Internal Limiting Membrane Peeling in Vitreo-retinal Surgery

Biological ultrathin amniotic membrane flap to close refractory macular holes associated with high myopia

PURPOSE

To propose an ultrathin biological amniotic membrane (btAM) thinner than 10 μm as the graft to treat highly myopic macular holes (MH).

METHODS

This pilot study included 14 patients affected by refractory macular holes associated with high myopia. btAM was used as a bandage covering the holes. The best-corrected visual acuity (BCVA), fundus photography, and optical coherence tomography (OCT) before and after surgery were compared.

RESULTS

The mean MH size was 865.93 ± 371.72 μm and all the MHs achieved anatomical closure. The btAM located centrally and fully on MHs from fundus photography yet no obvious visual masking was complained. The average BCVA 1 month, 3, and 6 months after surgery were 0.95 ± 0.24, 0.92 ± 0.23, 0.92 ± 0.23 logMAR, respectively, improved significantly compared to pre-operative BCVA (1.24 ± 0.42 logMAR, all P < 0.05). Ten out of 14 (71.4%) exhibited 2C closure patterns (formally closed and no bare RPE) on OCT.

CONCLUSION

The btAM thinner showed a favorable anatomical success with less risk of parafoveal atrophy or iatrogenic injuries and shortened the dissolving time.

Analysis of the progression rate of idiopathic macular holes and the optimal cut-off for baseline minimum linear diameter and base diameter

PURPOSE

To determine the cut-off points of minimum linear diameter (MLD) and base diameter (BD) at which the progression rate of idiopathic full-thickness macular holes (MHs) decreases before vitrectomy.

STUDY DESIGN

A retrospective study.

METHODS

We investigated the differences in MLD and BD between baseline and operation days in patients with stages 2, 3, and 4 MHs using optical coherence tomography (OCT). Each difference in OCT parameters was divided by the time interval to calculate the MH progression rates and the cut-off points of MLD and BD.

RESULTS

Overall, 269 patients (282 eyes) were included. It took an average of 36.02 ± 24.69 (7-197) days from baseline to operation. MLD and BD progressed faster in stages 2 and 3 without posterior vitreous detachment (PVD) than in stage 4 with PVD (MLD: p < 0.001 and p = 0.007; BD: p < 0.001 and p = 0.019, respectively). Simple linear regression showed the relationship between baseline MLD and BD, and the progression rate; the progression rate decreased as baseline MLD (p = 0.004) and BD increased ( p < 0.001). For baseline MLD and BD, the cut-off points where the progression rate decreased were 306.0 and 470.0 μm, respectively.

CONCLUSION

The group without PVD progressed faster than the group with PVD. Moreover, the progression rates were faster in MHs with MLD < 306.0 μm and BD < 470.0 μm. In these patients, vitrectomy without delay is expected to improve the visual prognosis.

Treatment of Failure of Macular Hole Closure due to Post-Vitrectomy Macular Edema Using Sub-Tenon Triamcinolone Acetonide Injection: A Case Report

Introduction

Post-vitrectomy cystoid macular edema (CME) can lead to failure of macular hole (MH) closure. We report 2 cases of failure of MH closure due to post-vitrectomy CME, which were successfully treated using sub-Tenon triamcinolone acetonide (STTA) injection.

Case Presentations

Case 1 involved a 72-year-old male patient with a Gass Stage 3 MH in the right eye. He underwent pars plana vitrectomy (PPV), internal limiting membrane translocation, and sulfur hexafluoride (SF6) gas injection with cataract surgery in his right eye. The MH did not close postoperatively; further, CME developed at the edge of the MH. Accordingly, the patient underwent an STTA injection. Approximately 2 weeks after the STTA injection, the CME disappeared and the MH closed, which has remained closed 1 year after PPV. Case 2 involved a 78-year-old female patient with Gass Stage 3 MH in the left eye. The patient underwent the same surgical procedure as that performed in case 1. Further, she presented with failure of MH closure caused by CME; therefore, an STTA injection was performed. Approximately 6 weeks after STTA injection, the CME disappeared and the MH closed; further, there was maintained improvement of best-corrected visual acuity for 6 months.

