Prognostic factor analysis of vitrectomy for retinal detachment associated with myopic macular holes

Inverted Internal Limiting Membrane Flap Coverage With Autologous Blood Technique After Air-Fluid Exchange and Silicone Oil Tamponade for Extensive Macular Hole Retinal Detachment in Highly Myopic Eyes

PURPOSE

To report a technique consisting of inverted internal limiting membrane (ILM) flap coverage with autologous blood after air-fluid exchange and silicone oil tamponade in treating extensive retinal detachment secondary to a myopic macular hole (MH).

METHODS

This was a retrospective case series. 18 eyes with MHRD extending beyond the equator were included in this study with a minimum follow-up of 6 months. The procedures for pars plan vitrectomy (PPV) included the following: 1) The ILM was peeled to the superior and inferior arcade margins and, except for the ILM in the temporal region, was hinged toward the edge of the MH. 2) Air-fluid exchange was then performed to drain the subretinal fluid through the MH with a flute needle, ensuring that a small amount of subretinal fluid remained to facilitate ILM flap inversion. 3) The ILM flap was used to cover the MH with the assistance of autologous blood.

RESULTS

Six months after surgery, the MH was successfully anatomically closed, and retinal reattachment was observed in all 18 eyes of 18 patients. The mean best-corrected visual acuity logarithm of the minimum angle of resolution (logMAR) improved from 2.03 ± 0.61 (ranging from hand motion [2.6] to finger counting [2.3]) to 1.23 ± 0.63 (ranging from hand motion [2.6] to 20/28 [0.15]) ( P < 0.01) at 6 months.

CONCLUSION

This surgical technique using an inverted ILM flap combined with autologous blood provides an option for the treatment of extensive MHRD.

Enhancing Inverted Internal Limiting Membrane Flap Stability in Macular Hole Retinal Detachment by the "Viscoelastic Agent Pool" Technique

PURPOSE

To evaluate the surgical, anatomical, and functional results of "viscoelastic agent pool" technique-assisted stability of inverted internal limiting membrane flap in macular hole retinal detachment.

METHODS

The innovative surgical technique was performed on 10 patients with macular hole retinal detachment. The primary outcomes included best-corrected visual acuity after surgery, rate of closure of macular hole, retinal reattachment, and occurrence of complications.

RESULTS

The mean age of the individuals was 67.70 ± 8.75 (range, 55-84) years; mean axial length, 29.34 ± 1.53 (range, 27.10-30.93) mm; mean corrected MH diameter, 685.30± 345.65 (range, 172-1,325) µ m; and average follow-up period, 6.01 ± 1.71 (range, 3.10-8.4) months. In 6 eyes (60%), the postoperative best-corrected visual acuity showed improvement. All patients had macular hole closure, and the retinal reattachment rate was 100%. No postoperative complications were noted.

CONCLUSION

The "viscoelastic agent pool" technique, an innovative surgical approach designed to enhance the stability of the internal limiting membrane flap, serves as an effective adjunctive procedure for the inverted internal limiting membrane flap technique. It presents a viable option for patients with macular hole retinal detachment.

PRETREATED LYOPHILIZED HUMAN AMNIOTIC MEMBRANE GRAFT COVERING FOR RETINAL DETACHMENT WITH POSTERIOR RETINAL BREAKS ABOVE CHORIORETINAL ATROPHY IN PATHOLOGIC MYOPIA

PURPOSE

To compare the surgical results of vitrectomy with untreated or pretreated lyophilized human amniotic membrane grafts covering in treating retinal detachment related to posterior retinal breaks above chorioretinal atrophy in pathologic myopia.

METHODS

Nineteen patients with retinal detachment related to macular hole (MH) located above macular atrophy and/or posterior paravascular retinal breaks (PRBs) located above patchy chorioretinal atrophy in pathologic myopia were included. The eyes of these patients underwent vitrectomy with untreated lyophilized human amniotic membrane covering (n = 10) or perfluorocarbon liquid (PFCL)-assisted pretreated lyophilized human amniotic membrane covering (n = 9; grafts were pretreated in 0.125% indocyanine green and 50% hypertonic glucose solution for 15-20 minutes). The closure of the MH or PRBs, reattachment of the retina, and best-corrected visual acuity were measured postoperatively.

RESULTS

Postoperatively, graft dislocation or shift was only found in two eyes (20%) in the untreated group. The closure rate of the MH or PRBs was 80% (8/10) and 100% (9/9) in the untreated group and the pretreated group, respectively. The occurrence rate of excessive gliosis was 40% and 11% in the untreated group and the pretreated group, respectively. In both groups, best-corrected visual acuity was improved and the retinal reattachment rate was 100% at the final visit.

CONCLUSION

Perfluorocarbon liquid-assisted pretreated lyophilized human amniotic membrane graft covering was effective in treating retinal detachment related to MH and/or PRBs situated above macular atrophy or patchy chorioretinal atrophy in pathologic myopia. This technique appeared to reduce graft dislocation or shift, promote the closures of MHs/PRBs, and reduce the occurrence of gliosis.

Vitrectomy for retinal detachment associated with macular hole: Prognostic factor analysis under different axial length conditions

PURPOSE

To identify prognostic factors for complete anatomical success (CAS) under different axial length (AL) conditions after vitrectomy plus internal limiting membrane (ILM) peeling for retinal detachment associated with macular hole (MHRD).

METHODS

This retrospective study included 243 patients (251 eyes) with MHRD who underwent primary vitrectomy plus ILM peeling. Multivariate logistic regression explored prognostic factors for CAS in AL <30 mm and ≥ 30 mm groups.

RESULTS

Overall, 113 eyes (45.0% of 251) exhibited complete CAS after initial surgery. Eyes with CAS had greater best-corrected visual acuity improvement than eyes without CAS (p < 0.001). CAS was more common in eyes with AL < 30 mm (50.3% of 155) than in eyes with AL ≥ 30 mm (36.5%, 35/96; p = 0.032). In the AL < 30 mm group, CAS was associated with ILM insertion (odds ratio [OR], 2.824, 95% confidence interval [CI], 1.189-6.710; p = 0.019), silicone oil (SO)/perfluoropropane (C3F8) tamponade (SO: OR, 0.408, 95% CI, 0.191-0.873; C3F8: OR, 2.448, 95% CI, 1.145-5.234; p = 0.021) and staphyloma (OR, 0.318, 95% CI, 0.143-0.707; p = 0.005). In the AL ≥30 mm group, CAS was associated with ILM insertion (OR, 11.621, 95% CI, 2.557-52.813; p = 0.001), SO /C3F8 tamponade (SO: OR, 5.305, 95% CI, 1.206-23.334; C3F8: OR, 0.188, 95% CI, 0.043-0.829; p = 0.027) and age (OR, 0.928, 95% CI, 0.876-0.983; p = 0.011).

CONCLUSION

Vitrectomy plus ILM peeling can effectively treat MHRD but has limited efficacy in eyes with AL ≥ 30 mm. ILM insertion was associated with more frequent CAS at any AL. C3F8 tamponade yielded better outcomes with AL < 30 mm; SO tamponade yielded better outcomes with AL ≥ 30 mm.

Optimized design of surgical steps in pars plana vitrectomy for macular hole retinal detachment in pathological myopia decreases rate of iatrogenic retinal break and shortens length of operation

BACKGROUND

To investigate the effect of surgical steps optimization in pars plana vitrectomy (PPV) with internal limiting membrane (ILM) flap for macular hole retinal detachment (MHRD) in pathological myopia.

