (p < 0.05). The postoperative mean pfVD in the SCP in the MH group was significantly lower than that in the ERM group (p = 0.003). The presence of a dissociated optic nerve fiber layer (DONFL) was 75% in the MH group and 22% in the ERM group (p = 0.018). The correlation between the pfVD and DONFL was not statistically significant.

CONCLUSION

Postoperative pfVD reduction in the temporal sector, a corresponding area in which DONFL is present after MH surgery, was significantly observed. After vitreoretinal surgery in MH patients, OCTA may serve as a useful tool for monitoring perifoveal microvascular changes, especially in temporal sectors.

Changes in vascular density in the macula after pars plana vitrectomy for idiopathic macular hole with macular peeling and one type of flap

BACKGROUND AND AIMS

The aim of this study was to evaluate changes in vascular density in the macula after pars plana vitrectomy for idiopathic macular hole (IMD) with macular peeling and flap.

METHODS

A prospective study of 35 eyes in 34 patients who had undergone standard surgery. Evaluated parameters were best-corrected visual acuity (BCVA), intraocular pressure (IOP), central macular thickness (CRT), macular volume (TMV) and vascular density of the superficial and deep capillary plexus. The follow-up period was one year.

RESULTS

We divided the total group into two: temporal and circular flap and total group. We compared the values after surgery with the preoperative values. In the total group, BCVA increased from 48.38 to 71.44 letters (P≤0.05). IOP changed from 15.24 to 14.76 mmHg (P>0.05). CRT decreased from 432.27 to 323.64 µm (P≤0.05). TMV changed from 0.26 to 0.25 mm3 (P>0.05). The vascular density of the superficial plexus decreased from 32 to 28% (P≤0.05). The intercapillary space of the superficial plexus increased from 68 to 72% (P≤0.05). The vascular density of the deep plexus increased from 17 to 23%. The intercapillary space of the deep vascular plexus decreased from 83 to 77%. Changes in vascular density and intercapillary space of the deep plexus were statistically significant for certain months after operations (P≤0.05). There were no significant differences between subgroups.

CONCLUSION

The superficial plexus vascular density is almost the same in the temporal flap and in the foveal-sparing flap is decreased, and the deep plexus vascular density increased statistically significantly during the follow-up period after surgery.

Optical Coherence Tomography Angiography in Macular Holes Autologous Retinal Transplant

In this paper, we compare the post-operative macular microvascular parameters (vascular density and foveal avascular zone) in eyes with refractory macular hole (MH) that underwent pars plana vitrectomy and autologous retinal transplant (ART) with the fellow unoperated eye. We conducted a retrospective case control study of six consecutive patients who underwent pars plana vitrectomy and ART with at least six months of post-operative follow-up. Pre-operatively, all eyes underwent SD-OCT (Spectral Domain Optical Coherence Tomography) examination. Post-operative OCT-A analyses included vascular density (VD) and the foveal avascular zone (FAZ) area. Six patients with a mean age of 63.7 ± 14.3 years were included. The mean follow-up was 24 months (range 6–30 months). The pre-operative BCVA (best-corrected visual acuity) was 0.99 ± 0.46 logMAR and 1.02 ± 0.23 logMAR at the last post-operative visit (p = 1.00). The mean MH diameter was 966 ± 620 µm. VD in the MH group was 28.1 ± 7.3% compared to 20.2 ± 2.9% in the fellow eyes group (p < 0.05). The mean post-operative FAZ area in the MH group was 109.8 ± 114.6 mm2 compared to 41.5 ± 10.4 mm2 in the control group (p < 0.05). In all six eyes, MH closure was obtained. The post-operative visual acuity did not improve after ART. Eyes with a closed MH showed a bigger FAZ with a higher VD compared to the fellow healthy eye.

