United Kingdom National Ophthalmology Database Study of Vitreoretinal Surgery: Report 2, Macular Hole

Vitrectomy in Small idiopathic MAcuLar hoLe (SMALL) study: Internal limiting membrane peeling versus no peeling

PURPOSE

To compare vitrectomy with and without internal limiting membrane (ILM) peeling in small idiopathic macular holes.

METHODS

Retrospective multicentre study including consecutive eyes with ≤250 μm idiopathic macular hole treated with vitrectomy. The primary outcome was hole closure rate. Best-corrected visual acuity (BCVA) change, closure patterns on optical coherence tomography, rates of external limiting membrane (ELM) and ellipsoid zone (EZ) recovery, and rate of complications were also investigated.

RESULTS

In total, 693 eyes were included. Hole closure rate was 98% in the peeling and 85% in the no-peeling group (p < 0.001). At 12 months, mean BCVA change was 0.38 ± 0.22 logMAR in the peeling and 0.45 ± 0.21 logMAR in the no-peeling group (p = 0.02); 66% versus 80% of eyes had a U-shaped morphology, respectively; EZ recovery rate was 75% and 93%, respectively (p = 0.02). In the no-peeling group, eyes with a vitreomacular traction (VMT) showed a 96% closure rate, comparable to the peeling group (p = 0.40). The incidence of adverse events was similar except for dissociated optic nerve fibre layer (55% in the peeling vs. 9% in the no-peeling group, p < 0.001).

CONCLUSIONS

In small idiopathic macular holes, ILM peeling provides a higher closure rate compared to no-peeling; however, if a VMT is present closure rates are comparable. In closed macular holes, the no-peeling technique provides advantages in terms of visual outcome and anatomical recovery.

Platelet concentrates in macular hole surgery. A journey through the labyrinth of terminology, preparation, and application: a comprehensive review

The surgical management of macular holes is undergoing continuous evolution, with recent focus on the utilization of platelet concentrates as a promising adjunctive intervention. Currently, they present a valid surgical approach for achieving anatomical and functional success with a non-inferiority comparably to the alternative surgical techniques. Nonetheless, the utilization of varied platelet concentrates terminologies, coupled with the lack of standardization in their preparation methodologies, engenders both lexical confusion and challenges in comparing scientific studies published up until now. In this review, we summarized the published evidence concerning the application of platelet concentrates in macular holes surgery, aiming to clarify the terminology and methodologies employed and to establish a common consensus facilitating further development and diffusion of this promising technique.

Clinical trial to test the safety of the EVA Nexus surgical platform

BACKGROUND

The EVA Nexus system offers several technical improvements over its predecessor. The newly designed Aveta cannula system for vitrectomy surgery avoids the need for removal of the valve from the infusion cannula. The chamfered leading edge of the cannula also reduces the insertion force needed. The new EquiPhaco needles in combination with SmartIOP provide excellent anterior chamber stability during phaco-emulsification surgery, enabling to work at lower infusion pressures, and the multiburst phaco mode allows easier removal of hard cataracts. The system offers a secondary active infusion line for independent control of pressure to the anterior and posterior chambers, monitoring of flow rate/reflux and warning of infusion bottle emptying. This study evaluated whether these technical improvements result in improved surgical safety.

METHODS

In total, 250 eyes that underwent vitrectomy (53%) or phaco-vitrectomy (47%) using the EVA Nexus system were prospectively included. The occurrence of intraoperative adverse events was compared to that of historically operated eyes using the EVA system.

RESULTS

The average age of the patients was 63 years. A total of 33% of the patients were operated on for retinal detachment, 17% for macular pucker, 11% for treating floaters, 9% for removing silicone oil, 8% for macular hole repair and 22% for other diseases. In 75% of surgeries, 23 G instruments were used, and 27 G instruments were used in 25% of cases. Device issues that occurred included priming cycle issues (n = 4), eye pressure stability problems (n = 6) and vitrectome performance issues (n = 1), all of which in the first 100 patients who were included and were fixed with software updates. The frequency of surgical complications in the anterior segment was lower than that in the historically recorded surgical reports. Intraoperative events in the posterior segment included hemorrhage from retinal vessels, choroidal hematoma, iatrogenic retinal damage/tear, and subchoroidal infusion. Again, these events occurred rarely and less frequently than in the historical surgical reports.

CONCLUSIONS

The EVA Nexus provides a surgical platform that reduces the incidence of intraoperative adverse events and iatrogenic complications in both anterior and posterior segment surgery. This could increase surgical safety during cataract and vitrectomy surgery. TRIAL REGISTRATION NUMBER CLINICALTRIALS.GOV: : NCT05229094 Data 22/5/2021.

[Vitreomacular traction: diagnostics, natural course, treatment decision and guideline recommendations]

Vitreomacular traction is a tractive foveolar adhesion of the posterior vitreous limiting membrane, resulting in pathological structural alterations of the vitreomacular interface. This must be differentiated from physiological vitreomacular adhesion, which exhibits a completely preserved foveolar depression. Symptoms depend on the severity of the macular changes and typically include reduced visual acuity, reading problems and metamorphopsia. High-resolution spectral domain optical coherence tomography (SDOCT) imaging enables classification of the sometimes only subtle morphological changes. If pronounced vitreomacular traction is accompanied by epiretinal gliosis and alterations to the outer retina, it is referred to as a vitreomacular traction syndrome. Vitreomacular traction has a high probability of spontaneous resolution within 12 months. Therefore, treatment should only be carried out in cases of undue suffering of the patient and with symptoms during bilateral vision and a lack of spontaneous resolution. In addition to pars plana vitrectomy, alternative treatment options, such as intravitreal injection of ocriplasmin and pneumatic vitreolysis are discussed for vitreomacular traction with an associated macular hole; however, ocriplasmin is no longer available in Germany. The best anatomical results in comparative investigations were achieved by vitrectomy. Pneumatic vitreolysis is controversially discussed due to the increased risk of retinal tears. In one of the current S1 guidelines of the German ophthalmological societies evidence-based recommendations for the diagnostics and treatment of vitreomacular traction are summarized.

Surgery for idiopathic full-thickness macular holes within four months of symptom onset yields superior visual outcomes: Results from an Irish patient cohort

PURPOSE

To describe the anatomical, visual, and safety results of full-thickness macular hole (FTMH) repair surgery and determine factors influencing outcomes.

PATIENTS AND METHODS

A retrospective chart review was performed on all patients who underwent primary FTMH repair surgery by a single surgeon over a 3-year period. For comparisons, Snellen visual acuity (VA) was converted to logMAR equivalent. Anatomical hole closure, visual improvement, and final VA of ≤ 0.30 logMAR were the primary outcome measures.

RESULTS

Twenty eyes of 19 patients were included. Mean patient age was 69 years (range 55 to 80 years) and 74% were female. Mean minimum linear diameter (MLD) was 440 μm (range 170 μm to 1200 μm). Mean duration of symptoms before surgery was 16 weeks (range 3 to 39 weeks). 100% of eyes achieved successful anatomical FTMH closure. Mean VA improved from 1.03 ± 0.43 logMAR (Snellen 6/60) preoperatively to 0.35 ± 0.22 logMAR (Snellen 6/15) postoperatively (p = 0.0001). Patients with worse preoperative VA gained more vision than those with better preoperative VA (p = 0.01). Eyes operated on within 4 months of symptom onset were more than twice as likely to achieve a postoperative VA of ≤ 0.30 logMAR (Snellen 6/12 or better) compared to eyes with a longer duration of symptoms (p = 0.03).

CONCLUSION

FTMH repair surgery was safe and effective, with outcomes comparing favourably with published international studies. All patients benefited from surgery regardless of symptom duration, presenting VA or FTMH size. However, surgery performed within 4 months of symptom-onset was particularly beneficial, highlighting the need for prompt referral and surgery.

Why Perfluorocarbon nanoparticles encounter bottlenecks in clinical translation despite promising oxygen carriers?

Artificial Oxygen Carriers (AOCs) have emerged as ground-breaking biomedical solutions, showcasing tremendous potential for enhancing human health and saving lives. Perfluorocarbon (PFC)-based AOCs, in particular, have garnered significant interest among researchers, leading to numerous clinical trials since the 1980 s. However, despite decades of exploration, the success rate has remained notably limited. This comprehensive review article delves into the landscape of clinical trials involving PFC compounds, shedding light on the challenges and factors contributing to the lack of clinical success with PFC nanoparticles till date. By scrutinizing the existing trials, the article aims to uncover the underlying issues like pharmacological side effects of the PFC and the nanomaterials used for the designing, complex formulation strategy and poor clinical trial designs of the formulation. More over each generation of the PFC formulation were discussed with details for their failure in the clinical trials limitations that block the path of PFC-based AOCs' full potential. Furthermore, the review emphasizes a forward-looking approach by outlining the future pathways and strategies essential for achieving success in clinical trials. AOCs require advanced yet biocompatible single-componentformulations. The new trend might be a novel drug delivery technique, like gel emulsion or reverse PFC emulsion with fluoro surfactants. Most importantly, well-planned clinical trials may end in a success story.