METHODS

A retrospective, consecutive, nonrandomized comparative study. High myopic eyes diagnosed with MHRD receiving PPV with ILM flap from March 2019 to June 2020 in Department of Ophthalmology, Xiangya Hospital, Central South University were included in the study. Patients were included into two groups based on different design of surgical steps. In the routine group, extension of posterior vitreous detachment (PVD) towards periphery was performed right after induction of PVD. In the experiment group, the retina was reattached with drainage of subretinal fluid through macular hole before peripheral vitreous was dealt with. Complete ophthalmic examinations were performed before and after surgery. The follow-up time was at least 6 months. The rate of iatrogenic retinal break and length of operation were compared between the two groups.

RESULTS

Thirty-one eyes from 31 patients were included in the study with 15 in the experiment group and 16 in the routine group. Demographics showed no statistically significant difference between the two groups. Post-op BCVA, rate of macular hole closure and rate of retinal reattachment were similar in the two groups. The rate of iatrogenic retinal break in the experiment group was significantly lower than that in the routine group (6.7% vs. 37.5%, P < 0.05). The average length of operation was 78.6 ± 18.8 min in the routine group and 64.0 ± 12.1 min in the experiment group (P < 0.05).

CONCLUSIONS

Optimized design of surgical steps in PPV for MHRD could effectively decrease the rate of iatrogenic retinal tear and shorten the length of operation.

Inverted multi-layer internal limiting membrane flap for macular hole retinal detachment in high myopia

To investigate the surgical outcomes of pars plana vitrectomy (PPV) combined with inverted multi-layer internal limiting membrane (ILM) flap for the treatment of macular hole retinal detachment in high myopia. We retrospectively analysed the medical records of macular hole retinal detachment (MHRD) patients with high myopia. The patients were divided into two groups with different surgical procedure: inverted multi-layer ILM flap group (group 1, 27 eyes) and the ILM peeling group (group 2, 29 eyes). Retinal reattachment rate, macular hole closure rate at last follow-up and BCVA at 6 months post-operation were compared between the two groups. After primary PPV and silicone oil removal, the retinal reattachment rate was 96.3% in group 1 and 93.1% in group 2 respectively at last follow-up, showing no statistically significant difference (odds ratio = 0.525, P = 1.000). All eyes in group 1 had type I macular closure (100%, 27/27), while only 7 eyes (24.1%, 7/29) in group 2 have type I macular hole closure. The difference was statistically significant (odds ratio = 0, P < 0.05). The mean logMAR BCVA both improved significantly at 6 months post-operation compared with pre-operation (t = 4.181, P < 0.001; t = 3.217, P < 0.001), however the difference of post-operation BCVA between the two groups was not statistically significant (t = 0.906, P > 0.05). PPV combined with inverted multi-layer ILM flap could achieve better anatomical outcomes than ILM peeling technique with no significant advantage in functional outcomes.

Vitrectomy with residual internal limiting membrane covering and autologous blood for a secondary macular hole: A case report

BACKGROUND

Myopic foveoschisis (MF) is a common complication of pathological myopia. A macular hole (MH) usually results from the natural progression of MF and is a common complication of vitrectomy. Vitrectomy combined with residual internal limiting membrane (ILM) covering and autologous blood was effective for closing a secondary MH.

CASE SUMMARY

A 52-year-old woman presented to our clinic with a complaint of blurred vision in the right eye for 7 years. Her best corrected visual acuity (BCVA) was 20/100, axial length was 25.79 mm and standard equivalent refractive error was -10.5 dioptres. Preoperative optical coherence tomography revealed foveoschisis in the right eye. Vitrectomy with fovea-sparing ILM peeling was performed. An MH developed and gradually expanded 5 mo after the initial vitrectomy. Vitrectomy with residual ILM covering and autologous blood was performed. The MH closed 3 wk after the second vitrectomy.

CONCLUSION

Fovea-sparing ILM peeling can provide residual ILM for the treatment of MH secondary to vitrectomy for MF. Vitrectomy combined with residual ILM covering and autologous blood is effective for closing secondary MH and improving BCVA.

Correlation of morphological characteristics of staphyloma with the structural and functional outcomes of myopic traction maculopathy after macular buckle surgery

Purpose:

To compare morphological features of staphyloma (type and grade) with structural and functional outcomes in 11 patients with symptomatic myopic tractional maculopathy (MTM) who underwent macular buckle surgery.

Methods:

A retrospective observational case series, where a chart review was conducted of the type (Curtin classification) and grade of staphyloma (USG B-scan based). Optical coherence tomography (OCT) macula analysis done preoperatively and postoperatively 1 and 6–8 weeks), Visual acuity was recorded in log mar.

Results:

With an average myopia of −10.35 D (−5 to −14.5 D), there were four patients with types II and IX staphyloma and seven with type I staphyloma. The average axial length was 28.6 ± 0.98 mm in type II/IX and 26.2 ± 0.8 mm in type I. Preoperative OCT features were outer retinal layer schisis (11), retinal detachment (foveal: 2, macular: 8), macular hole (lamellar: 3, full thickness: 4), and taut posterior hyaloid (3). Postoperatively, patients with type II/IX staphyloma had significant gain in visual acuity from 1.05 ± 0.3 to 0.74 ± 0.2 Log Mar. The structural features also responded better in patients with types II/IX staphyloma, with all patients having more than 90% reduction in schisis and retinal attachment at 6 weeks. Whereas only two patients with type I staphyloma had similar reduction in schisis at 6 weeks and only one had complete retinal attachment.

Conclusion:

In patients with MTM, the staphyloma characteristics preoperatively can help us prognosticate about structural and functional success after macular buckle surgery. In our small case series, patients with type II/IX staphyloma and larger axial length had better structural and functional outcomes.

IMI Pathologic Myopia

Pathologic myopia is a major cause of visual impairment worldwide. Pathologic myopia is distinctly different from high myopia. High myopia is a high degree of myopic refractive error, whereas pathologic myopia is defined by a presence of typical complications in the fundus (posterior staphyloma or myopic maculopathy equal to or more serious than diffuse choroidal atrophy). Pathologic myopia often occurs in eyes with high myopia, however its complications especially posterior staphyloma can also occur in eyes without high myopia.

Owing to a recent advance in ocular imaging, an objective and accurate diagnosis of pathologic myopia has become possible. Especially, optical coherence tomography has revealed novel lesions like dome-shaped macula and myopic traction maculopathy. Wide-field optical coherence tomography has succeeded in visualizing the entire extent of large staphylomas. The effectiveness of new therapies for complications have been shown, such as anti-VEGF therapies for myopic macular neovascularization and vitreoretinal surgery for myopic traction maculopathy.

Myopia, especially childhood myopia, has been increasing rapidly in the world. In parallel with an increase in myopia, the prevalence of high myopia has also been increasing. However, it remains unclear whether or not pathologic myopia will increase in parallel with an increase of myopia itself. In addition, it has remained unclear whether genes responsible for pathologic myopia are the same as those for myopia in general, or whether pathologic myopia is genetically different from other myopia.

INTRAOPERATIVE AND POSTOPERATIVE MONITORING OF AUTOLOGOUS NEUROSENSORY RETINAL FLAP TRANSPLANTATION FOR A REFRACTORY MACULAR HOLE ASSOCIATED WITH HIGH MYOPIA

PURPOSE

To describe the intraoperative and postoperative morphological and functional outcomes after autologous neurosensory retinal flap transplantation (ART) for a high myopia-related refractory macular hole (MH).