The effect of retinal perfusion on the bioelectric activity of the retina in full-thickness macular holes

BACKGROUND: Information on retinal capillary perfusion in idiopathic full-thickness macular hole (FTMH) is limited, and there are no data on the possible effect of blood supply to individual areas and layers of the retina on their functional activity. AIM: To study the relationship between vascular perfusion in the superficial and deep capillary plexuses (SCP and DCP) and the bioelectrical activity of the retina in full-thickness macular hole. MATERIALS AND METHODS: Multifocal electroretinography (mfERG), optical coherence tomography (OCT), and OCT-angiography (OCTA) were performed in 18 eyes with FTMH and 10 intact eyes. In the projection of individual hexagons of the mfERG pattern, parameters of bioelectrical activity were compared with structural changes (hole, cystic changes), capillary density in the SCP and DCP. RESULTS: In the FTMH group, the density of capillaries in the superficial capillary plexuses correlated with P1 implicit time in the R2 ring hexagons (R = 0.23, p 0.05), in the hole zone and intraretinal cystic changes (R = 0.21 and R = 0.22, p 0.05), P1 amplitude in the hole zone (R = 0.24, p 0.05). In deep capillary plexuses, the capillary density correlated with N1 implicit time at the fixation point and the hole zone (R = 0.57 and R = 0.19, p 0.05), P1 implicit time at the hole zone (R = 0.2, p 0.05), P1 amplitude in the hexagons of the R2 and R3 rings (R = 0.46 and R = 0.44, p 0.05), more pronounced in the hole zone and cystic changes (R = 0.54 and R = 0.29, p 0.05). CONCLUSIONS: There is a correlation between capillary perfusion in different layers of the retina and its bioelectrical activity in FTMH. A decrease in perfusion in the deep capillary plexus of the macula with a chronic macular hole may be a predictor of a low functional prognosis in the outcome of surgical treatment of FTMH.

Treatment of recurrent high myopic macular hole associated with retinal detachment using a human amniotic membrane

PURPOSE

To determine the efficacy of using a human amniotic membrane to close macular hole retinal detachment in highly myopic eyes.

STUDY DESIGN

Prospective, consecutive, nonrandomized interventional study.

METHODS

We included 19 high myopic eyes from 19 patients affected by macular hole retinal detachment who had already undergone vitrectomy with internal limiting membrane peeling. The patients underwent vitrectomy with amniotic membrane transplant.

RESULTS

Primary success was achieved after 3 months in 89.5% (17 of 19 eyes) and final macular hole closure was obtained in 94.7% (18 of 19 eyes) of the patients. The final retinal reattachment rate was 100%. The final 12-month mean BCVA improved from 20/2000 (2 logMAR) to 20/250 (1.1 logMAR). OCT-angiography revealed a high correlation between the superficial and deep capillary plexus and the final BCVA.

CONCLUSION

Human amniotic membrane patches can effectively repair macular hole retinal detachment in high myopic eyes in terms of anatomic results and BCVA recovery.

OCT ANGIOGRAPHY IN DISEASES OF THE VITREORETINAL INTERFACE

AIMS

Present the use of Optical Coherence Tomography Angiography (OCTA) in vitreoretinal interface diseases and results of macular capillary network evaluation before and after idiopathic macular hole surgery (IMD).

METHODOLOGY

Prospective evaluation of functional results, anatomical and OCTA findings before and after IMD surgery. The group consists of 8 eyes of eight patients. Preoperatively and 1, 3 and 6 months after surgery, the best corrected visual acuity (BCVA) was examined, fundus photography was performed, examination of the macula by spectral-domain optical coherence tomography (SD OCT), determination of the stage of IMD according to Gases and also OCTA examination. The area of the foveal avascular zone (FAZ) and vascular density (VD) were evaluated by using of the OCTA. The operation was performed in all cases by transconjunctival suture 25G vitrectomy by one surgeon, always peeling the inner limiting membrane. An expansive gas, 7x 20% SF6, 1x 15% C3F8, was used for vitreous tamponade.

RESULTS

In all 8 cases, the primary closure of the IMD occurred after the operation. The mean BCVA improved statistically significantly from 0.74 to 0.48 logMAR (p = 0.0023). The average FAZ area decreased from 0.345 mm² to 0.25 mm² after surgery (p = 0.0458). The mean VD increased from 7.93 mm-1 to 8.38 mm-1 (p = 0.2959).

CONCLUSIONS

Assessment of the macular capillary network in patients with diseases of the vitreoretinal interface offers new findings and important details that can lead to prognostic information and a better understanding of the pathogenesis of the disease. We demonstrated a statistically significant reduction in FAZ in the eyes after successful IMD surgery and an indirect relationship between the improvement of BCVA and the change in FAZ area in our cohort.