Minimal Posterior Pole Vitrectomy and Fixing the Inverted Internal Limiting Membrane Flap with DisCoVisc for Macular Hole: No Gas or Air Tamponade

PURPOSE

To investigate an alternative surgical method for macular hole repair without fluid-air exchange, gas tamponade, and prone positioning.

METHODS

Eighteen eyes of 17 patients with macular holes underwent minimal posterior pole vitrectomy with an inverted internal limiting membrane flap technique. Ophthalmic viscosurgical device was used to fix the inverted internal limiting membrane flap in the balanced salt solution. No fluid-air exchange, gas tamponade, or prone positioning was needed. Follow-ups were performed at 1 day, 1 week, and the last visit (ranging from 3 to 6 months) after surgery. Optical coherence tomography examination, intraocular pressure, and best-corrected visual acuity measurements were performed preoperatively and at every follow-up, postoperatively.

RESULTS

Primary closure of the macular hole was observed in all 18 eyes (100%). Optical coherence tomography showed U-type closure in 12 eyes, V-type closure in five eyes, and W-type closure in one eye. Preoperative, postoperative 1 week, and last follow-up best-corrected visual acuity were 0.90 (Snellen equivalent 20/159) ± 0.31 LogMAR, 0.72 (Snellen equivalent 20/105) ± 0.33 LogMAR, and 0.48 (Snellen equivalent 20/60) ± 0.32 LogMAR, respectively. Postoperative visual acuity was significantly improved compared with preoperative values ( F = 19.250, P = 0.000). No significant difference in intraocular pressure was found compared with preoperative values ( F = 1.933, P = 0.168). No significant complications were observed.

CONCLUSION

This surgical method can effectively close macular holes, improve visual acuity, enhance surgical efficiency, reduce surgical complications, and improve patients' postoperative experience without the need for fluid-air exchange, gas tamponade, or prone positioning.

Accuracy of biomicroscopy, ultrasonography and spectral-domain OCT in detection of complete posterior vitreous detachment

BACKGROUND

To evaluate the accuracy of preoperative biomicroscopy (BM), ultrasonography (US), and spectral domain optical coherence tomography (SD-OCT) to determine complete posterior vitreous detachment (PVD) confirmed by intraoperative findings of triamcinolone acetonide-assisted pars plana vitrectomy (PPV).

METHODS

This prospective study included all consecutive patients admitted for surgical treatment of the epiretinal membrane (ERM) and macular hole (MH). The presence of complete PVD was determined one day before PPV using BM, US, SD-OCT. The preoperative findings were compared to the PVD status determined during PPV.

RESULTS

A total of 123 eyes from 123 patients were included in the study. Indications for PPV included ERM in 57 (46.3%), full thickness macular hole in 57 (46.3%) and lamellar macular hole in 9 (7.3%) patients. Complete PVD during PPV was observed in 18 (31.6%; 95%CI:18.7-49.9) patients with ERM and 13 (19.7%; 95%CI:10.4-33.7) patients with MH. The sensitivity of preoperative BM, US, SD-OCT was 48.4% (95%CI:30.2-66.9), 61.3% (95%CI:42.2-78.2) and 54.8% (95%CI:36.0-72.7) respectively. The specificity of preoperative BM, US, SD-OCT was 81.5% (95%CI:72.1-88.9), 90.2% (95%CI:82.2-95.4) and 85.9% (95%CI:77.0-92.3) respectively. With a prevalence of 25.2% of PVD in our sample the positive predictive value of preoperative BM, US, SD-OCT was 46.9% (95%CI:29.1-65.3), 67.9% (95%CI:47.6-84.1) and 56.7% (95%CI:37.4-74.5) respectively.

CONCLUSION

Preoperative BM, US, and SD-OCT showed relatively low sensitivity but also good specificity in assessing complete PVD. A combination of all three diagnostic methods can provide a good assessment of the vitreoretinal interface state.

Relaxing Retinotomy in Recurrent and Refractory Full-Thickness Macular Holes: The State of the Art

The prevailing standard of care for primary repair of full-thickness macular holes (FTMHs) is pars plana vitrectomy with internal limiting membrane (ILM) peeling and gas tamponade, as it gives a high closure rate of roughly 90%. On the other hand, the surgical management of recurrent and refractory FTMHs represents, so far, a demanding and debated subject in vitreoretinal surgery since various approaches have been proposed, with no consensus concerning both adequate selection criteria and the best surgical approach. In addition, the existence of multiple case series/interventional studies showing comparable results and the lack of studies with a direct comparison of multiple surgical techniques may lead to uncertainty. We present an organized overview of relaxing retinotomy technique, a surgical approach available nowadays for the secondary repair of recurrent and refractory FTMHs. Besides the history and the description of the various techniques to perform relaxing retinotomies, we underline the results and the evidence available to promote the use of this surgical approach.

Outcomes of revision surgery for idiopathic macular hole after failed primary vitrectomy

Persistent idiopathic macular hole (PIMH), the occurrence of idiopathic macular holes that have failed to close after standard pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling, has become a global health threat to the aging population. Because postoperative anatomic closure or restoration of visual acuity is more difficult to achieve in PIMH, surgical approaches that would yield the best outcomes remain to be elucidated. On paper, extended ILM peeling combined with silicone oil (SiO) tamponade is believed to be a feasible option for excellent macular hole closure. However, no studies on this combined treatment for PIMH is compared with simple air tamponade have been conducted. Thus, in this retrospective case series, we used spectral-domain optical coherence tomography (SD-OCT) and other technologies to investigate real-world evidence for the anatomical and functional outcomes of revisional PPV with either SiO or air tamponade for failed primary idiopathic macular hole surgery. We included the records of 76 patients with PIMH who had SD-OCT examinations and best-corrected visual acuity (BCVA). Regression analysis was performed to find factors affecting PIMH fracture closure. Seventy-six participants were allocated to a SiO group (n = 21, with an extended ILM peeling and SiO tamponade) or an air group (n = 55, with extended ILM peeling and air tamponade). Anatomical success was achieved in 18 (85.7%) and 40 (72.7%) eyes in the SiO and air groups, respectively (p = 0.37). BCVA was significantly improved in both subgroups of closed PIMH (SiO group: p = 0.041; air group: p < 0.001). Minimum linear diameter (MLD) was closely related to the closure rate (OR, 1.0; 95% CI (0.985-0.999); p = 0.03). MLD = 650 μm seemed like a cut-off point for closure rate (MLD ≤ 650 μm vs. MLD > 650 μm; 88.4% vs. 52%, p = 0.002). In conclusion, we demonstrated that extended ILM peeling combined with SiO or air tamponade is effective in PIMH treatment. Moreover, though not statistically significant herein, the anatomic closure rate was better for silicone-operated eyes than for air-operated eyes. MLD is the best predictor of PIMH closure; MLD ≤ 650 μm could achieve a significantly higher closure rate.

Vitrectomy with sulfur hexafluoride versus air tamponade for idiopathic macular hole: a retrospective study

BACKGROUND

To evaluate the effect of room air and sulfur hexafluoride (SF6) gas in idiopathic macular hole(MH)surgery.

METHODS

Retrospective, interventional, and comparative study. 238 eyes with the idiopathic macular hole that underwent pars plana vitrectomy, internal limiting membrane peeling, fluid-air exchange, and 20% SF6 (SF6 group:125 eyes) or room air tamponade (air group: 113 eyes) were reviewed. The primary outcome measure was the closure rate of primary surgery.

RESULTS

The baseline characteristics of the SF6 group and air group were comparable except for the hole size (479.90 ± 204.48 vs. 429.38 ± 174.63 μm, P = 0.043). The anatomical closure rate was 92.8% (116 / 125) with the SF6 group and 76.1% (86 / 113) with the air group (P < 0.001). A cut-off value of MH size to predict primary anatomical closure was 520 μm, which is based on the lower limit of 95% confidential interval of the MH size among the unclosed patients in the air group. There was no significant difference in anatomical closure rates between SF6 and air group (98.7% vs. 91.9%, P = 0.051) for MH ≤ 520 μm, whereas a significantly lower anatomical closure rate was shown in the air group than SF6 group (46.2% vs. 84.0%, P < 0.001) for MH > 520 μm.