METHODS

This prospective interventional study enrolled five eyes of five patients (age range 54-84 years) with highly myopic refractory MHs who underwent ART. All cases were evaluated with intraoperative optical coherence tomography and postoperative optical coherence tomography, optical coherence tomography angiography, and microperimetry for at least 6 months postoperatively.

RESULTS

Intraoperatively, the MH was covered by an ART flap with a persistent small subretinal space that was filled with the ART flap after 4 days to 6 days. Optical coherence tomography discriminated the original from the transplanted retina. The mean basal diameter of the original MH decreased from 1,504 ± 684 µm preoperatively to 1,111 ± 356 µm postoperatively. The best-corrected visual acuity improved in two cases, was stable in two cases, and deteriorated in one case. Microperimetry demonstrated no obvious postoperative changes in the fixation points and the absolute scotoma corresponding to the base of MHs with chorioretinal atrophy. In two eyes, choroidal neovascularization developed beneath the transplanted retinas.

CONCLUSION

Transplanted tissue was in a fixed position by 1 week postoperatively with a decreased diameter of the original MH. Postoperative fixation points were on the original retina at the MH edge. Because choroidal neovascularization may develop, detailed monitoring is required.

Surgical Outcomes of Vitrectomy for Macular Hole-induced Retinal Detachment According To Various Surgical Methods: A Multicenter Retrospective Study

PURPOSE

To investigate the surgical outcomes of vitrectomy for macular hole-induced retinal detachment(MHRD), with respect to the surgical adjunctive method used.

METHOD

We performed retrospective multicenter study of patients who underwent vitrectomy for MHRD. The visual/anatomical outcomes after vitrectomy were analyzed. We also analyzed these outcomes according to surgical method and the presence of persistent macular hole after the vitrectomy.

RESULT

Thirty-four patients (34 eyes) from 6 hospitals were included in this study. The mean age of the patients was 64.56 ± 12.23 years; 31 patients (91.2%) were female. The mean LogMAR best-corrected visual acuity (BCVA) significantly improved 6 months after vitrectomy (p < .001). Retinal detachment completely improved in 32 eyes (94.1%). The visual prognoses and macular hole closure rates were not different depending on subretinal fluid drainage site. The presence or absence of a persistent macular hole after vitrectomy did not affect the visual outcomes. However, the recurrence of MHRD was significantly higher in eyes with persistent macular holes(p = .015).

CONCLUSION

The surgeries to treat MHRD differed in terms of the procedure depending on the surgeons, but the visual outcomes did not differ depending on the surgical adjunctive method employed. There were no differences in the visual prognoses, regardless of whether there was a persistent macular hole; however, recurrence was significantly higher in eyes with persistent macular holes. Therefore, further surgical treatment might be considered for eyes with persistent macular holes after MHRD surgery.

Risk Factors for Recurrent Myopic Macular Hole Retinal Detachment after Silicone Oil Removal in Patients with Open Flat Macular Hole

OBJECTIVE

To evaluate the risks that might be associated with recurrent macular hole retinal detachment (MHRD) after silicone oil (S.O) removal in myopic patients with open flat macular hole (MH).

METHODS

In this retrospective series, we assessed the different factors that might be associated with recurrent MHRD after S.O removal in 48 eyes with open flat MH that underwent S.O removal after successful MHRD repair. We divided the enrolled eyes into 2 groups: group 1 included 38 eyes with flat open MH and flat retina after S.O removal, and group 2 included 10 eyes with flat open MH and recurrent MHRD after S.O removal.

RESULTS

Ten of 48 eyes (20.8%) with open flat MH developed recurrent MHRD after S.O removal. Univariate logistic regression analysis revealed that MH at the apex of PS, MH minimum diameter, hole form factor (HFF), and MH index (MHI) were significant risk factors for recurrent MHRD after S.O removal in myopic patients with open flat MH.

CONCLUSIONS

If there is a "flat open" MH that is large, located at the apex of PS, or with an HHF or MHI <0.9-0.5, there is a high chance of recurrent MHRD after S.O removal.

COMPARISON OF THE INTERNAL LIMITING MEMBRANE INSERTION TECHNIQUE AND THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE WITH VITRECTOMY TO TREAT MACULAR HOLE-ASSOCIATED RETINAL DETACHMENT

PURPOSE

To compare the anatomical and functional outcomes of macular hole (MH)-associated retinal detachment after vitrectomy with the internal limiting membrane (ILM) insertion technique or the inverted ILM flap technique.

METHODS

In this retrospective observational study, we reviewed the medical records of 49 eyes with MH-associated retinal detachment that underwent vitrectomy with the ILM insertion (26 eyes) or ILM flap (23 eyes) technique.

RESULTS

The MH closure rate at 12 months was greater in the ILM flap group versus the ILM insertion group (95% vs. 73%, respectively, P = 0.059). The postoperative best-corrected visual acuity (BCVA) at 12 months was significantly better in the ILM flap group (P = 0.014). All eyes (100%) showed an improvement in the BCVA of ≥0.3 logarithm of the minimum angle of resolution (15 Early Treatment Diabetic Retinopathy Study letters) in the ILM flap group versus 20 eyes (77%) in the ILM insertion group (P = 0.026). The preoperative BCVA and the ILM flap technique were significantly correlated with the postoperative BCVA (P = 0.028 and 0.027, respectively) and BCVA improvement (≥0.3 logarithm of the minimum angle of resolution [15 Early Treatment Diabetic Retinopathy Study letters]; P = 0.003 and 0.026, respectively).

CONCLUSION

The inverted ILM flap technique was more effective in improving the postoperative BCVA in patients with MH-associated retinal detachment when compared with the ILM insertion technique. The preoperative BCVA and the ILM flap technique were independent prognostic factors for visual outcomes in patients with MH-associated retinal detachment.

Parafoveal retinal massage combined with autologous blood cover in the management of giant, persistent or recurrent macular holes

AIM

To assess the efficacy and safety of parafoveal retinal massage combined with autologous whole blood cover in the treatment of refractory macular holes (MHs) and present the surgical procedure.

METHODS

Patients with giant (minimum diameter ≥800 µm), recurrent or persistent MHs who underwent PPV combined with parafoveal retinal massage and autologous whole blood cover using C3F8 as tamponade agent from February 2018 to May 2019 were enrolled in this retrospective study. After surgery, all patients were informed to maintain a prone position for at least 7d. Preoperative and postoperative best-corrected visual acuities (BCVAs) were compared and MH closure rate was measured as the main outcome.

RESULTS

A total of 13 MH patients consisted of 6 giant MHs, 4 persistent holes and 3 recurrent holes (5 men and 8 women; average age was 56.40±11.72y) were enrolled in this study. MH closure was achieved in 11 eyes by this modified surgical technique while 2 eyes failed. Revitrectomy with autologous neurosensory retinal patch transplantations was applied for those 2 patients and then both holes were closed. No intraoperative complications were observed. BCVA improved from 1.73 logMAR to 0.74 logMAR at 6mo postoperation. There was significant difference in BCVA before versus after the surgery (P<0.05). There were no adverse events occurred during the follow-up period.

CONCLUSION

With easier surgical procedure, parafoveal retinal massage combined with autologous whole blood cover is an effective addition to the surgical options for the management of refractory MHs.