A fingerprint hidden inside the eye. A unique pattern of outer retina splitting as seen on en-face OCT and OCT-angiography

A splitting of the outer plexiform retinal layer in a saw-like hyporeflective pattern in addition to partially formed concentric circles centred at the foveola were observed using en-face OCT and OCT-angiography in a 27-year-old female patient with rhegmatogenous retinal detachment and a 50-year-old female patient with Vogt-Koyanagi-Harada chorioretinopathy.

Intraretinal Cysts in Macular Hole: A Structure-Function Correlation Based on En Face Imaging

Purpose

To characterize retinal micromorphic changes on en face optical coherence tomography (OCT) and to determine their role in pathogenesis and visual outcomes in macular hole (MH) surgery.

Patients and Methods

This is a retrospective, interventional, consecutive case series of 28 eyes undergoing successful MH surgery. Pre- and post-operative en face OCT were manually segmented, and the correlation between parameters such as MH basal diameter and minimal inlet area, area of cyst in inner plexiform layer (IPL) and outer plexiform layer (OPL), percentage of cyst in IPL and OPL, and amount of ellipsoid zone (EZ) defect and external limiting membrane (ELM) defect was performed. Their relationship with visual acuity (VA) outcomes (Group 1: ≥20/60; 14 eyes; Group 2: <20/60; 14 eyes) was also evaluated.

Results

A significant positive correlation was noted between the cyst area in OPL and IPL (r=0.768; p<0.001), which in turn were positively correlated with the basal diameter of the MH in all eyes. The cyst area was significantly more in IPL as compared to OPL in all eyes (p=0.049) and in group 2 (p=0.03) but not in group 1 (p=0.62). As compared to group 2, eyes in group 1 had significantly better pre- and post-operative VA, and significantly smaller basal diameter, minimal inlet area, area of cyst in IPL and OPL, and amount of defect in the ELM (postoperative) and EZ (pre- and post-operative), respectively.

Conclusion

An increase in the basal diameter of the MH is associated with a simultaneous congruous enlargement of the area of cyst in IPL and OPL. Based on these imaging findings, we propose that the possible rationale for the origin of these intraretinal cysts could be a breakdown in the physiological retinal pigment epithelium (RPE) pump due to the anatomical separation of the neurosensory retina from the underlying RPE, ie, "RPE contact loss" theory.

[Biomarkers in full-thickness and lamellar defects of the macula]

BACKGROUND

Biomarkers are characteristic biological measurable signs and objective parameters to detect the state of health. Besides functional and temporal factors, imaging biomarkers play an increasingly important role. In full-thickness and lamellar defects of the macula numerous imaging parameters have been described. This knowledge resulted in new classifications for both clinical pictures, which are based on important biomarkers of these clinical pictures and characteristic features of described subtypes.

METHODS

Imaging biomarkers for full-thickness and lamellar macular defects are described with respect to the classification and their functional prognostic importance. The importance of these biomarkers is presented.

RESULTS

The current classification of full-thickness and lamellar macular defects is based on structural biomarkers. Biomarkers are important for prognostic and therapeutic evaluation and they have an impact on the surgical strategy. There are various surgical strategies for treatment of full-thickness macular holes depending on the size of the foramen and other biomarkers. The inverted ILM flap technique improves the closure rate of large macular holes. In lamellar macular holes showing signs of progression an early surgical intervention results in a good anatomical and functional prognosis.

CONCLUSION

Multimodal diagnostics provide important preoperative, intraoperative, and postoperative features for macular holes and lamellar macular holes, which are essential biomarkers for the exact classification, the therapeutic strategy and for assessment of the prognosis.

ASSESSING THE ABILITY OF PREOPERATIVE QUANTITATIVE SPECTRAL-DOMAIN OPTICAL COHERENCE TOMOGRAPHY CHARACTERISTICS TO PREDICT VISUAL OUTCOME IN IDIOPATHIC MACULAR HOLE SURGERY

PURPOSE

To determine which spectral domain optical coherence tomography biomarkers of idiopathic macular hole (MH) correlate with the postoperative best-corrected visual acuity (BCVA) in anatomically closed MH.