CONCLUSION

SF6 exhibited more effectiveness than air to achieve a good anatomical outcome for its longer tamponade when MH > 520 μm.

Comparison of Intraocular Tamponade in Patients with Peripheral Tear-Induced Retinal Detachment and Coexisting Macular Hole without High Myopia

INTRODUCTION

To introduce the surgical results and examine the effect of intraocular tamponades on surgical outcomes in patients with coexisting macular hole (MH) and rhegmatogenous retinal detachment (RRD) without high myopia.

METHODS

This retrospective, cross-sectional, two-center study was carried out with 29 eyes of 29 patients. The patients were divided into two groups according to the intraocular tamponade used in surgery: silicone oil (Group 1) and C3F8 gas (Group 2). In all patients, the internal limiting membrane was peeled during surgery. Exclusion criteria were determined as RRD with MH due to high myopia (≥ 6 D) without peripheral retinal tears and traumatic MH.

RESULTS

In Group 1, the median preoperative best-corrected visual acuity (BCVA) was 3.0 (M ± SD: 2.85 ± 0.27) logMAR, while the median postoperative BCVA was 1.0 (M ± SD: 1.39 ± 0.83) logMAR (p < 0.001). In Group 2, the median preoperative BCVA was 3.0 (M ± SD: 2.37 ± 0.93) logMAR, while the median postoperative BCVA was 0.76 (M ± SD: 1.06 ± 0.86) logMAR (p = 0.008). The retinal attachment success rate was 15/17 (89.3%) in Group 1, and 11/12 (91.7%) in Group 2 (p = 0.64). The MH closure rate was 12/17 (71.6%) in Group 1, and 10/12 (78.1%) in Group 2 (p = 0.52). No difference was determined between the groups in terms of preoperative and postoperative BCVA, preoperative and postoperative intraocular pressure, and BCVA improvement.

CONCLUSIONS

The study results showed no significant difference between using silicone oil or C3F8 gas as an intraocular tamponade after internal limiting membrane peeling in patients with RRD due to peripheral tear with coexisting MH.

The effect of ethnicity on anatomic success following macular hole surgery: a multicentre cohort study

PURPOSE

The purpose is to assess the effect of ethnicity on surgical macular hole closure.

METHODS

A retrospective cohort study was undertaken in five UK National Health Service Hospitals. We included all patients with known ethnicity undergoing vitrectomy, internal limiting membrane peel, and gas/oil tamponade for all stages of primary full-thickness macular hole (FTMH). The primary outcome was anatomic success, defined as FTMH closure with one operation. The secondary outcome was mean change in best-corrected visual acuity (BCVA) comparing baseline with final review.

RESULTS

Of 334 operations, the ethnicity profile comprised 78.7% White patients, 11.7% Black patients, 8.1% Asian patients, and 1.5% in mixed/other ethnicities. Mean age was 69.7 years with 68.5% females. Overall, 280 (83.8%) had anatomic success. Anatomic failure occurred in 38.5% of Black patients versus 12.6% of White patients (relative risk: 1.788; 95% CI: 1.012 to 3.159; P = 0.045). Overall, baseline logarithm of the minimum angle of resolution BCVA improved by 0.34, from 0.95 (95% CI: 0.894 to 1.008) to 0.62 (95% CI: 0.556 to 0.676). Mean BCVA improved by 0.35 in White patients, 0.37 in Black patients, 0.23 in Asian patients, and 0.38 in mixed/other ethnicity (P = 0.689). Greater FTMH minimum linear diameter was associated with an increased risk of anatomic failure (relative risk: 1.004; 95% CI: 1.002 to 1.005; P < 0.0001), whereas better pre-operative BCVA (F [1,19] = 162.90; P < 0.0001) and anatomic success (F [1,19] = 97.69; P < 0.0001) were associated with greater BCVA improvement. Socio-economic status did not significantly influence anatomic success or BCVA change.

CONCLUSIONS

Black ethnicity is associated with an approximately twofold greater risk of failed FTMH surgery. The reasons for this difference warrant further study.

Non-Invasive Retinal Imaging Modalities for the Identification of Prognostic Factors in Vitreoretinal Surgery for Full-Thickness Macular Holes

In this review, we will focus on different non-invasive retinal imaging techniques that can be used to evaluate morphological and functional features in full-thickness macular holes with a prognostic purpose. Technological innovations and developments in recent years have increased the knowledge of vitreoretinal interface pathologies by identifying potential biomarkers useful for surgical outcomes prediction. Despite a successful surgery of full-thickness macular holes, the visual outcomes are often puzzling, so the study and the identification of prognostic factors is a current topic of interest. Our review aims to provide an overview of the current knowledge on prognostic biomarkers identified in full-thickness macular holes by means of different retinal imaging tools, such as optical coherence tomography, optical coherence tomography angiography, microperimetry, fundus autofluorescence, and adaptive optics.

The Effect of Macular Hole Duration on Surgical Outcomes: An Individual Participant Data Study of Randomized Controlled Trials

TOPIC

To define the effect of symptom duration on outcomes in people undergoing surgery for idiopathic full-thickness macular holes (iFTMHs) by means of an individual participant data (IPD) study of randomized controlled trials (RCTs). The outcomes assessed were primary iFTMH closure and postoperative best-corrected visual acuity (BCVA).

CLINICAL RELEVANCE

Idiopathic full-thickness macular holes are visually disabling with a prevalence of up to 0.5%. Untreated BCVA is typically reduced to 20/200. Surgery can close holes and improve vision. Symptom duration is thought to affect outcomes with surgery, but the effect is unclear.

METHODS

A systematic review identified eligible RCTs that included adults with iFTMH undergoing vitrectomy with gas tamponade in which symptom duration, primary iFTMH closure, and postoperative BCVA were recorded. Bibliographic databases were searched for articles published between 2000 and 2020. Individual participant data were requested from eligible studies.

RESULTS

Twenty eligible RCTs were identified. Data were requested from all studies and obtained from 12, representing 940 eyes in total. Median symptom duration was 6 months (interquartile range, 3-10). Primary closure was achieved in 81.5% of eyes. There was a linear relationship between predicted probability of closure and symptom duration. Multilevel logistic regression showed each additional month of duration was associated with 0.965 times lower odds of closure (95% confidence interval [CI], 0.935-0.996, P = 0.026). Internal limiting membrane (ILM) peeling, ILM flap use, better preoperative BCVA, face-down positioning, and smaller iFTMH size were associated with increased odds of primary closure. Median postoperative BCVA in eyes achieving primary closure was 0.48 logarithm of the minimum angle of resolution (logMAR) (20/60). Multilevel logistic regression showed for eyes achieving primary iFTMH closure, each additional month of symptom duration was associated with worsening BCVA by 0.008 logMAR units (95% CI, 0.005-0.011, P < 0.001) (i.e., ∼1 Early Treatment Diabetic Retinopathy Study letter loss per 2 months). ILM flaps, intraocular tamponade using long-acting gas, better preoperative BCVA, smaller iFTMH size, and phakic status were also associated with improved postoperative BCVA.

CONCLUSIONS

Symptom duration was independently associated with both anatomic and visual outcomes in persons undergoing surgery for iFTMH. Time to surgery should be minimized and care pathways designed to enable this.

Macula-Off Retinal Detachment with Refractory Macular Hole Previously Closed with Autologous Platelet-Rich Plasma: A Case Report

The purpose of this report was to present a case of a refractory full-thickness macular hole (FTMH) complicated with recurrent retinal detachment (RD) previously treated with an autologous platelet-rich plasma (aPRP) plug. A 65-year-old male patient presented to our department with a FTMH, RD, and a giant retinal break. Preoperative best corrected visual acuity (BCVA) was 1.40 logMAR (20/500). A 25-G pars plana vitrectomy (PPV) was performed, with peripheral retinal-breaks laser barrage, peeling of the internal limiting membrane, and silicon oil injection. One month later, spectral domain optical coherence tomography (SD-OCT) showed the persistence of the FTMH with a diameter of 712 μm. Therefore, the patient underwent silicon oil removal and aPRP injection with good anatomical outcome and improvement of BCVA to 0.6 log-MAR (20/80). Two months later a recurrence of macula-off RD was detected, but SD-OCT showed that the aPRP plug was still in place and kept the two margins of the macular hole together. The patient underwent a further PPV with silicon oil injection and subsequent silicon oil removal with no postoperative complications. Two months later, the retina remained attached, SD-OCT confirmed FTMH closure and BCVA was 0.52 logMAR (20/63). In conclusion, this case report aims to underline the remarkable efficacy of aPRP in promoting FTMH closure, which was maintained despite subsequent recurrence of macula-off RD.