Successful Technique for Closure of Macular Hole Retinal Detachment Using Autologous Retinal Transplant

Macular hole retinal detachment (MHRD) for the most part develops in highly myopic eyes. Several surgical methods have been introduced to treat MHRD. We describe our experience with the autologous retinal transplant in patient with MHRD. A 49-year-old female presented with a 2-week history of a sudden decrease in the central vision in the right eye (RE). A 3-port, 25-gauge pars plana vitrectomy was performed with the ILM dye staining and peeling. Endodiathermy was applied around a 1.5-disc diameter neurosensory donor site in the supertemporal retina. The graft was cut with standard 25-gauge curved scissors. Perfluoro-n-octane (PFO) was instilled. The free graft was gently handled until its packing into the macular hole. Two months following the initial PPV, the macular hole was closed, and vision improved from 0.05 to 0.25 logMAR.

Treatment of macular hole retinal detachment with macular plug in highly myopic eyes: three-year results

PURPOSE

To investigate the long-term surgical outcomes of macular hole retinal detachment (MHRD) following vitrectomy with macular plug in highly myopic eyes.

METHODS

Thirty-five cases of highly myopic eyes with MHRD in 35 patients who underwent an initially successful vitrectomy with macular plug and were followed up for at least 3 years were reviewed. The anatomical outcomes were evaluated by fundus examination, fundus photographs and optical coherence tomography (OCT). Myopic features after the surgery were differentiated according to recommendations of the Meta-analysis of Pathologic Myopia (META-PM) Study Group. The best-corrected visual acuities (BCVAs) before and after surgery were analysed as the functional outcome. Main outcome measures time-course changes in BCVA and complications.

RESULTS

The mean patient age was 61.0 ± 11.4 years. The follow-up was 45.2 ± 8.6 months (ranged from 36 to 71 months). The mean axial length was 29.3 ± 1.2 mm. All eyes demonstrated attached retina, but 2 eyes (5.7%) developed reopened macular holes until the last follow-up. Complications of postoperative rhegmatogenous retinal detachment were detected in 2 eyes (5.7%) within 1 year and retina reattached after the secondary vitrectomy. Three cases (8.6%) of prolonged subretinal fluid lasting more than 1 year were detected but finally absorbed completely. Comparing 1-3 years postoperatively, myopic features showed significant progression of myopic maculopathy category (p = 0.035). Functionally, significantly improved BCVA could be maintained postoperatively between 6 months and 3 years. However, vision of 14 eyes (40.0%) worsened within 1-3 years postoperatively, and visual deterioration was associated with progression of myopic maculopathy (p = 0.004) and pre-existing disease of glaucoma (p = 0.006).

CONCLUSIONS

A vitrectomy combined with macular plug provided favourable outcomes in the long term, over the ≥3-year follow-up period.

Prognostic Factor Analysis of Visual Outcome after Vitrectomy for Rhegmatogenous Retinal Detachment

Pars plana vitrectomy (PPV) is a surgical approach mainly chosen for complex rhegmatogenous retinal detachment (RRD) repair with highly variable functional results. The aim of this analysis was to evaluate the impact of preoperative factors and postoperative optical coherence tomography (OCT) macular findings on the functional outcome of patients undergoing primary PPV for RRD. A retrospective analysis was performed on 88 eyes of 88 patients with complex RRD managed by PPV. A swept source OCT was used to obtain images at the postoperative visit at least 6 months after PPV. Hierarchical linear regression model was used to evaluate the influence of preoperative factors related to patient, ocular clinical and postoperative OCT macular findings on functional outcomes of PPV for RRD. Duration of symptoms (p = 0.031) and discontinuity of the ellipsoid zone (EZ) on OCT (p = 0.024) showed statistically significant negative correlation, while preoperative best-corrected visual acuity (BCVA; p < 0.001) showed statistically significant positive correlation to postoperative BCVA. Preoperative BCVA and duration of symptoms can be used as prognostic factors for visual outcome in patients undergoing PPV for RRD. Discontinuity of the EZ was the only postoperative OCT variable related to worse postoperative visual outcome.

Inverted Internal Limiting Membrane Flap Technique versus Internal Limiting Membrane Peeling for Vitrectomy in Highly Myopic Eyes with Macular Hole-Induced Retinal Detachment: An Updated Meta-Analysis

BACKGROUND

The aim of this meta-analysis was to compare morphological and functional outcomes between vitrectomy with the inverted internal limiting membrane (ILM) flap technique and vitrectomy with internal limiting membrane peeling in highly myopic eyes with macular hole- (MH-) induced retinal detachment (MHRD).

METHODS

The PubMed, Web of Science, Embase, and Cochrane Library databases were comprehensively searched from inception to November 10, 2019, for published studies comparing the two techniques for the treatment of MHRD. The outcomes in the collected articles included the postoperative MH closure rate, retinal reattachment rate, and best-corrected visual acuity (BCVA). Review Manager (version 5.3) was used for analyses.

RESULTS

In total, seven retrospective studies comparing the inverted ILM flap technique with ILM peeling for the treatment of MHRD were included. The MH closure rate was significantly higher in the inverted ILM flap group than in the ILM peeling group at 6 and 12 months after initial surgery (OR = 15.39; 95% CI: 6.68 to 35.43;P < 0.00001 and OR = 12.58, 95% CI: 3.51 to 45.08; P=0.0001), while the retinal reattachment rate was similar in both groups at 6 months after initial surgery (OR = 2.40; 95% CI: 0.89 to 6.50; P=0.08). Besides, the postoperative BCVA was significantly better in the inverted ILM flap group than in the ILM peeling group at 12 months after initial surgery (MD = -0.35; 95% CI: -0.52 to -0.18; P < 0.0001).

CONCLUSIONS

Thus, the MH closure rate and postoperative BCVA may be better with the inverted ILM flap technique than with ILM peeling for myopic MHRD, while the postoperative retinal reattachment rate appears to be similar with both techniques. Therefore, in the future, vitrectomy with the inverted ILM flap technique should be preferred over standard ILM peeling technique for the treatment of MHRD in highly myopic eyes.

MORPHOLOGIC CHARACTERISTICS OF MACULAR HOLE AND MACULAR HOLE RETINAL DETACHMENT ASSOCIATED WITH EXTREME MYOPIA

PURPOSE

To investigate the surgical results and morphologic characteristics of macular hole (MH) and macular hole retinal detachment (MHRD) associated with extreme myopia.

METHODS

We retrospectively reviewed consecutive cases with axial length ≥28 mm who were treated with pars plana vitrectomy for MH or MHRD. The choroidal and scleral thickness at the fovea, presence of dome-shaped macula, and the height of posterior staphyloma 3 mm from the fovea were measured from postoperative optical coherence tomography images.

RESULTS

Significant improvement in visual acuity was obtained postoperatively in both MH (16 eyes; 15 patients) and MHRD (19 eyes; 18 patients) groups (P < 0.05). Final MH closure rate was not significantly different between the groups (MH: 15/16, MHRD: 14/19, P = 0.19). Axial length was not significantly different between the groups (MH: 30.5 ± 1.5 mm, MHRD: 29.6 ± 1.3 mm, P = 0.098). Eyes with MH had significantly greater choroidal thickness (MH: 61.9 ± 66.0 μm, MHRD: 24.1 ± 19.8 μm, P = 0.045), greater scleral thickness (MH: 294 ± 77 μm, MHRD: 232 ± 89 μm, P = 0.008), higher frequency of dome-shaped macula (MH: 6/16, MHRD: 1/19, P = 0.032), and lower staphyloma height (MH: 190 ± 113 μm, MHRD: 401 ± 156 μm, P < 0.001).