METHODS

Retrospective analysis of spectral domain optical coherence tomography scans of 44 patients presenting with MH followed for a mean of 17 months. Widths of MH aperture, base, and ellipsoid zone disruption were calculated from presenting foveal spectral domain optical coherence tomography B-scans. Macular hole base area and ellipsoid zone disruption area were calculated through the custom in-house software.

RESULTS

Poorer postoperative BCVA correlated with increased preoperative choroidal hypertransmission (r = 0.503, P = 0.0005), minimum diameter (r = 0.491, P = 0.0007), and base diameter (r = 0.319, P = 0.0348), but not with preoperative ellipsoid zone width (r = 0.199, P = 0.2001). Applying en-face analysis, the BCVA correlated weakly with preoperative ellipsoid zone loss area (r = 0.380, P = 0.013), but not with preoperative MH base area (r = 0.253, P = 0.1058).

CONCLUSION

Increased MH minimum diameter, base diameter, base area, and choroidal hypertransmission are correlated with a poorer postoperative BCVA. Ellipsoid zone loss measurements were not consistently correlated with a BCVA. Choroidal hypertransmission width may be an easy-to-visualize predictive imaging biomarker in MH surgery.

Secondary Vitrectomy with Internal Limiting Membrane Plug due to Persistent Full-Thickness Macular Hole OCT-Angiography and Microperimetry Features: Case Series

Purpose

To study the features in OCT-angiography and microperimetry in eyes with persistent full-thickness macular hole (FTMH) closed with the secondary plana vitrectomy (PPV) with autologous internal limiting membrane (ILM) plug.

Methods

Secondary PPV was performed with closing the persistent FTMH with ILM plug, C₃F₈ tamponade, and face-down positioning. Four patients were followed for 6 months with best corrected visual acuity (BCVA) measurement, SD-OCT and OCT-A, and microperimetry. The results were compared with the fellow eye; in two patients, it was the healthy eye, and in two remaining eyes, successfully closed FTMH after primary PPV.

Results

ILM flap was integrated in all cases with V-shape of closure, and atrophy was found in one case, with the largest diameter of FTMH. BCVA improved in two cases and remained the same in two cases. In OCT-A, the area of foveal avascular zone (FAZ) was larger, and foveal vessel density (FVDS) was smaller in eyes after secondary PPV in comparison to fellow eyes. In microperimetry, retinal sensitivity was lower in eyes after secondary PPV, and eccentric fixation was found in 2 of 4 patients.

Conclusion

Although the anatomical results of repeated surgeries of FTMH with ILM plug are favorable, visual function results may be limited. Secondary closure of FTMH with ILM plug may lead to atrophy, changes in the macular vasculature, and eccentric fixation. The trial is registered with NCT03701542.

Optical coherence tomography angiography using the black-and-white pixel binarization histogram software: a new technique for evaluating healing of macular holes in two surgical techniques

Background

Many factors can influence the functional outcomes of macular hole surgery and some studies have tried to describe anatomical features that could predict successful treatment. The purpose of this study is to describe a new technique for evaluating the healing of macular holes after two surgical techniques using a black-and-white pixel binarization histogram software by optical coherence tomography angiography and its potential functional implications.

Methods

This was a retrospective, observational case series of patients who presented with idiopathic full-thickness macular holes and underwent vitreoretinal surgery for successful macular hole closure using the internal limiting membrane peeling technique or the inverted peeling technique or the free internal limiting membrane flap technique. Optical coherence tomography angiography 3.0 × 3.0-mm scans were obtained postoperatively. The outer retina layer was analyzed separately; three different analyses were performed within a 3.0-mm-diameter area central circle, a 1.5-mm-diameter area, and a 0.5-mm-diameter area from the foveal center. The outer retinal layer images were evaluated by counting the number of black and white pixels. The inclusion criteria were patients with idiopathic macular holes who underwent ophthalmologic examinations and swept-source optical coherence tomography 1 week and 1 and 6 months postoperatively. The exclusion criteria were a traumatic macular hole or a history of eye trauma and a diagnosis of glaucoma or any other chronic ocular disease. The Mann–Whitney test was used to determine significance; P < 0.05 was considered significant.