The Importance of Anatomic Configuration and Cystic Changes in Macular Hole: Predicting Surgical Success with a Different Approach

PURPOSE

This study aimed to define a novel metric for the area of the macular hole (MH) and cysts located around the hole using an optical coherence tomography (OCT) device.

METHODS

This study was conducted with 58 eyes of 56 patients. The patients were divided into two groups according to anatomic closure after surgery. Using the metrics of macular hole index (MHI), tractional hole index (THI), hole forming factor (HFF), macular hole area (HA), the cystoid space areas in the inner retinal layers (CA), and our novel metric, the cyst hole area index (CHAI) was calculated. The correlation of the CA, the HA, and the CHAI with other indexes were assessed. Receiver operating characteristic (ROC) curves and cut-off values were derived for indexes predicting type 1 or type 2 closures.

RESULTS

The CA showed a strong positive correlation with the base MH size and the maximum MH height (r = 0.624, p < 0.001; r = 0.722, p < 0.001, respectively). The HA showed a strong positive correlation with basal MH size and minimum MH size (r = 0.934, p < 0.001; r = 0.765, p < 0.001). The HA showed a moderate positive correlation with maximum MH height (r = 0.483, p < 0.001, respectively). CHAI showed a moderate positive correlation with minimum MH size (r = 0.297, p = 0.02). CHAI and HA showed a moderate negative correlation with post-operative BCVA (r = -0.39, p = 0.003; r = -0.357, p = 0.006; respectively). ROC curve analysis showed that MHI (0.823), THI (0.750), and HFF (0.722) predicted type 1 closure and that CHAI (0.769) and HA (0.709) predicted type 2 closures.

CONCLUSION

MHI and our novel index CHAI, which can be calculated without any additional software, could successfully predict type 1 and type 2 closures, respectively.

Refractory full thickness macular hole: current surgical management

This review aims to collect the proposed surgical techniques for treating full thickness macular hole (FTMH) refractory to pars plana vitrectomy and internal limiting membrane (ILM) peeling and to analyse and compare anatomical and functional outcomes in order to evaluate their efficacy. The articles were grouped according to the surgical techniques used. Refractory FTMH closure rate and best-corrected visual acuity (BCVA) gain were the two analysed parameters. Thirty-six articles were selected. Ten surgical technique subgroups were defined: autologous platelet concentrate (APC); lens capsular flap transplantation (LCFT); autologous free ILM flap transplantation (free ILM flap); enlargement of ILM peeling, macular hole hydrodissection (MHH), autologous retinal graft (ARG), silicon oil (SO), human amniotic membrane (hAM), perifoveal relaxing retinotomy, arcuate temporal retinotomy. Refractory FTMH closure rate was similar among subgroups, not significant heterogeneity emerged (p = 0.176). BCVA gain showed a significant dependence on surgical technique (p < 0.0001), significant heterogeneity among subgroups emerged (p < 0.0001). Three sets of surgical technique subgroups with a homogeneous BCVA gain were defined: high BCVA gain (hAM); intermediate BCVA gain (APC, ARG, LCFT, MHH, SO); low BCVA gain (free ILM flap, enlargement of peeling, arcuate temporal retinotomy). In terms of visual recovery, the most efficient technique for treating refractory FTMH is hAM, lens capsular flap and APC that allow to obtain better functional outcomes than free ILM flap. MHH, ARG, perifoveal relaxing and arcuate temporal retinotomy require complex and unjustified surgical manoeuvres in view of the surgical alternatives with overlapping anatomical and functional results.

Full-Thickness Macular Hole Closure Following a Single Intravitreal Injection of Aflibercept in an Eye With Diabetic Macular Edema

Purpose:

This work aims to discuss the case of a 32-year-old man with diabetic macular edema (DME) who underwent successful treatment of a full-thickness macular hole (FTMH) with a single dose of aflibercept.

Methods:

A case report is presented.

Results:

A 32-year-old man with reduced vision and DME in the right eye was found to have a FTMH. The patient was scheduled for pars plana vitrectomy; however, following a single dose of intravitreal aflibercept, the FTMH closed and the patient avoided surgical intervention.

Conclusions:

FTMH formation in DME is a rare complication that typically requires surgical intervention. We present a case of FTMH closure after a single dose of intravitreal aflibercept, which to our knowledge is the first of its kind. This report highlights the importance of considering conservative treatment initially to avoid surgery.

Macular Holes: Main Clinical Presentations, Diagnosis, and Therapies

Macular holes are a spectrum of retinal diseases that comprehends full-thickness macular holes (FTMHs), refractory/recurrent macular holes, lamellar macular holes (LMHs), myopic macular holes (MMHs), traumatic macular holes, and macular holes secondary to other retinal pathologies or injuries. There are various classifications of the subtypes of macular hole, and only in recent times researchers defined a common nomenclature, especially thanks to the evolution in retinal imaging, offered by new instruments like the swept-source OCT. The proposed therapies for macular holes are different and range from a “wait-and-see” approach to the vitrectomy, with different results in each subtype of macular hole. This narrative review has the purpose to investigate the available evidence in literature to give a summary of the knowledge about these retinal pathologies.

Epimacular brachytherapy for previously treated neovascular age-related macular degeneration: month 36 results of the MERLOT randomised controlled trial

BACKGROUND/AIM

To assess the long-term safety and efficacy of epimacular brachytherapy (EMB) for chronic, active, neovascular age-related macular degeneration (nAMD).

METHODS

This pivotal, randomised, controlled surgical device trial recruited patients with chronic nAMD receiving intravitreal ranibizumab from 24 UK hospitals. Participants were randomised to either pars plana vitrectomy with 24 Gray EMB and pro re nata (PRN) ranibizumab (n=224) or PRN ranibizumab monotherapy (n=119). Although masking was not possible, masked clinicians assessed best-corrected visual acuity (BCVA) and imaging. After month 24, participants reverted to standard care, with either ranibizumab or aflibercept, returning for a month 36 study visit.

RESULTS

Of 363 participants, 309 (85.1%) completed month 36. The number of injections was 12.1±8.1 in the EMB group versus 11.4±6.1 in the ranibizumab group (difference 0.7, 95% CI of difference -0.9 to 2.3, p=0.41) between months 1 and 36, and 3.6±3.3 (n=200) versus 3.9±2.7 (n=102) (difference -0.3, 95% CI of difference -1.0 to 0.4, p=0.43) between months 25 and 36 (standard care). Over 36 months, BCVA change was -19.7±18.5 letters in the EMB group and -4.8±12.5 in the ranibizumab group (difference -14.9, 95% CI of difference -18.5 to -11.2, p<0.0001). The month 36 BCVA of 20 EMB-treated participants with microvascular abnormalities (MVAs) at month 24 was similar to EMB-treated participants without MVAs (-21.8 vs -19.4 letters, p=0.65).

CONCLUSION

EMB does not reduce the number of anti-vascular endothelial growth factor (VEGF) injections, either within or outside of a trial setting, and is associated with worse BCVA than anti-VEGF monotherapy.

TRIAL REGISTRATION NUMBER

NCT01006538.

Application of Platelet-rich Fibrin Transplantation for Large Macular Hole

Purpose Large idiopathic macular hole (MH) has a lower closure rate and poor visual prognosis. To increase the closure rate and the visual outcome in patients with large MH, we evaluate a technique of platelet-rich fibrin (PRF) membrane transplantation for the treatment of large MH.Methods This was a prospective interventional study. Seventeen eyes of 17 patients (8 males and 9 females) with large MH (654.94 ± 188.08 μm) underwent pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peeling followed by PRF transplantation between January 2019 to December 2020. The patients were followed up for at least 6 months. Preoperatively and postoperatively, all patients underwent comprehensive ophthalmic examinations, including best-corrected visual acuity (BCVA), intraocular pressure, slit-lamp biomicroscopy, indirect ophthalmoscopy, ultra-widefield retinal imaging, optical coherent tomography (OCT), and optical coherent tomography angiography (OCTA).Results All the patients achieved complete and consistent hole closure after the surgery (100%). At six months follow-up, the external limiting membrane (ELM) defects were observed in 3 eyes (17.64%), and the ellipsoid zone (EZ) defects were observed in 10 eyes (58.82%). The preoperative BCVA was 1.21 ± 0.33 in logMAR. Postoperatively, the BCVA was significantly improved to 0.64 ± 0.22 in logMAR at 6 months (P < 0.001). The foveal avascular zone (FAZ) reduced significantly from 0.41 ± 0.08 mm² to 0.26 ± 0.07 mm² (P < 0.001). No complications were observed during or after the operation.Conclusions All patients in this study have achieved good anatomic and functional results, which indicate that the application of PRF transplantation is an effective and safe technique for large MH.