CONCLUSION

Surgical outcomes were generally favorable. The pathogenetic differences between the two conditions may be attributable to differences with respect to eye morphology.

Applications of the Amniotic Membrane in Vitreoretinal Surgery

Recently, the use of the human amniotic membrane (hAM) has been extended to treat retinal disorders, such as macular holes that failed to close and retinal tears. The hAM has demonstrated the induction of a recovery process of the external retinal layers involving the external limiting membrane (ELM) and the ellipsoid zone (EZ). After that, the application of the hAM for retinal pathologies was extended to large macular tears, high myopic retinal detachment associated with MH, paravascular tears, serous macular detachment associated with optic pit, complicated retinal detachment and advanced age-related macular degeneration (AMD). The hAM has shown a potential in repairing retinal tissue through a regeneration process. This review aims to highlight the use of the hAM in various vitreo-retinal surgical fields, and to confront it with other cutting-edge surgical techniques used to treat challenging vitreo-retinal pathologies.

Comparison of Internal Limiting Membrane Peeling and Flap Removal to Flap Insertion on Visual Outcomes in Highly Myopic Eyes with Macular-Hole Retinal Detachment

INTRODUCTION

To compare the morphological and visual outcomes after pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling and flap removal to that with flap insertion in eyes with myopic macular-hole retinal detachment (MHRD).

METHODS

Forty-six eyes of 45 patients with MHRD were studied. Eighteen eyes were treated by PPV with ILM peeling and flap removal and 28 eyes by flap insertion, respectively. The baseline characteristics and postoperative findings were compared between the 2 groups.

RESULTS

The average age of the cases was 70.0 ± 8.5 years. The best-corrected visual acuity (BCVA) improved, from 1.51 ± 0.14 to 1.31 ± 0.20 logMAR units in the flap removal group, and from 1.20 ± 0.10 to 0.88 ± 0.10 logMAR units in the flap insertion group (p = 0.049). A significantly larger number of MHs were closed in the flap insertion group (96 vs. 50% in the removed group; p < 0.001). Restoration of the ellipsoid zone (EZ) and external limiting membrane (ELM) was also better in the flap insertion group than in the flap removal group (EZ 14 vs. 6%, p = 0.003; ELM 36 vs. 6%, p < 0.001).

DISCUSSION

The technique of ILM peeling with flap insertion is more effective in closing the MH, and results in better BCVA and better restoration of the outer retinal microstructures than flap removal.

A human Amniotic Membrane plug to manage high myopic macular hole associated with retinal detachment

OBJECTIVE

To assess the efficacy of the human amniotic membrane (hAM) to treat (HMMH) associated with retinal detachment (RD).

MATERIAL AND METHODS

Ten eyes of 10 patients with recurrent HMMH and RD, who had already undergone one or more pars plana vitrectomy (PPV), underwent a PPV with an hAM plug implanted in the macular hole. The initial five patients enrolled were tamponaded with (SO) while the subsequent five patients with 10% octafluoropropane (C₃ F₈ ). Silicon oil was removed in all five patients 2 months later. No statistical differences were reported between the two groups.

RESULTS

Final retinal reattachment was achieved in all the patients. BCVA improved from 1.73 logMAR to 0.94 logMAR after 6 months. No adverse events were registered during follow-up.

CONCLUSION

An hAM plug is an efficient substrate to manage HMMH associated with RD resulting in encouraging visual acuity recovery.

Inverted internal limiting membrane (ILM) flap technique for macular hole closure: patient selection and special considerations

This paper reviews the current status of the newer inverted internal limiting membrane flap technique for macular hole surgery. It gives an overview of the importance of patient selection and special considerations along with variations in technique. It discusses the pathophysiology and how the technique has been an important addition in the armamentarium of vitreoretinal surgeons to attain better anatomical as well as functional results in challenging situations.

Vitrectomy with inverted internal limiting membrane flap versus internal limiting membrane peeling for macular hole retinal detachment in high myopia: a systematic review of literature and meta-analysis

PURPOSE

To evaluate the effect of vitrectomy with inverted internal limiting membrane (ILM) flap for the treatment of macular hole retinal detachment (MHRD) in high myopia compared with that of ILM peeling.

METHODS

PubMed, EMBASE, Web of Science, MEDLINE, Ovid, Wan Fang and CNKI were systematically reviewed. The primary outcome parameters were the MH closure rate, retinal reattachment rate and postoperative BCVA. Secondary outcome parameters, included intraoperative or postoperative complications.

RESULTS

Seven retrospective comparative studies including 228 eyes were selected. No significant difference was detected in either postoperative BCVA (MD -0.07; 95% CI: -0.17 to 0.03; p = 0.16) or the improvement in postoperative BCVA (MD -0.17; 95% CI: -0.50 to 0.16; p = 0.32) between the ILM flap group and ILM peeling group. The retinal reattachment rate using inverted ILM flap was not significantly different from that using ILM peeling (odds ratio (OR) 2.24; 95% CI: 0.75-6.73; p = 0.15). The MH closure rate was higher with inverted ILM flap than with ILM peeling (OR 11.86; 95% CI: 5.65 to 24.92; p < 0.00001). There was no significant difference in intraoperative or postoperative complications, including concomitant cataract rate (OR 1.22; 95% CI: 0.42-3.58; p = 0.71).

CONCLUSION

The inverted ILM flap technique could contribute to a higher MH closure rate than ILM peeling, but visual improvement was similar. Both surgical methods could obtain a high-retinal reattachment rate with fewer intraoperative and postoperative complications.

Macular Hole in Myopic Eyes: A Narrative Review of the Current Surgical Techniques

Macular hole (MH) in myopic eyes is a disease arising from complex tractional forces exerted by vitreomacular interface, epiretinal tissue, and progressive scleral ectasia of the posterior ocular globe wall. This retinal disease requires vitreoretinal treatment for its repair, and the surgical intervention remains a challenge also for experienced surgeons. The aim of this review is to describe the current knowledge regarding the pathogenesis of MH in myopic eyes and to detail novel surgical techniques and technological advancements in its surgical management.

Autologous Retinal Transplant for Refractory Macular Holes: Multicenter International Collaborative Study Group

PURPOSE

To report the structural and functional outcomes of autologous neurosensory retinal transplant for closure of refractory large macular holes (MHs).

DESIGN

Multicenter, retrospective, consecutive case series.

PARTICIPANTS

A total of 41 eyes of 41 patients with a full-thickness MH refractory to prior vitrectomy with internal limiting membrane (ILM) peel and tamponade.

METHODS

All patients underwent pars plana vitrectomy, autologous neurosensory retinal transplant with gas, silicone oil tamponade, or short-term perfluoro-n-octane heavy-liquid tamponade. All patients had at least 6 months' follow-up.

MAIN OUTCOME MEASURES

Anatomic closure of MH, change in ellipsoid zone (EZ) and external limiting membrane (ELM) defect on OCT, visual acuity (VA) recovery, and surgical complications were analyzed.