Conclusions

STTA injection could be considered before reoperation in cases involving failure of MH closure due to postoperative CME.

Face-down positioning or posturing after macular hole surgery

BACKGROUND

Macular holes cause severe impairment of sight. With the aim of improving the outcome of surgery for macular holes, particularly larger macular holes (those measuring over 400 μm), a variable period of face-down positioning may be advised. This review is an update of a Cochrane Review published in 2011.

OBJECTIVES

To evaluate the effect of postoperative face-down positioning on the outcome of surgery for macular hole.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 5), which contains the Cochrane Eyes and Vision Trials Register, Ovid MEDLINE, Ovid Embase, the ISRCTN registry, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform. There were no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 25 May 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which postoperative face-down positioning was compared to no face-down positioning following surgery for macular holes. The primary outcome of interest was closure of the macular hole. Other outcomes of interest included visual outcomes, quality of life outcomes, and the occurrence of adverse events. Pairs of review authors independently selected studies for inclusion, extracted data, assessed risk of bias, and evaluated the certainty of evidence using GRADE.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We analysed dichotomous data as risk ratios (RRs), and continuous data as mean differences (MDs), with 95% confidence intervals (CI). The unit of analysis was eyes.

MAIN RESULTS

We included eight studies allocating a total of 709 eyes (699 participants). There was heterogeneity in study design, including the control group treatment (from no positioning to strict maintenance of other 'face-forward' postures) and surgical procedures (with or without inner limiting membrane peeling, with or without cataract surgery). There were also different durations of positioning, with two studies using 3 days, two studies using 5 days, and three studies using 10 days of face-down positioning. Whilst the overall risk of bias was low, all included studies were judged to be at high or unclear risk of bias due to absence of assessment of adherence to the 'prescribed' intervention of face-down positioning or posturing. The primary outcome of successful anatomical hole closure at one to six months following surgery was reported in 95 of every 100 eyes of participants advised to position face-down for at least three days after surgery, and in 85 of every 100 eyes of participants not advised to position face-down (RR 1.05, 95% CI 0.99 to 1.12, 709 eyes, 8 studies, I² = 44%). Amongst the 327 eyes of participants with macular holes of at least 400 μm, hole closure was noted in 94 of every 100 eyes of participants advised to position face-down, and in 84 of every 100 eyes of participants not advised to position face-down (RR 1.08, 95% CI 0.93 to 1.26, 5 studies, I² = 62%). Amongst the 129 eyes of participants with macular holes of less than 400 μm, hole closure was noted in 100 of every 100 eyes of participants advised to position face-down, and in 96 of every 100 eyes of participants not advised to position face-down (RR 1.03, CI 0.97 to 1.11, 4 studies, I² = 0%). The certainty of the evidence was low, downgraded for imprecision (CIs including no effect) and study design limitations (with different durations of face-down posturing used in the absence of a dose-response gradient, and limitations in measuring the exposure). Meta-analysis of visual acuity data was challenging given the use of different definitions of postoperative visual outcome across studies. Three studies reported findings by gain in Early Treatment Diabetic Retinopathy Study (ETDRS) letters (MD 2.04, 95% CI -0.01 to 4.09, very low-certainty evidence). Meta-analyses of quality of life data were not possible because of inconsistency in outcome metrics across studies. One study reported no difference between groups in quality of life, as reported on a validated quality of life metric scale (the National Eye Institute Visual Function Questionnaire - 25 (NEI VFQ-25), between face-down positioning for five days and non-face-down positioning (median NEI VFQ-25 score was 89 (interquartile range (IQR) 76 to 94) in the face-down group versus 87 (IQR 73 to 93) in the non-face-down group (adjusted mean difference on a logistic scale 0.02, 95% CI -0.03 to 0.07, P = 0.41)). Two studies reported increased ease of positioning and less pain in non-face-down positioning groups on non-validated 0-to-10-point visual analogue scores. On an ease-of-positioning score running from 0 (very difficult) to 10 (very easy), there were consistent reports of the discomfort associated with face-down positioning: the median participant-reported ease-of-positioning score was 6 (IQR 4 to 8) in those undergoing 5 days of face-down positioning versus 9 (IQR 7 to 10) in the comparator group (P = 0.01). On a pain score with 0 being pain-free and 10 being in severe pain, mean pain score was 6.52 ± 2.48 in the face-down positioning group versus 2.53 ± 2.6 in the non-face-down positioning group. The adverse event of postoperative nerve compression occurred in less than 1 in every 100 (3 per 1000) participants advised to position face-down, and 0 in every 100 participants not advised to position face-down (699 participants, 8 studies, moderate-certainty evidence).