Visual Outcome after Vitrectomy with Subretinal tPA Injection to Treat Submacular Hemorrhage Secondary to Age-Related Macular Degeneration or Macroaneurysm

Purpose

To determine the efficacy and safety of 23G transconjunctival sutureless vitrectomy, subretinal injection of tissue plasminogen activator using the EVA Surgical System, and pneumatic displacement with air to treat submacular hemorrhages.

Methods

Retrospective analysis of 93 eyes surgically treated for submacular hemorrhage caused by neovascular AMD or retinal macroaneurysms. Main Outcome Measures. Postoperative visual acuity and surgical complications.

Results

After surgery, visual acuity improved after 6 weeks but decreased again at the final postoperative visit at 8 months due to progression of the underlying disease. Complications consisted of 2 cases of retinal pigment epithelial tear, 7 vitreous hemorrhages, 4 hyphema, 6 cases of retinal detachment, and 2 subchoroidal hemorrhages during the follow-up period.

Conclusions

This study suggests that a surgical approach with 23G vitrectomy, subretinal tPA injection, and pneumatic displacement using air may be an effective procedure for submacular hemorrhage displacement in patients with AMD and retinal macroaneurysms. However, visual outcome is limited by the underlying macular pathology. Larger multicenter randomized controlled studies are warranted to determine the therapeutic effect of this surgical approach.

A prospective, interventional study comparing the outcomes of macular hole surgery in eyes randomized to C3F8, C2F6, or SF6 gas tamponade

PURPOSE

Analysis of outcomes of macular hole (MH) surgery using 12% C₃F₈, 16% C₂F₆, or 18% SF₆ as randomized gas tamponading agent.

METHODS

This is a prospective, randomized, interventional study of 159 eyes with idiopathic MH undergoing 23/25G pars-plana vitrectomy with internal limiting membrane peeling and gas tamponade. Eyes were stratified into two groups: Group I (MH < 800 µ) and group II (MH > 800 µ) according to MH apical diameter. Eyes in group I were randomized to receive either 18% SF₆, 16% C₂F_6, or 12% C₃F₈. Eyes in group II were randomized to either 16% C₂F₆ or 12% C₃F₈. Clinical details, MH parameters on optical coherence tomography, surgical details and complications were analyzed. Outcome measures were type of hole closure (I/II), best corrected visual acuity, intraocular pressure, and cataract progression.

RESULTS

In Group I (n = 139), type 1 closure was achieved in 107 (77%) eyes. Type 1 closure rates in group I per gas tamponade were as follows: SF₆ (70%), C₂F₆ (80%), C₃F₈ (78%) (p = 0.503, chi-square test for independence). There was no statistical difference in MH closure rates between SF₆ and C₂F₆ (p = 0.134), SF₆ and C₃F₈ (p = 0.186), and C₂F₆ and C₃F₈ (p = 0.373). In Group II (n = 20), type 1 closure was achieved in 12 (60%) eyes. Type 1 closure rates in group II per gas tamponade were as follows: C₂F₆ (75%), C₃F₈ (50%) (p = 0.132, Two proportion Z test). Mean follow-up after surgery was 2.66 ± 2.74 months.

CONCLUSION

Given the similar outcomes of using 18% SF₆, 16% C₂F_6, or 12% C₃F₈ in idiopathic macular hole surgery, the advantage of using a shorter acting tamponade translates into earlier recovery and rehabilitation.

Benchmarking automated detection of the retinal external limiting membrane in a 3D spectral domain optical coherence tomography image dataset of full thickness macular holes

In this article, we present a new benchmark for the segmentation of the retinal external limiting membrane (ELM) using an image dataset of spectral domain optical coherence tomography (OCT) scans in a patient population with idiopathic full-thickness macular holes. Specifically, the dataset used contains OCT images from one eye of 107 patients with an idiopathic full-thickness macular hole. In total, the dataset contains 5243 individual 2-dimensional (2-D) OCT image slices, with each patient contributing 49 individual spectral-domain OCT tagged image slices. We display precise image-wise binary annotations to segment the ELM line. The OCT images present high variations in image contrast, motion, brightness, and speckle noise which can affect the robustness of applied algorithms, so we performed an extensive OCT imaging and annotation data quality analysis. Imaging data quality control included noise, blurriness and contrast scores, motion estimation, darkness and average pixel scores, and anomaly detection. Annotation quality was measured using gradient mapping of ELM line annotation confidence, and idiopathic full-thickness macular hole detection. Finally, we compared qualitative and quantitative results with seven state-of-the-art machine learning-based segmentation methods to identify the ELM line with an automated system.

MACULAR HOLE ASSOCIATED WITH AGE-RELATED MACULAR DEGENERATION: Pathogenesis and Surgical Outcomes

PURPOSE

To ascertain the pathogenesis of macular hole (MH) associated with age-related macular degeneration (AMD) and its surgical outcomes.

METHODS

Patients with full-thickness MH associated with AMD (higher grades than intermediate) were enrolled. The mechanism of MH formation and closure rate after vitrectomy (surgical outcome) were determined using optical coherence tomography imaging.

RESULTS

The mechanism of MH formation (35 eyes) associated with AMD was classified into four types: vitreomacular traction (42.9%), gradual retinal thinning caused by subretinal drusen or pigment epithelial detachment (22.9%), massive subretinal hemorrhage (20.0%), and combined (14.3%). In the 41 eyes that underwent vitrectomy, the logarithm of the minimum angle of resolution best-corrected visual acuity improved from 0.82 (0.10-2.30) preoperative to 0.69 (0.10-2.30) postoperative (P = 0.001). Successful closure of the MH was achieved in 33 eyes (80.5%) after vitrectomy. No significant association was observed between the closure rate of MH after vitrectomy and mechanism of MH formation (P = 0.083).

CONCLUSION

The mechanism of MH formation associated with AMD was classified into four types and was not related to its surgical outcome. Considering visual improvement and surgical outcome after vitrectomy in our study, active surgical treatment can be considered for MH associated with AMD.

[Profile of macular holes in Cotonou]

PURPOSE

To establish the epidemiological and tomographic profile of macular holes in the Beninese subject.

PATIENTS AND METHODS

This cross-sectional study included consecutive patients seen for macular testing during the period from January 2016 to August 2017 at the St. Anthony of Padua Retinal Testing Center in Cotonou (Benin). All patients who had a macular hole and macular OCT were included. To define macular hole types, we used the 2013 DUKER New Classification and analyzed for each case: age sex, history, involved eye, fellow eye, visual acuity, hole type, hole diameter, status of the vitreous cortex, edge edema, mean macular thickness, presence of vitreomacular traction, epimacular membrane, and retrofoveal choroidal thickness. Patients with a pseudo-macular hole or lamellar hole were excluded.

RESULTS

During this study period, 401 patients underwent a macular OCT procedure at the Retinal Testing Center, with 22 patients having a macular hole, of which 15 women and 07 men for a sex ratio of 2.14 women to men. The mean age of the patients was 61±10 years, with a median age of 63 years. The mean diameter of the holes was 705μm±232μm. No small holes were found. The mean central macular thickness was 272μm±39μm. In 52.4% of cases, the condition of the felloweye indicated the presence of vitreomacular traction. The etiological profile of the macular hole found in 72.7% a primary origin, and a secondary origin (diabetic and traumatic) in 13.6% and 9.09% respectively.

DISCUSSION

The majority of the macular holes observed were large macular holes, which could be explained by the progressive course of these macular holes as well as late detection. Over half of the fellow eyes showed vitreomacular traction, reflecting the potential risk of bilateralization.

CONCLUSION

Macular hole is a pathology of the vitreomacular interface, tending to be large in our geographic context. On OCT, the data found remain comparable those reported in the literature.

Lens densitometry for assessment and prediction of cataract progression after pars plana vitrectomy with C3F8-gas for retinal detachment

Purpose

Lens opacification is a common complication after pars plana vitrectomy (PPV) and knowing its progression would facilitate consulting patients. The purpose of this study was to evaluate a quantitative model for lens-status-monitoring after PPV with C3F8 gas. Our model was evaluated in rhegmatogenous retinal detachment (RRD) patients of various age and lens densitometry (LD).