RESULTS

Mean number of prior surgeries was 1.5±0.94 (range, 1-3), and patients were followed for a mean of 11.1±7.7 months (range, 6-36 months). Complete anatomic closure of MH by OCT was achieved in 36 of 41 eyes (87.8%). Mean corrected VA (logarithm of the minimum angle of resolution [logMAR]) improved (P = 0.03) from 1.11±0.66 (range, 0.48-3) to 1.03±0.51 (range, 0.1-2) at the last postoperative visit. The VA improved (≥0.3 logMAR units) in 15 eyes (36.6%), was stable in 17 eyes (41.5%), and worsened in 9 eyes (21.9%). Among eyes with anatomic closure, VA improved in 52.3% and worsened in 13.8%, whereas in those without closure, VA worsened in 40% and improved in none. Mean preoperative largest basal diameter was 1468.1±656.4 μm (range, 621-2600 μm), and mean inner-opening diameter was 825±422.5 μm (range, 336-1649 μm). Mean preoperative EZ defect was 1777.3±513.8 μm (range, 963-2808 μm), which decreased to 1370±556.9 μm (range, 288-2000 μm) at final follow-up (P = 0.007). Mean preoperative ELM was 1681.5±429 μm (range, 1172-2606 μm), which decreased to 1408.5±571.2 μm (range, 200-2000 μm) at final follow-up (P = 0.017). Major postoperative complications were retinal detachment (n = 1) and vitreous hemorrhage (n = 1). There were no cases of proliferative vitreoretinopathy, endophthalmitis, suprachoroidal hemorrhage, or choroidal neovascularization.

CONCLUSIONS

The autologous retinal transplant technique offers a high degree of anatomic success and proved safe in this initial experience for closure of refractory MHs.

Inverted internal limiting membrane insertion combined with air tamponade in the treatment of macular hole retinal detachment in high myopia: study protocol for a randomized controlled clinical trial

Background

Macular hole retinal detachment (MHRD) occurs most commonly in high myopia and causes severe visual impairment and greatly reduces the quality of life. The aim of this study is to evaluate the efficacy and safety of inverted internal limiting membrane insertion combined with air tamponade in the treatment of MHRD in high myopia, and also to compare the treatment efficacy with that of the conventional “vitrectomy plus internal limiting membrane peeling plus silicone oil tamponade” method for high myopia-associated MHRD.

Methods/design

In this clinical trial, 38 patients with MHRD in high myopia will be randomly assigned to two groups (Group 1: standard 3-port 23-gauge pars plana vitrectomy plus internal limiting membrane peeling plus air-fluid exchange plus silicone oil infusion; Group 2: standard 3-port 23-gauge pars plana vitrectomy plus internal limiting membrane peeling plus inverted internal limiting membrane insertion plus air-fluid exchange). The primary outcome is macular hole closure rate in 3 months after the initial surgery. The secondary outcomes are best corrected visual acuity (BCVA), reattachment rate of retinal detachment, and postoperative complication rate.

Discussion

The study results may help to evaluate the efficacy and safety of inverted internal limiting membrane insertion combined with air tamponade in the treatment of MHRD in high myopia, and also compare the efficacy of the new treatment with the conventional “vitrectomy plus internal limiting membrane peeling plus silicone oil tamponade” method. This trial may provide a novel surgical treatment for MHRD in high myopia with more effectiveness and less pain.

Trial registration

ClinicalTrials.gov, NCT03383731. Registered on 19 December 2017. Retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2833-y) contains supplementary material, which is available to authorized users.

THE CURRENT SURGICAL MANAGEMENT OF LARGE, RECURRENT, OR PERSISTENT MACULAR HOLES

PURPOSE

To evaluate the current surgical options available for the management of large (>400 μm), recurrent, or persistent macular holes (MHs).

METHODS

A review of the literature was performed, focusing on the epidemiology, pathophysiology, diagnosis, and surgical treatments of large, recurrent, or persistent MHs. Based on this review, a comprehensive overview was provided regarding the topic of large, recurrent, or persistent MHs and focused on recent surgical management updates.

RESULTS

For large MHs, variations of the inverted internal limiting membrane flap technique demonstrated promising rates of primary hole closure and significant visual acuity improvements. For recurrent or recalcitrant MHs, early repeat vitrectomy with extension of the internal limiting membrane peel remains the most straightforward and optimal surgical technique to achieve secondary closure. Regardless of the surgical approach, the goal of each technique described is to induce or aid in stimulating gliosis within the MH to maximize closure.

CONCLUSION

Despite the high success rate of modern MH surgery, large, recurrent, or persistent MHs remain a challenge for retinal surgeons. This review provides a detailed summary on the rationality and efficacy of current surgical options.

The management of macular hole retinal detachment and macular retinoschisis in pathological myopia; a UK collaborative study

PURPOSE

To study UK practice patterns for the management of retinal detachment secondary to macular hole (MHRD) and macular retinoschisis (MRS) in pathological myopia (PM). To review the anatomical and visual outcomes of the surgically managed cases.

METHODS

A prospective observational case series for the management of MHRD was undertaken in association with the British Ophthalmological Surveillance Unit (BOSU). The results were combined with retrospective data, collected by the COllaboration of British RetinAl Surgeons (COBRA), on the management of both MHRD and MRS in PM in the UK. A total of 20 cases of MHRD and 53 cases of MRS (27 surgical cases and 26 cases managed conservatively) are reported in this combined study.

RESULTS

MHRD: Mean baseline best corrected visual acuity (BCVA) was 1.60 logMAR. All cases underwent pars plana vitrectomy (PPV). Mean post-operative BCVA was 1.49 logMAR (p = 0.674). The macular hole was closed in 5/20 (25%) cases, open/flat in 10/20 (50%) cases and open/elevated in 4/20 cases (20%). MRS: Mean baseline BCVA was 0.87 logMAR in the surgical group and 0.45 logMAR in the conservatively managed group (p = 0.002). All eyes that had surgical intervention underwent PPV. Mean post-operative BCVA was 0.68 logMAR (p = 0.183). Anatomical outcomes demonstrated a persistent MRS in 2/27 (7.4%) cases, partial resolution in 7/27 (25.9%) cases and complete resolution in 16/27 (59.2%) cases.

CONCLUSIONS

PPV is the only surgical procedure performed for the management of MHRD and MRS amongst the study participants. Success rates and visual outcomes are limited for MHRD and consistent with the current literature for MRS.

Macular buckle technique in myopic traction maculopathy: a 16-year review of the literature and a comparison with vitreous surgery

PURPOSE

The aim of this study is to review anatomical and functional outcomes following macular buckling (MB) in high myopia and to compare such results with those obtained by pars plana vitrectomy (PPV).

METHODS

PubMed articles on MB in high myopia (2000-2016) were reviewed. Main outcomes included retinal reattachment and macular hole (MH) closure rates, resolution of myopic foveoschisis (MFS), and postoperative visual acuity.

RESULTS

Thirty-one articles included 16 in patients with retinal detachment due to MH (MHRD group), 11 in MFS with or without foveal detachment (MFS group), and 4 in MH patients with MFS (MH-MFS group). Surgical techniques mainly differed in the type of buckle, rectus muscles involvement, and concurrent PPV. In eyes with persistent MH, prognosis in the MHRD and MH-MFS groups differed between eyes receiving MB compared to PPV: functional outcome was markedly poorer and there was a higher risk of retinal redetachment associated with PPV. In the MSF group, secondary MHs were more likely to develop in eyes treated with PPV and internal limiting membrane peeling than those undergoing MB alone or combined with PPV. Retinal pigment epithelium changes, malpositioning, perforation, and choroidal detachment were the main complications.

CONCLUSIONS

Although different approaches are used, complete resolution of foveoschisis, retinal reattachment, and MH closure seem to be achieved more frequently with MB than PPV.

Vitrectomy in patients 85 years of age and older: surgical outcomes and visual prognosis

Purpose

To evaluate visual and surgical outcomes in very elderly patients (above 85 years of age) undergoing pars plana vitrectomy (PPV).