AUTHORS' CONCLUSIONS

We identified eight RCTs evaluating face-down positioning following surgery for macular hole. The included studies were not all directly comparable due to differences in the surgical techniques used and the durations of postoperative positioning advised. Low-certainty evidence suggests that face-down positioning may have little or no effect on macular hole closure after surgery. Face-down positioning is a low-risk intervention, with serious adverse events affecting fewer than 1 in 300 people. We suggest that any future trials focus on patients with larger macular holes, with interventions and outcome measures used in previous trials (i.e. with inner limiting membrane peeling, positioning durations of three to five days, and validated quality of life metrics) to allow future meta-analyses to determine any effect with greater precision and confidence.

Macular hole Delphi consensus statement (MHOST)

PURPOSE

To derive a Delphi method-based consensus for the surgical management of Full Thickness Macular Hole (FTMH) and Lamellar Macular Hole (LMH).

METHODS

37 expert VR surgeons from 21 mainly European countries participated in Delphi method-based questionnaire for diagnosis and treatment of FTMHs and LMHs.

RESULTS

A total of 36 items were rated in round 1 by 37 participants, of which 10 items achieved consensus: intraoperative verification of PVD; clinical superiority of OCT-based FTMH classification; practical ineffectiveness of ocriplasmin; circular 360° ILM peeling for small macular holes; use of regular surgical technique for the size of the hole in concomitant retinal detachment; performing complete vitrectomy; SF6 gas as preferred tamponade; cataract surgery if crystalline lens is mildly/moderately opaque; removal of both ILM and LHEP in LMH surgery. In round 2, 18 items with moderate consensus (45-70% agreement) in round 1 were rated by 35 participants. Final consensus was reached in 35% of questions related to both diagnosis and surgical procedures.

CONCLUSIONS

This Delphi study provides valuable information about the consensus/disagreement on different scenarios encountered during FTMH and LMH management as a guide tosurgical decision-making. High rate of disagreement and/or variable approaches still exist for treating such relatively common conditions.

[Effects of internal limiting membrane peeling in epiretinal membrane surgery on OCT-angiography]

PURPOSE

To assess macular microvascular parameters using OCT-angiography (OCT-A) in idiopathic epiretinal membrane surgery with or without internal limiting membrane peeling.

MATERIALS AND METHODS

We retrospectively studied 17 eyes of 17 patients who underwent vitrectomy surgery for idiopathic epiretinal membrane with (n=10) or without (n=7) internal limiting membrane peeling. Patients operated on between July 2020 and June 2022 at the Colmar Hospital (France) by a single surgeon were evaluated before and 1 month after surgery, using OCT-A (Spectralis OCT-A module, Heidelberg Engineering®, Germany). The parameters studied were the area, perimeter and acircularity index of the foveal avascular zone (FAZ), the foveolar (FVD) and parafoveolar (PRVD) perfusion density and the macular vessel density ratio (MVR) in the superficial vascular complex (SVC) and the deep vascular complex (DVC). These parameters were measured using ImageJ software (National Institutes of Health, Bethesda, Maryland, USA).