Methods

Data between March 2018 and March 2020 were evaluated retrospectively. LD measurements of the PentacamHR® Nucleus Staging mode (PNS) were used to quantify lens opacification over time. A mixed-effect regression model was designed, to enable LD predictions at any time postoperatively. Calculations were based on patient’s age and baseline LD as dependent variables. Six patients were randomly excluded during model development, to be used for testing its power afterwards.

Results

34 patients (male 19 [55.9%], female 15 [44.1%]) matched the inclusion criteria. Average age was 58.5 years (32–77;±4.3) and average follow-up was 7.2 months (3,4–23.1;±1,8). Mean baseline LD of the treated and fellow eye before surgery were 10.9% (8.7%-14.8%;±0.8) and 10.7% (8.5%-14.1%;±0.6), respectively. Using our prediction model, LD values for the six pre-selected patients closely match the observed data with an average deviation of 1.07%.

Conclusions

Evaluation of age and baseline LD using a mixed-effect regression model might predict cataract progression in RRD patients treated with PPV and C3F8-gas. Such a tool could be considered during cataract surgery consultation in these patients.

Current management strategies for atypical macular holes

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

Factors predicting normal visual acuity following anatomically successful macular hole surgery

PURPOSE

To assess the incidence of normal vision following anatomically successful macular hole surgery and associated clinical variables.

METHODS

Multicentre, retrospective chart review. Preoperative, intraoperative and postoperative clinical data were extracted from electronic medical records from seven European vitreoretinal units. Inclusion criteria were as follows: eyes undergoing primary vitrectomy for idiopathic full-thickness macular hole from January 2015 to January 2018; postoperative macular hole closure confirmed by spectral domain optical coherence tomography (OCT); preoperative pseudophakia or phakic eyes receiving combined cataract surgery; one-year follow-up. The primary outcome was 'normal vision' defined as a final best-corrected visual acuity (BCVA) ≥ 20/25. Univariate, multivariate and decision-tree analyses were conducted to evaluate the clinical variables associated with 'normal vision'. Odds ratios (OR) and confidence intervals (CIs) were calculated.

RESULTS

Of 327 eligible cases, 91 (27.8%) achieved 'normal vision' at 1 year. Multivariate analysis identified variables significantly associated with 'normal vision': shorter symptom duration (odds ratio [OR]=1.05; 95% confidence interval [CI]:1.02-1.09; p = 0.002), smaller preoperative OCT minimum linear diameter (OR per 100-micron increase = 1.65; 95%CI:1.31-2.08; p < 0.001) and better mean preoperative BCVA (OR = 15.13; 95%CI: 3.59-63.65; p < 0.001). The decision-tree analysis found that the most significant variable associated with 'normal vision' was symptom duration. 'Normal vision' was achieved in 70.6% of eyes operated within one week from symptom onset and in 45% of eyes with symptom duration between 1 and 3 weeks.

CONCLUSIONS

These findings suggested urgent surgery is justified for small macular holes of short duration.

Treatment of Chronic Large and Persistent Macular Hole by a new technique in a Tertiary Care Hospital

Objective:

To assess the anatomical and functional outcomes of treating chronic persistent large macular hole by macular hole hydrodissection technique in a tertiary eye care hospital.

Methods:

This interventional case series study was conducted in the Vitreoretinal department of LRBT Tertiary Teaching Eye Hospital, Karachi, from October 2017 to March 2018, with follow-ups till February 2019. The study included eighteen cases of chronic (symptoms of loss of central vision ≥ 2years), persistent (previously failed macular hole surgery), large (aperture diameter of ≥ 400µm) macular hole. Out of the eighteen patients, eight (44.4%) were males and ten (55.6%) were females. All operated patients underwent macular hole hydrodissection by balanced salt solution using a silicone soft tip extrusion cannula. Patients were followed up post operatively to assess post-operative complications and surgical results.

Results:

Among eighteen patients with a mean aperture diameter of 477.1±102.9 µm and basal diameter of 849.4± 92.6µm, complete anatomical closure was achieved in sixteen (88.8%). Five (27.7%) out of the eighteen patients achieved best corrected visual acuity improvement of 6/36, whereas seven (38.8%) patients reached up to a BCVA of 6/60, with maximum improvement of two lines. The mean post-operative follow-up was 332.3± 46.7 days.

Conclusion:

Macular hole hydrodissection is a relatively new emerging technique with promising results for the closure of chronic persistent large macular hole.

Comparative study of combined vitrectomy with phacoemulsification versus vitrectomy alone for primary full-thickness macular hole repair

Background

To assess the effectiveness and safety of 23-gauge pars plana vitrectomy combined with phacoemulsification versus vitrectomy alone in patients over 50 years with primary full-thickness macular holes (FTMH).

Methods

We retrospectively reviewed the medical records related to 406 consecutive vitrectomies performed for primary FTMH. Phacovitrectomy was performed in 294 phakic eyes whereas vitrectomy alone in 112 pseudophakic eyes. The cases were divided into three groups according to the stage of the FTMH: stage 2 (n = 93), stage 3 (n = 270), or stage 4 (n = 43). The primary outcome measure was the closure of the FTMH. The secondary outcome measures were the evolution of visual acuity as well as intraoperative and postoperative complications.

Results

Neither the primary nor the secondary outcomes differed between phacovitrectomy and vitrectomy alone for all three stages. The FTMH were closed in 375 eyes (92.4 %) after a first operation. The closure rate was higher for stage 2 (96.8 %) than for stages 3 (91.1 %) or 4 (90.75 %), but not significantly (P = 0.189). The mean visual acuity increased significantly from preoperatively LogMAR 0.68 (± SD 0.2) to LogMAR 0.43 (± SD 0.24) at the end of the follow-up (p < 0.001).

Conclusions

Combined 23-gauge pars plana vitrectomy with phacoemulsification for primary FTMH repair in patients over 50 years is as efficient and safe when compared with vitrectomy only.

Trial registration

The study was approved on 30^th April 2020 by the local ethics committee (Ethikkommission Ostschweiz, EKOS 20/074; BASEC Nr. 2020-01033).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-01918-2.

The Effectiveness of the Supine Position in Managing Inferior Breaks in Rhegmatogenous Retinal Detachment After Vitrectomy with Gas Tamponade

Objective

This study aims to determine whether the supine position is effective for the management of inferior peripheral breaks after pars plana vitrectomy with gas tamponade.

Methods

A total of 29 patients (29 eyes) with acute rhegmatogenous retinal detachment and causative peripheral inferior breaks, located between the four o’clock and eight o’clock positions, underwent pars plana vitrectomy with gas tamponade. These patients maintained a face-up supine position for at least six hours each day for 14 days postoperatively. The alternate lateral position was used for the remaining hours, depending on the distribution of the retinal breaks.

Results

The final retinal reattachment rate was 100%, and the visual acuity improvement rate was 100% postoperatively, with no recurrence during the one-year follow up. No patients suffered from any sight-threatening complications. Of the 16 patients with preoperatively clear lenses, 3 were documented to have a cataract during their three-month postoperative follow up. Four patients were documented to have increased intraocular pressure, which was controllable during the early postoperative days.

Conclusion

Postoperative pars plana vitrectomy and gas tamponade in the supine position is effective for managing primary rhegmatogenous retinal detachment with causative breaks between the four o’clock and eight o’clock positions.

Incidence of Retinal Detachment after Macular Surgery

Macular surgery has become an increasingly atraumatic procedure for the eye with the surgical methods that have been further developed in recent years. The most common complications include cystoid macular oedema and retinal detachment, more rarely endophthalmitis. The aim of this retrospective study is to record the number of retinal detachments following elective macular surgery. In this study we included all patients who underwent pars plana vitrectomy (ppV, 20 or 25 gauge) in the years 2009 - 2016. We then identified the patients who were hospitalised again because of retinal detachment. For the affected patients, the rate of retinal detachment, functional outcomes and possible risk factors were recorded. A total of 904 eyes were identified, of which 667 had surgery for epiretinal membrane, 188 for macular hole, and 49 for vitreomacular traction with a 20 or 25 gauge ppV. Of these 904, retinal detachment occurred in 17 (1.88%) cases. The mean time between first ppV and second ppV with retinal detachment was 248 days (3 - 1837 days). Two of the 17 patients had at least one retinal break before or during surgery. The retinal break was located inferior in six cases, superior in four; in four cases PVR retinal detachment and in three cases the foramina were distributed. Mean visual acuity was 0.27 (decimal) before macular surgery and 0.28 at the time of last presentation. Modern vitrectomy techniques reduce the complications in elective macular surgery, but do not replace the surgeon's experience.