Results

Ten eyes of 10 patients who underwent vitreoretinal surgery to treat a macular hole either with the conventional peeling technique (n = 5) or the inverted/free internal limiting membrane flap technique (n = 5) were included. In the peeling group, the percentage of white pixels ranged from 7.22% to 18.40% in the 0.5 × 0.5-millimeter area in the macular center; the mean postoperative logarithm of the minimum angle of resolution best-corrected visual acuity was 0.3 ± 0.2. In the inverted flap group, the percentage of white pixels ranged from 3.65% to 8.93% in the 0.5 × 0.5-millimeter area in the macular center; the mean logarithm of the minimum angle of resolution best-corrected visual acuity was 0.9 ± 0.4.

Conclusions

A simple method of optical coherence tomography angiography imaging analysis of the outer retina using a binarization technique of the black and white pixels was created and may have functional implications during the analysis of the healing process after macular hole surgery. We hypothesized that higher numbers of white pixels correspond to viable cellularity and better prognoses postoperatively.

iOCT-assisted macular hole surgery: outcomes and utility from the DISCOVER study

BACKGROUND/AIMS

This study aimed to characterise the clinical outcomes and utility of intraoperative optical coherence tomography (iOCT)-assisted macular hole (MH) repair.

METHODS

This was a post hoc analysis of eyes in the D etermination of feasibility of I ntraoperative S pectral domain microscope C ombined/integrated O CT V isualization during E n face R etinal and ophthalmic surgery (DISCOVER) study undergoing surgical MH repair with use of iOCT. Functional and surgical outcome data were collected through 12 months postoperatively. MH closure rate, postoperative visual acuity (VA), percentage of cases in which iOCT provided valuable feedback and altered surgical decision making were measured.

RESULTS

Eighty-four eyes were included in this study. The mean preoperative VA measured 20/114. The mean postoperative VA improved to 20/68 (p<0.001) at month 1, 20/48 (p<0.001) at month 3 and 20/45 (p<0.001) at month 12 or later. In 43 cases (51%), surgeons reported that iOCT provided valuable information (eg, confirming release of vitreomacular traction and identification of occult residual membranes). In 10 cases (12%), iOCT data specifically altered surgical decision making. Postoperative day 1 transtamponade OCT confirmed tissue apposition and apparent hole closure in 74% of eyes (21/26). All five open holes on postoperative day 1 closed following positioning. Single-surgery MH closure was achieved in 97.6% of cases. One persistent MH was successfully closed with a subsequent surgical repair for a final overall closure rate of 98.8%. Due to chronicity and MH size, additional repair was not recommended for the single remaining persistent MH.

CONCLUSION

This study suggests that iOCT may have important utility in MH surgery, including impacting surgical decision making. iOCT-assisted MH surgery resulted in significant improvement in VA and high single-surgery success rate.

Correlations between intraretinal cystoid cavities and pre- and postoperative characteristics of eyes after closure of idiopathic macular hole

Intraretinal cystoid cavities have been detected at the edges of macular holes (MHs) but their clinical characteristics and their relationship to the MH variables have not been determined. We measured the areas of the intraretinal cystoid cavity in 111 eyes with MHs in the OCT images preoperatively. Our results showed that the intraretinal cystoid cavities were located in the Henle fiber layer-outer nuclear layer (HFL-ONL) complex in 106 eyes and in the inner nuclear layer (INL) in 89 eyes. All were resolved after the initial vitrectomy to close the MH. The mean area of the cystoid cavity was greater in the HFL-ONL complex (55.9 ± 42.7 × 10³ μm²) than in the INL (9.1 ± 9.8 × 10³ μm²; P < 0.001). The area of the cystoid cavities was significantly correlated with the basal MH size (r = 0.465,P < 0.001), the external limiting membrane height (r = 0.793, P < 0.001), and the maximum retinal thickness (r = 0.757, P < 0.001). The area of the cystoid cavities was significantly correlated with the preoperative best-corrected visual acuity (BCVA; r = 0.361, P < 0.001), but not with the postoperative BCVA or the integrity of any of the outer retinal microstructural bands. The presence of intraretinal cystoid cavities was related to some morphological characteristics, but not to the postoperative BCVA or the restoration of the outer retinal bands.