Patients and methods

A single-center, retrospective study was carried out on the medical records of 82 patients aged 85 years and older who had undergone PPV from 2006 to 2013. Patients ranged in age from 86 to 99 years, with a mean age of 88.9 years (±2.88). Visual results and intraoperative and postoperative complications were the main outcome measures. Visual improvement/worsening was defined as at least ±0.1 logMAR change.

Results

Mean follow-up was 7.25 months (±5.35), with a range of 1-28 months. General anesthesia was used in 63% of the operations. The most common indication was retinal detachment (27%). The ocular condition necessitating PPV was secondary to trauma (most commonly after a fall) in 10 eyes (12%). Mean visual acuity (VA) improved from 1/58 preoperatively to 1/29 at the final evaluation (p=0.014). Mean improvement in VA in eyes of patients with the comorbidity of age-related macular degeneration (n=34) was 41% lower compared to eyes of patients without the disease (n=48, p=0.013). In the subgroup of patients operated on for retinal detachment, 45.4% did not reach primary anatomic success and 45.4% needed additional retina-affecting surgery. One or more major ocular complications were reported in 24 eyes (29%), while 19 eyes (23%) had minor ocular complications.

Conclusion

Improved VA was documented in more than half of the older adults aged 85-99 undergoing vitrectomy. Despite the rate of complications in the very elderly, the possibility of optimizing visual function may positively affect quality of life in this subgroup.

Vitrectomy with a modified temporal inverted limiting membrane flap to reconstruct the foveolar architecture for macular hole retinal detachment in highly myopic eyes

PURPOSE

We investigated the surgical results of macular hole retinal detachment (MHRD) with a modified C-shaped temporal inverted internal limiting membrane (ILM) flap to reconstruct the foveolar architecture in highly myopic eyes.

METHODS

Eighteen highly myopic eyes with MHRD in 17 patients who underwent a vitrectomy with a modified C-shaped temporal inverted ILM flap were followed for 12 months. Anatomic outcomes were evaluated by fundus examinations and optical coherence tomography. The preoperative and postoperative best-corrected visual acuities (BCVAs) were compared as functional outcomes.

RESULTS

Women accounted for 88% of the MHRD patients. The mean age was 60.2 ± 8.2 years. The mean axial length was 29.25 ± 2.10 mm. Type 1 and type 2 MHRD was present in four eyes and 14 eyes, respectively. After a single surgery, the hole was closed in 18 eyes (100%). Retinal attachment was achieved in 95%. Persistent shallow subretinal fluid (SRF) was noted in one case, which was resolved at follow-up. The surgery significantly improved BCVAs (from 1.7 ± 0.6 to 0.72 ± 0.4 logarithm of the minimum angle of resolution units [p < 0.001]) at the last visit. In total, 94.4% of the eyes had restored foveolar architecture. Ellipsoid zone recovery within the foveola was found in 77.8% of the eyes.

CONCLUSION

A vitrectomy and modified C-shaped inverted temporal ILM flap is effective for closing MHs, reattaching the retina, restoring the foveolar architecture and significantly improving the postoperative BCVA in MHRD patients. This technique is feasible, and we propose 'presumed' Müller cell cone repair in MHRD surgery.

Vitrectomy with internal limiting membrane peeling versus inverted internal limiting membrane flap technique for macular hole-induced retinal detachment: a systematic review of literature and meta-analysis

BACKGROUND

To evaluate the effects on vitrectomy with internal limiting membrane (ILM) peeling versus vitrectomy with inverted internal limiting membrane flap technique for macular hole-induced retinal detachment (MHRD).

METHODS

Pubmed, Cochrane Library, and Embase were systematically searched for studies that compared ILM peeling with inverted ILM flap technique for macular hole-induced retinal detachment. The primary outcomes are the rate of retinal reattachment and the rate of macular hole closure 6 months later after initial surgery, the secondary outcome is the postoperative best-corrected visual acuity (BCVA) 6 months later after initial surgery.

RESULTS

Four studies that included 98 eyes were selected. All the included studies were retrospective comparative studies. The preoperative best-corrected visual acuity was equal between ILM peeling and inverted ILM flap technique groups. It was indicated that the rate of retinal reattachment (odds ratio (OR) = 0.14, 95% confidence interval (CI):0.03 to 0.69; P = 0.02) and macular hole closure (OR = 0.06, 95% CI:0.02 to 0.19; P < 0.00001) after initial surgery was higher in the group of vitrectomy with inverted ILM flap technique than that in the group of vitrectomy with ILM peeling. However, there was no statistically significant difference in postoperative best-corrected visual acuity (mean difference (MD) 0.18 logarithm of the minimum angle of resolution; 95% CI -0.06 to 0.43 ; P = 0.14) between the two surgery groups.

CONCLUSION

Compared with ILM peeling, vitrectomy with inverted ILM flap technique resulted significantly higher of the rate of retinal reattachment and macular hole closure, but seemed does not improve postoperative best-corrected visual acuity.

Vitrectomy in high myopia: a narrative review

Pathologic myopia is associated with degenerative changes of the globe, especially at the posterior pole. Eyes affected by pathologic myopia have higher odds to undergo posterior segment surgery and, in those eyes, vitreoretinal surgery is challenging. Many practical tips and tricks can make the surgical procedures simpler, significantly preventing sight-threatening intra- and post-operative complications. Moreover, novel surgical techniques and technological advancements (i.e. ad-hoc instrumentation, minimally invasive vitreoretinal surgery, filters, dye staining, intraoperative optical coherence tomography and 3-dimensional surgery) may play role in highly myopic eyes. The aim of the present work is to review practical tips and tricks, novel surgical techniques and technological advancements.

Double Internal Limiting Membrane Insertion for Macular Hole-Associated Retinal Detachment

Purpose

To describe a modified technique of internal limiting membrane (ILM) insertion for macular hole- (MH-) associated retinal detachment (RD) in highly myopic eyes.

Methods

Nine eyes underwent pars plana vitrectomy, cortical vitreous removal, and fovea-sparing ILM peeling. Double ILM insertion into the hole was performed with inverted perifoveal ILM and a free ILM flap followed by air-fluid exchange.

Results

Two of the 9 eyes had perifoveal ILM partially torn after cortical vitreous or epiretinal removal. All eyes had the ILM plug stabilized within the MH after double ILM insertion. Postoperatively, MH was sealed with the retina reattached in all the eyes.

Conclusion

Double ILM insertion may further secure the ILM flap in place in the eyes with MH-associated RD, especially in cases in which insufficient perifoveal ILM was left. This trial is registered with the clinical registration number Clinicaltrials.gov NCT03174639.

SCLERAL IMBRICATION COMBINED WITH PARS PLANA VITRECTOMY WITHOUT INTERNAL LIMITING MEMBRANE PEELING FOR MYOPIC SCHISIS

PURPOSE

We investigated whether scleral imbrication combined with pars plana vitrectomy without internal limiting membrane peeling would be effective in treating eyes with myopic macular schisis.

METHODS

In this retrospective, interventional case series, 8 eyes of 8 patients with myopic retinoschisis without a macular hole were studied. Scleral imbrication was done with 6-mm-wide mattress sutures placed at the temporal quadrants. Pars plana vitrectomy and removal of the vitreous cortex were performed, but the internal limiting membrane was not removed. The best-corrected visual acuity was measured, and the retinal morphology was determined by spectral-domain optical coherence tomography before and at 6 and 12 months postoperatively.