FIRST FAILED MACULAR HOLE SURGERY OR REOPENING OF A PREVIOUSLY CLOSED HOLE: Do We Gain by Reoperating?-A Systematic Review and Meta-analysis

Repeated idiopathic full-thickness macular hole surgery after primary failure or reopening of a previously closed hole seems beneficial both in terms of anatomical closure and improvement in best-corrected visual acuity.

To evaluate repeated surgery for idiopathic full-thickness macular hole that failed to close (FTC) after first surgery or reopened (RO) once originally closed.

Inverted internal limiting membrane flap technique in eyes with large idiopathic full-thickness macular hole: long-term functional and morphological outcomes

Purpose

To investigate morphological and functional outcomes of the inverted internal limiting membrane (I-ILM) flap technique in large (≥ 400 μm) idiopathic full-thickness macular holes (FTMH) over a follow-up period of 12 months.

Methods

In this retrospective study, 55 eyes of 54 consecutive patients were enrolled. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT, Heidelberg, Spectralis) were performed preoperatively as well as 1, 3, 6, 9, and 12 months postoperatively. Special focus was put on the reintegration of outer retinal layers and the different ILM flap appearances.

Results

FTMH closure rate was 100% (55/55). BCVA significantly improved over the follow-up period of 12 months from 0.98 ± 0.38 LogMAR preoperatively to 0.42 ± 0.33 LogMAR at 12 months postoperatively (p < 0.001). There was no significant correlation between the three different ILM flap appearances and BCVA. Better preoperative BCVA, complete restoration of the external limiting membrane (ELM), higher macular hole index (MHI), and smaller MH base diameter were associated with higher improvement of BCVA.

Conclusion

Our study highlights the favorable morphological and functional outcomes of the I-ILM flap technique in the short as well as in the long term. While complete ELM restoration revealed to be an important factor for improvement in BCVA, the different postoperative ILM flap appearances seem not to be related to BCVA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00417-021-05082-7.

Cost-effectiveness of the triple procedure - phacovitrectomy with posterior capsulotomy compared to phacovitrectomy and sequential procedures

PURPOSE

To evaluate the cost-effectiveness of the triple procedure (phacovitrectomy + posterior capsulotomy, PhacoPPVc) compared to the double- (phacovitrectomy, PhacoPPV) or single sequential procedures.

METHODS

Prospective study on 31 eyes from 31 patients (mean age: 72.1 ± 9.1 years; 55% females) was performed with a preoperative decision to undergo only pars plana vitrectomy (PPV) (26%) or PhacoPPV (74%) and/or posterior capsulotomy based upon presence or absence of lens opacification or pseudophakia. Time during and between surgeries, surgical procedure codes, medical and transport costs, outcome and likelihood of complications after surgery were all included in the analysis. Societal perspectives and visual acuity were considered as measures of quality of adjusted life years (QALYs).

RESULTS

About 23 eyes underwent triple procedure and eight eyes underwent vitrectomy only (mean surgery times: 35.9 and 24.0 min, respectively). Posterior capsulotomy took on average 30 s, while preparation and cataract procedure took 13.0 min. The patients travelled on average 80km (average cost: $280.12) to the surgery unit. The average reimbursement fee for the day procedures ranged between $174.17 (YAG capsulotomy; Diagnosis Related Group (DRG): 0.034), $1045.48 (Phaco + intraocular lens (IOL); DRG: 0.204) and $1701.32 (PPV; DRG: 0.332). The combined procedures excluded lens and laser reimbursements, while the calculated reimbursements for the double/triple procedures were $2713.08/$2901.45, respectively, without significant loss of QALYs. PhacoPPVc was found to be unequivocally cost-effective, while PhacoPPV remained cost saving compared to sequential procedures.

CONCLUSION

This study confirms that the triple procedure has benefits to the patients, health institution and surgeon. For patients, it saves them travel and healing time; for health institution, it justifies the calculated higher costs and need for higher reimbursement for the double/triple procedures, which are cost saving.

Combined phaco-vitrectomy provides lower costs and greater area under the curve vision gains than sequential vitrectomy and phacoemulsification

PURPOSE

A majority of phakic patients undergoing pars plana vitrectomy for epiretinal membrane or macular hole require subsequent cataract surgery within 1-2 years. Combined phaco-vitrectomy eliminates the need for a second surgery and may enable patients to attain their best vision sooner. This study aims to compare the visual outcomes, complication rates, and costs of combined phaco-vitrectomy versus sequential vitrectomy followed by cataract surgery.

METHODS

Records were searched by CPT® codes to identify patients with both cataract and vitrectomy surgery at our institution over a 5-year period (2013-2018). Chart review included medical history, demographics, exam findings, operating room records, visual acuity (VA), and clinical outcomes. Statistical analyses were performed with SPSS v19 (IBM). Area under the curve for visual acuity was calculated as the trapezoidal mean of the change in Early Treatment of Diabetic Retinopathy Study letters.

RESULTS

After exclusion, 81 eyes of 78 patients underwent both cataract and vitrectomy surgeries at our institution. Thirty-four eyes underwent separate, sequential vitrectomy then phacoemulsification surgery, and 47 eyes had combined phaco-vitrectomy surgery. Total operating room times (120.81 ± 3.41 vs 161.03 ± 5.45 min; p < 0.0001) and associated costs were significantly lower in the combined surgery compared with those in the sequential surgery group. Baseline and final visual acuity were similar between the two groups. Baseline VA was 35.53 letters (~ 20/200) and 32.81 letters (~ 20/220) and increased to final VA of 63.74 (~ 20/53) and 60.91 letters (~ 20/61), in the sequential and combined groups respectively. Area under the curve for vision was greater in the combined surgery group, with subjects gaining an average of + 9.11 ± 3.32 letters from sequential surgery, and + 19.53 ± 3.53 letters in the combined surgery group (p = 0.04). Additionally, patients in the combined group attained their best visual acuity 449 days (15 months) sooner than those receiving sequential surgery.

CONCLUSIONS

Combined phaco-vitrectomy surgery resulted in greater area under the curve visual acuity benefit and attainment of best visual acuity 15 months sooner compared with conventional sequential surgeries. There were no significant differences in complication rates or clinical outcomes between the groups, but operative times and costs were lower for combined surgery, supporting a favorable cost-benefit ratio. Graphical abstract.

Functional evaluation with microperimetry in large idiopathic macular holes treated by a free internal limiting membrane flap tamponade technique

Background

Free internal limiting membrane (ILM) flap tamponade technique is an alternative choice for treating large idiopathic macular holes (IMHs). However, the functional recovery related to this surgical approach is not well-characterized. This study aimed to evaluate morphological and microperimetric outcomes 6 months after free ILM flap tamponade technique for large IMHs.

Methods

Twenty-two patients (22 eyes) with large IMHs (minimal diameter > 400 μm) were retrospectively enrolled in this study. All patients underwent 23-gauge pars plana vitrectomy with ILM peeling and free ILM flap tamponade procedures. Snellen best-corrected visual acuity (BCVA), optical coherence tomography (OCT), and MP-1 microperimetry were measured at baseline and 6 months after surgery. Associations of postoperative BCVA with retinal sensitivity were detected.

Results

Macular hole closure was achieved in 21 eyes (95.5%). Dislodgement of free ILM flap was found in non-closed eye. Mean logMAR BCVA improved from 1.10 ± 0.33 at baseline to 0.67 ± 0.32 at 6 months postoperatively (P < 0.001). The mean overall macular sensitivity and foveal fixation stability increased respectively from 8.58 ± 3.05 dB and 65.64 ± 17.28% before surgery to 11.55 ± 2.72 dB and 78.59 ± 13.00% at 6 months after surgery (P < 0.001). The mean change in foveal sensitivity (within 2°) was significantly greater than the change achieved for peri-foveal sensitivity (2° to 10°) by 1.50 ± 2.62 dB (P = 0.014). Linear regression analysis showed that postoperative logMAR BCVA was significantly associated with duration of symptom (B = 0.063, P = 0.001), preoperative logMAR BCVA (B = 0.770, P = 0.000), preoperative peri-foveal (B = − 0.065, P = 0.000) and foveal sensitivity (B = − 0.129, P = 0.000). Moreover, multiple regression model revealed that preoperative foveal sensitivity was independently associated with postoperative logMAR BCVA (B = − 0.430, P = 0.040).