RESULTS

We found no statistically significant difference between the two groups postoperatively in either area, perimeter, or acircularity index of the FAZ, FVD, PRVD, or MVR in either the SVC or DVC.

CONCLUSION

Our results with regard to macular microvasculature demonstrate no difference related to peeling of the internal limiting membrane and thus do not argue against this practice during epiretinal membrane surgery.

Risk Factors and Outcomes of Postoperative Macular Hole Formation after Vitrectomy for Myopic Traction Maculopathy: SCHISIS Report No. 2

PURPOSE

To evaluate the incidence, pathogenesis, risk factors, and treatment outcomes of postoperative macular hole (MH) after pars plana vitrectomy (PPV) for myopic traction maculopathy (MTM).

DESIGN

Multicenter, interventional, retrospective case series.

SUBJECTS

Consecutive eyes that underwent PPV for MTM with a minimum 6-month follow-up.

METHODS

We investigated the characteristics and treatment outcomes of postoperative MH after MTM surgery.

MAIN OUTCOME MEASURES

Incidence, risk factors, and anatomic and visual outcomes of postoperative MH.

RESULTS

We included 207 eyes (207 patients) with a mean follow-up of 25.9 months. During follow-up, 24 (11.6%) eyes developed MH (10 with concurrent MH retinal detachment); 15 eyes within 30 days (early), 4 eyes between 31 and 180 days (intermediate), and 5 eyes after 180 days (late). Logistic regression analysis revealed male gender (odds ratio [OR], 2.917; 95% confidence interval [CI], 1.198-7.100; P = 0.018), thinner preoperative choroidal thickness (OR, 0.988; 95% CI, 0.976-1.000; P = 0.048), and use of indocyanine green for internal limiting membrane peeling (OR, 2.960; 95% CI, 1.172-7.476; P = 0.022) as significant risk factors for postoperative MH. Internal limiting membrane peeling with a fovea-sparing technique tended to protect against postoperative MH, but it was not statistically significant (P = 0.096), because 1 eye still developed MH. Postoperative MHs were treated by observation (6 eyes), in-office octafluoropropane (C3F8) gas injection (7 eyes), or PPV (11 eyes). Macular hole closure was achieved in 20 eyes (83%). The hole closure rate was 67% (4/6 eyes) after observation, 71% (5/7 eyes) after C3F8 gas injection, and 91% (10/11 eyes) after PPV. However, visual outcomes were significantly worse for eyes with postoperative MH than those without (0.38 ± 0.43 vs. 0.68 ± 0.46; P = 0.002).

CONCLUSIONS

Postoperative MH may occur in 11.6% of patients with MTM at any time after surgery. Retreatment resulted in relatively favorable anatomic closure but unfavorable visual outcomes.

FINANCIAL DISCLOSURE(S)

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

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.

Comparison of Different Internal Limiting Membrane Peeling Sizes for Idiopathic Macular Holes: A Systematic Review and Meta-Analysis

BACKGROUND

Although internal limiting membrane (ILM) peeling facilitates macular hole (MH) closure and reduces late hole reopening, it brings some detrimental consequences to the retinal microstructure and functional outcomes. So far, previous studies have not reached a consensus on the optimal ILM peeling size.

OBJECTIVES

The objective of this study was to evaluate the outcomes of different ILM peeling sizes for idiopathic MHs.

METHODS

PubMed, Embase, Cochrane Library, Web of Science, CNKI, and WANFANG were searched until April 10, 2022. Studies in English or Chinese that compare the effects of two ILM peeling sizes (>2 disk diameters [DDs] vs. ≤2DD) for idiopathic MHs were included. The overall closure rate, postoperative best-corrected visual acuity (BCVA), type 1 closure, and adverse events were extracted. BCVA was converted to logarithm of the minimum angle of resolution (LogMAR).