RESULTS

The mean age of the subjects was 67.1 years. The best-corrected visual acuity improved from 0.71 ± 0.25 to 0.36 ± 0.19 logarithm of the minimum angle of resolution units (Snellen equivalent: from 20/100 to 20/50) at 12 months (P = 0.028). The axial length was shortened from 29.5 ± 1.7 to 28.5 ± 2.5 at 12 months (P = 0.012). The central foveal thickness decreased from 540 ± 171 μm to 170 ± 85 μm at 12 months (P = 0.012). In the 6 macular-detached eyes, 5 eyes (83%) had a complete resolution. The curvature of posterior eye wall was flatter at 12 months (P = 0.049). No retinal complications were observed.

CONCLUSION

Scleral imbrication combined with pars plana vitrectomy can be an effective method of treating myopic schisis.

Clinical Investigation of the Posterior scleral contraction to Treat Macular Traction Maculopathy in Highly Myopic Eyes

Myopic traction maculopathy (MTM) can cause vision disabilities in highly myopic eyes. This retrospective case series investigated the clinical outcomes of posterior scleral contraction (PSC) using genipin-cross-linked sclera as the material to treat MTM in highly myopic eyes. In total, 32 eyes from 29 highly myopic patients who underwent PSC for MTM were recruited. The changes in best-corrected visual acuity (BCVA) and axial length were evaluated, macular reattachment and macular hole (MH) closure was assessed by optical coherence tomography, and complications were evaluated. At the final follow-up, the retina was completely reattached in 25 eyes (78.1%), essentially reattached in 4 eyes (12.5%), and partially reattached in 3 eyes (9.4%). The logMAR BCVA improved significantly from 1.18 ± 0.45 preoperatively to 0.87 ± 0.45 postoperatively (P < 0.001). The 32 eyes were further divided into the MH group (16 eyes) and the non-MH group (16 eyes) for comparison. The MH was closed in 9 eyes (56.3%). The retinal reattachment rate was 75.0% in the MH group and 81.25% in the non-MH group, and the logMAR BCVA improved significantly in both groups. The PSC using genipin-cross-linked sclera as the material can effectively treat MTM in highly myopic eyes, and significant visual improvement can be achieved with minimal complications.

Comparison of the Inverted Internal Limiting Membrane Flap Technique and the Internal Limiting Membrane Peeling for Macular Hole with Retinal Detachment

Purpose

To evaluate the efficacy of the inverted internal limiting membrane (ILM) flap technique in vitrectomy for macular hole (MH) with retinal detachment (RD) compared with vitrectomy using ILM peeling.

Methods

A retrospective case series study was performed. Twenty-two eyes of 22 patients who underwent vitrectomy for MH with RD and followed-up more than 12 months after the surgery were included in this study. We retrospectively reviewed the medical records of patients who underwent vitrectomy with inverted ILM flap technique or vitrectomy with ILM peeling. Ten patients who had been treated vitrectomy with inverted ILM flap technique, and 12 patients who had been treated vitrectomy with ILM peeling were analyzed. We evaluated changes in best-corrected visual acuity (BCVA) before and after surgery, closing rates of MH, and retinal reattachment rates and compared between both groups.

Results

MH was closed and RD was reattached postoperatively in 9 eyes (90%) in the inverted ILM flap group. In the ILM peeling group, the MH was closed in 4 eyes (33.3%) and the retinas were reattached in 6 eyes (50%) after surgery. Significant improvement in BCVA after surgery (P = 0.0017) was only found in the inverted ILM flap group.

Conclusions

Higher rates of closed MH and retinal reattachment, and small but significant improvement in BCVA were found in the inverted ILM flap group. Based on our data, the inverted ILM flap technique may be useful in vitrectomy for MH with RD.

A meta-analysis of vitrectomy with or without internal limiting membrane peeling for macular hole retinal detachment in the highly myopic eyes

Background

To evaluate the anatomical and visual outcomes by par plana vitrectomy with or without internal limiting membrane (ILM) peeling in highly myopic eyes with macular hole retinal detachment (MHRD).

Methods

MEDLINE (Ovid, PubMed) and EMBASE were used for data collection up to September 30, 2015. The parameters of anatomical success, macular hole closure and improved best corrected visual acuity (BCVA) at or beyond 6 months after operation were assessed as the primary outcome measurement. The meta-analysis was performed with the fixed-effects model.

Results

Seven comparative analyses involving a total of 373 patients were included in the present meta-analysis. Statistically the pooled data showed significant relative risk (RR) in terms of primary reattachment between ILM peeling and non-peeling groups (RR, 1.19; 95 % CI, 1.04 to 1.36; P = 0.012). An effect favoring ILM peeling with regard to macular hole closure was also detected (RR, 1.71; 95 % CI, 1.20 to 2.43; P = 0.003). However, no statistically significant difference was found in the improved BCVA (logarithm of the minimum angle of resolution) at 6 months or more (95 % CI, −0.31 to 0.44; P = 0.738).

Conclusions

There is no proved benefit of postoperative visual improvement. However, the available evidences from this study suggested a superiority of ILM peeling over no peeling for myopic patients with MHRD.

T-shaped macular buckling combined with 25G pars plana vitrectomy for macular hole, macular schisis, and macular detachment in highly myopic eyes

OBJECTIVE

To report our experience using the T-shaped macular buckle (MB) with or without pars plana vitrectomy (PPV) as primary surgery or with a previous failed surgical approach in patients affected by high myopia and macular hole (MH) with or without macular detachment and with or without macular schisis. The primary goal was to evaluate complete closure of the MH and reattachment of the retina.

DESIGN

Retrospective case series of 21 consecutive patients who underwent T-shaped MB implant alone or combined with PPV at the Academic Medical Center in Amsterdam, The Netherlands, between January 2013 and November 2014. The mean axial length was 31.22 mm. The mean follow-up period was 7 months.

RESULTS

Retinal reattachment was achieved in 100% of cases while MH closure was achieved in 90.5%. No major perioperative complications were observed. Best corrected visual acuity improved in 71.4% of patients.

CONCLUSIONS

MB combined with PPV should be considered as the preferred surgical approach both in primary and recurrent retinal detachment secondary to MH in high myopic eyes.

Inverted Internal Limiting Membrane Insertion for Macular Hole-Associated Retinal Detachment in High Myopia

PURPOSE

To investigate the surgical outcomes of inverted internal limiting membrane (ILM) insertion in macular hole (MH)-associated retinal detachment (RD) in high myopia.

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

This study was conducted at 2 medical centers. Consecutive cases of highly myopic eyes with MH-associated RD were included. Forty eyes were divided into 2 groups: Group 1 (20 eyes) received vitrectomy, ILM peeling within the arcade area, and air-fluid exchange, and Group 2 (20 eyes) received vitrectomy, inverted ILM inserted into the macular hole, and air-fluid exchange. Optical coherence tomography was used to observe the closure of the macular hole. Corrected visual acuity (VA) was also recorded. Two-sample t test and Mann-Whitney U test were used for statistical analysis to compare differences between the 2 groups.

RESULTS

MH was closed in 35% of the eyes in Group 1 and in all eyes in Group 2 (P < .001). Significant improvement in VA in logarithm of minimal angle of resolution (logMAR) was achieved in both groups. There was no difference in the initial, final, or improvement of logMAR VA in the 2 groups.

CONCLUSION

Inverted ILM insertion into a macular hole effectively helps close the macular hole in MH-associated RD in high myopia. This may prevent the possible re-detachment from the MH. A prospective study with a larger number of cases and longer follow-up may help validate our findings.