Conclusions

Vitrectomy combined with ILM peeling and free ILM flap tamponade technique results in effective morphological and functional recovery for large IMHs. Preoperative foveal sensitivity might be a prognostic indicator for postoperative BCVA.

Factors affecting anatomical and visual outcome after macular hole surgery: findings from a large prospective UK cohort

OBJECTIVES

To reassess the definition of a large macular hole, factors predicting hole closure and post-surgery visual recovery.

DESIGN

Database study of 1483 primary macular hole operations. Eligible operations were primary MH operations treated with a vitrectomy and a gas or air tamponade. Excluded were eyes with a history of retinal detachment, high myopia, previous vitrectomy or trauma.

RESULTS

A higher proportion of operations were performed in eyes from females (71.1%) who were 'on average' younger (p < 0.001), with slightly larger holes (p < 0.001) than male patients. Sulfur hexafluoride gas was generally used for smaller holes (p < 0.001). From 1253 operations with a known surgical outcome, successful hole closure was achieved in 1199 (96%) and influenced by smaller holes and complete ILM peeling (p < 0.001), but not post-surgery positioning (p = 0.072). A minimum linear diameter of ~500 μm marked the threshold where the success rate started to decline. From the 1056 successfully closed operations eligible for visual outcome analysis, visual success (defined as visual acuity of 0.30 or better logMAR) was achieved in 488 (46.2%) eyes. At the multivariate level, the factors predicting visual success were better pre-operative VA, smaller hole size, shorter duration of symptoms and the absence of AMD.

CONCLUSIONS

Females undergoing primary macular hole surgery tend to be younger and have larger holes than male patients. The definition of a large hole should be changed to around 500 μm, and patients should be operated on early to help achieve a good post-operative VA.

Prophylactic Circumferential Laser Retinopexy in Macular Hole and Epiretinal Membrane Surgeries

Background:

The role of PCLR in vitrectomy surgeries for macular diseases is controversial. Several studies report a reduction in post-operative RD rates, while other studies do not show such reduction. reducing complications stemming from intra- and post- operative retinal tears, especially at sclerotomy sites, are suggested as reasons for PCLR use.

Objective:

To investigate the effect of PCLR on the rate of post-operative RD in patients undergoing pars plana vitrectomy for either Macular Hole (MH) or epiretinal membrane (ERM).

Methods:

This retrospective study included 179 eyes of 170 patients who underwent vitrectomy for either MH or ERM between 2006-2012. Recorded parameters included demographic information, diagnosis, lens status, use and type of tamponade, whether PCLR was performed, follow-up period, the occurrence of RD, the cause and time of RD. Outcome and complication rates were compared between patients who received PCLR (PCLR group) and those who did not (Control group).

Results:

The study included 179 eyes of 170 patients. 126 eyes had PCLR while 53 eyes did not. Pre-operative demographics data, best-corrected visual acuity, lens status and indication for macular surgery were similar between the two groups. Post-operative RD was diagnosed in one eye (1.8%) in the control group and 5 eyes (3.9%) in the PCLR group (Kaplan-Meier survival analysis, log-rank p = 0.28).

Conclusion:

PCLR was not correlated with a decrease in RD in MH and ERM surgeries in our cohort. Intra-operative and post-operative examination for small retinal breaks is essential in all surgeries. PCLR might be unnecessary in small gauge vitrectomies.

Cost-effectiveness analysis of ocriplasmin versus watchful waiting for treatment of symptomatic vitreomacular adhesion in the US

Aim: Evaluate the cost-effectiveness of ocriplasmin in symptomatic vitreomacular adhesion (VMA) with or without full-thickness macular hole ≤400 μm versus standard of care. Methods: A state-transition model simulated a cohort through disease health states; assignment of utilities to health states reflected the distribution of visual acuity. Efficacy of ocriplasmin was derived from logistic regression models using Ocriplasmin for Treatment for Symptomatic Vitreomacular Adhesion Including Macular Hole trial data. Model inputs were extracted from Phase III trials and published literature. The analysis was conducted from a US Medicare perspective. Results: Lifetime incremental cost-effectiveness ratio was US$4887 per quality-adjusted life year gained in the total population, US$4255 and US$10,167 in VMA subgroups without and with full-thickness macular hole, respectively. Conclusion: Ocriplasmin was cost effective compared with standard of care in symptomatic VMA.

Evaluation of Retinal Detachment After Diabetic Vitrectomy: Causes and Ways of Management

Purpose

To assess the causes and the ways of management of rhegmatogenous retinal detachment (RRD) after pars plana vitrectomy (PPV) performed in diabetic patients with advanced diabetic eye disease.

Methods

Retrospective review of the records of the patients who had undergone PPV for complicated proliferative diabetic retinopathy (PDR) was done. Cases with RRD after the PPV were analyzed in the study (n = 32). Preoperative, operative, and postoperative data of the patients were recorded. All patients were recruited for a final follow-up visit.

Results

This retrospective case-control study included 400 eyes of 345 patients. Prolonged surgical duration increased the risk of developing RRD (odds ratio = 1.6342, p = 0.0321). The presence of intraoperative retinal breaks increased the risk of developing postoperative RRD (odds ratio = 2.2308, p = 0.0380). Also, complex diabetic detachment that needed for bimanual dissection of the membranes during surgery were associated with a higher risk of developing postoperative RRD (odds ratio = 2.7311, p = 0.0401).

Conclusion

Rhegmatogenous retinal detachment following diabetic vitrectomy needs a further vitrectomy for the management and usually has poor visual outcome. Prolonged surgical duration, the presence of intraoperative retinal breaks, and the need for bimanual dissection of the membranes (major complex cases) during surgery were associated with higher risk of developing RRD postoperatively.

Conventional internal limiting membrane peeling versus temporal inverted internal limiting membrane flap for large macular holes

PURPOSE

To compare the functional, anatomical, and morphological results of conventional internal limiting membrane peeling versus temporal inverted internal limiting membrane flap technique for the treatment of macular holes larger than 400 μm.

DESIGN

Retrospective, comparative case series.

METHODS

A total of 33 patients were included, of whom 18 were treated with internal limiting membrane peeling (Group 1) and 15 were treated with temporal inverted internal limiting membrane flap technique (Group 2). Complete ophthalmic examination, such as microperimetry and optical coherence tomography, was performed preoperatively and at 12 months after surgery.

RESULTS

The closure rates accomplished in Groups 1 and 2 were 72.2% and 100%, respectively (p = 0.036). The mean improvement in best-corrected visual acuity was logMAR 0.49 ± 0.17 in Group 1 and logMAR 0.91 ± 0.15 in Group 2 (p = 0.037). U-shaped closure was achieved in one eye in Group 1 and 12 eyes in Group 2 (p < 0.001). Complete restoration of external limiting membrane and ellipsoid zone rates were significantly higher in Group 2 (p = 0.027 and p = 0.001, respectively).

CONCLUSION

The single-layered temporal inverted internal limiting membrane flap technique improves not only anatomical and morphological but also functional outcomes of surgery for large macular holes. Furthermore, this technique seems to minimize the risk of iatrogenic trauma to the nasal part of the fovea and the corresponding papillomacular bundle fibers.

Vitrectomy for Idiopathic Macular Hole in Patients Aged 80 Years or Older: Efficacy and Safety

Purpose: To assess the efficacy and safety of idiopathic macular hole (MH) surgery in elderly patients (≥ 80 years of age).Methods: Prospective study enrolled consecutive patients who underwent pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling under retrobulbar anesthesia between February 2016 and May 2018. Twenty-eight eyes of 28 patients aged 80 years or older were classified into the elderly group, a matched group of 56 eyes from 56 younger patients as the control group. The main outcome measures included best-corrected visual acuity (BCVA) and intraoperative and postoperative complications.Results: Statistically, there was no significant difference in visual acuity improvement and incidences of complications between the elderly group and the control group (p = .784 and p = .712, respectively). No operation in either group was postponed or canceled due to complications associated with retrobulbar anesthesia, or physical discomfort before and during the operation. Moreover, no case suffered from myocardial infarction, stroke or death during the perioperative period. Except for one case of retinal detachment postoperatively in the control group, no case required a secondary surgery. All complications were successfully resolved or managed.Conclusions: The results from our study indicate the efficacy and safety of vitrectomy for idiopathic macular hole in patients aged 80 years or older, and idiopathic MH surgery should not be denied on basis of patient age alone.