RESULTS

Seven eligible studies (560 eyes) including 3 randomized clinical trials, 3 prospective trials, and one retrospective cohort were included. Pooled results showed a significantly better postoperative BCVA (mean difference = -0.16; 95% confidence interval [CI]: -0.27 to -0.04; LogMAR) and higher type 1 closure rate (risk ratio [RR] = 1.24; 95% CI: 1.08-1.43) in eyes with ILM peeling >2DD than those with peeling ≤2DD. No significant difference was found in overall closure rate and adverse events between the two groups. Subgroup analysis indicated that in MHs >400 μm, peeling >2DD helped obtain a better postoperative BCVA (mean difference = -0.17; 95% CI: -0.29 to -0.04; LogMAR) and higher frequency of type 1 closure (RR = 1.25; 95% CI: 1.03-1.51).

CONCLUSIONS

Peeling >2DD shares similar safety level with peeling ≤2DD and has a superiority of facilitating visual recovery. Larger ILM peeling may be more beneficial for large MHs.

Effect of Macular Internal Limiting Membrane Peeling on Single Surgery Success Rates of Vitrectomy for Uncomplicated, Primary Macula-Off Retinal Detachment

Purpose: To determine the anatomic and visual outcomes of pars plana vitrectomy for uncomplicated, primary macula-off rhegmatogenous retinal detachment (RRD) with and without internal limiting membrane (ILM) peeling. Methods: This retrospective chart review comprised 129 patients with uncomplicated, primary macula-off RRD presenting between January 1, 2016, and May 31, 2021. Thirty-six patients (27.9%) had ILM peeling and 93 (72.0%) did not. The primary outcome was the rate of recurrent RRD. Secondary outcomes included preoperative and postoperative best-corrected visual acuity (BCVA), epiretinal membrane (ERM) formation, and macular thickness. Results: No significant difference was found in the risk for recurrent RRD between patients who had ILM peeling and those who did not (2.8% [1/36] and 5.4% [5/93], respectively) (P = 1.00). The final postoperative BCVA was better in eyes that did not have ILM peeling (P< .001). No ERM occurred in the group with ILM peeling, whereas ERM occurred in 27 patients (29.0%) who did not have ILM peeling. The temporal macular retina was thinner in eyes in which ILM peeling was performed. Conclusions: The risk for recurrent RRD was not statistically lower in eyes having ILM peeling of the macula in uncomplicated, primary macula-off RRD. Despite a reduction in postoperative ERM formation, eyes having macular ILM peeling had worse postoperative VA.

The Short-Term Results of Autologous Platelet-Rich Plasma as an Adjuvant to Re-Intervention in the Treatment of Refractory Full-Thickness Macular Holes

The purpose of this study was to investigate the short-term efficacy and safety of autologous platelet-rich plasma (a-PRP) as an adjuvant to revisional vitrectomy for refractory full-thickness macular holes (rFTMHs). We conducted a prospective, non-randomized interventional study including patients with rFTMH after a pars plana vitrectomy (PPV) with internal limiting membrane peeling and gas tamponade. We included 28 eyes from 27 patients with rFTMHs: 12 rFTMHs in highly myopic eyes (axial length greater than 26.5 mm or a refractive error greater than -6D or both); 12 large rFTMHs (minimum hole width > 400 μm); and 4 rFTMHs secondary to the optic disc pit. All patients underwent 25-G PPV with a-PRP, a median time of 3.5 ± 1.8 months after the primary repair. At the six-month follow-up, the overall rFTMH closure rate was 92.9%, distributed as follows: 11 out of 12 eyes (91.7%) in the highly myopic group, 11 out of 12 eyes (91.7%) in the large rFTMH group, and 4 out of 4 eyes (100%) in the optic disc pit group. Median best-corrected visual acuity significantly improved in all groups, in particular from 1.00 (interquartile range: 0.85 to 1.30) to 0.70 (0.40 to 0.85) LogMAR in the highly myopic group (p = 0.016), from 0.90 (0.70 to 1.49) to 0.40 (0.35 to 0.70) LogMAR in the large rFTMH group (p = 0.005), and from 0.90 (0.75 to 1.00) to 0.50 (0.28 to 0.65) LogMAR in the optic disc pit group. No intraoperative or postoperative complications were reported. In conclusion, a-PRP can be an effective adjuvant to PPV in the management of rFTMHs.