Inner Retinal Layer and Outer Retinal Layer Findings after Macular Hole Surgery Assessed by means of Optical Coherence Tomography

Aim

To summarize the spectrum of optical coherence tomography (OCT) and OCT angiography (OCTA) features after full-thickness macular hole (MH) repair surgery.

Methods

A PubMed engine search was carried out using the terms "Macular Hole," "Optical Coherence Tomography," and "Optical Coherence Tomography Angiography." All reports published in English up to October 2018, irrespective of their publication status, were included. Tomographic signs analyzed were divided according to the involved portion of the retina in "inner retinal layers" and "external retinal layers." Despite predominantly involving the inner retinal layers, cystoid macular edema (CME) has been treated as a separate entity. Finally, report on vessel density (VD) changes and the foveal avascular zone (FAZ) area modifications have been included.

Results

Different clinical findings can be observed on OCT of patients who underwent MH repair surgery. There is general consent that retinal thinning involving primarily the retinal nerve fiber layer and the ganglion cell layer takes place after surgery. In the postoperative period, the outermost retinal layers get progressively restored. Persistent defects in the ellipsoid zone or in the external limiting membrane correlate with worse postoperative visual outcome. OCTA has globally demonstrated that eyes after MH closure show a reduction in macular and paramacular VD and smaller FAZ areas, compared with control or fellow eyes.

Conclusion

Clinicians should be aware of the most common tomographic findings to properly manage each condition. In addition, significant advantages for the postoperative application of OCT and OCTA include noninvasiveness, rapid and simple execution, repeatability, and precise measurements.

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.

Multi-Scale Segmentation and Surface Fitting for Measuring 3-D Macular Holes

Macular holes are blinding conditions, where a hole develops in the central part of retina, resulting in reduced central vision. The prognosis and treatment options are related to a number of variables, including the macular hole size and shape. High-resolution spectral domain optical coherence tomography allows precise imaging of the macular hole geometry in three dimensions, but the measurement of these by human observers is time-consuming and prone to high inter- and intra-observer variability, being characteristically measured in 2-D rather than 3-D. We introduce several novel techniques to automatically retrieve accurate 3-D measurements of the macular hole, including: surface area, base area, base diameter, top area, top diameter, height, and minimum diameter. Specifically, we introduce a multi-scale 3-D level set segmentation approach based on a state-of-the-art level set method, and we introduce novel curvature-based cutting and 3-D measurement procedures. The algorithm is fully automatic, and we validate our extracted measurements both qualitatively and quantitatively, where our results show the method to be robust across a variety of scenarios. Our automated processes are considered a significant contribution for clinical applications.

Macular capillary plexuses after macular hole surgery: an optical coherence tomography angiography study

AIMS

To investigate the structural changes of the superficial capillary plexuses (SCP) and deep capillary plexuses (DCP) using optical coherence tomography (OCT) angiography (OCTA) in patients with idiopathic macular hole (MH) after surgery, determine the factors related to changes of macular capillary plexuses and evaluate its association with postoperative visual outcomes.

METHODS

Thirty-three patients with unilateral MH who were followed for ≥6 months after surgery were included. Ophthalmologic evaluations included best corrected visual acuity (BCVA) and spectral-domain OCT before surgery and 6 months postsurgery. En face OCTA images were obtained for both eyes at 6 months postsurgery, and the postoperative foveal avascular zone (FAZ) area and parafoveal vascular density were identified.

RESULTS

Compared with fellow eyes, eyes after MH surgery had a smaller FAZ area in both SCP and DCP (p<0.05 for all). The FAZ area was positively correlated with postoperative foveal thickness of the whole, inner and outer layers (p<0.05 for all). In the parafoveal region, eyes after MH surgery had a tendency to have lower parafoveal vascular density, particularly in DCP (p=0.019). The parafoveal vascular density in DCP was positively correlated with retinal thickness of the whole, inner and outer layers (p<0.05 for all). Correlations between BCVA and FAZ area in both SCP and DCP were significant 6 months after MH surgery (p<0.05 for all).

CONCLUSION

Assessment of macular capillary plexuses using OCTA may be useful for monitoring retinal structural and functional changes in MH.