Spotlight on the Internal Limiting Membrane Technique for Macular Holes: Current Perspectives

Pars plana vitrectomy has become the standard procedure for primary macular holes (MHs) repair, including the removal of the posterior cortical vitreous, the stripping of eventual epiretinal membranes, and finally an intraocular gas tamponade. During this procedure, peeling the internal limiting membrane (ILM) has been proven to increase closure rates and avoid postoperative reopening in several researches. In fact, even in large MHs more than 400 µm, the advantage of peeling off the ILM was highlighted by better anatomical closure rates. Nevertheless, some authors suggested that ILM peeling is not always essential, because it generates various side effects in retinal structure and function. Furthermore, the ideal amount of ILM peeling and the most effective strategies for removing the ILM are still subject of research. Different surgical modifications have been reported as alternatives to traditional peeling in certain clinical settings, including ILM flaps, ILM scraping, and foveal sparing ILM peeling. As regards large MHs, the introduction of ILM inverted flap appeared as a game changer, offering a significantly higher >90% closure rate when compared to traditional ILM peeling. Modifications to inverted ILM flap procedures have been claimed in recent years, in order to define the best area and direction of ILM peeling and its correlation with functional outcomes. Moreover, several innovations saw the light in the setting of recurrent MHs, such as ILM free flap transposition, inverted ILM flap combined autologous blood clot technique, neurosensory retinal flap, and human amniotic membrane (HAM) plug, claiming higher anatomical success rate also in those complex settings. In conclusion, the aim of this review is to report how the success rate of contemporary macular surgery has grown since the turn of the century, especially for big and chronic MHs, analyzing in which way ILM management became a crucial point of this kind of surgery.

Evaluation of retinal functional changes after macular hole surgery using heavy brilliant blue G dye for internal limiting membrane staining: A prospective, single blind, randomized controlled trial

Purpose:

To evaluate retinal functional changes after idiopathic macular hole (MH) surgery using heavy brilliant blue G (hBBG) dye for internal limiting membrane (ILM) staining.

Methods:

Forty-four eyes with idiopathic MH were randomized into two groups – 24 eyes undergoing vitrectomy with ILM peeling using hBBG staining and 20 eyes without staining; anatomical and functional status (with microperimetry (MP)) at baseline and during postoperative follow-up were noted and compared.

Results:

All eyes had closure of MH postoperatively and overall baseline MP indices (average threshold, AT; foveal sensitivity, FS) improved significantly at 6 weeks and 6 months of follow-up. AT and FS showed significant improvement at 6 weeks and 6 months from baseline in both individual groups (P < 0.001). Intergroup comparison showed that there was no statistically significant difference in AT and FS values at any point of time (baseline, 6 weeks, 6 months) between staining and no-stain group. No eyes in our cohort had any unexplained visual loss.

Conclusion:

Functional parameters of macula improved significantly after successful MH surgery using hBBG for staining the ILM.

EFFECT OF INVERTED INTERNAL LIMITING MEMBRANE FLAP ON CLOSURE RATE, POSTOPERATIVE VISUAL ACUITY, AND RESTORATION OF OUTER RETINAL LAYERS IN PRIMARY IDIOPATHIC MACULAR HOLE SURGERY

PURPOSE

To investigate the role of an internal limiting membrane (ILM) flap in macular hole (MH) surgery on closure rate, visual acuity, and integrity of the outer retinal layers.

METHODS

Retrospective, nonrandomized interventional analysis in which 117 eyes of 117 patients were included who had undergone pars-plana vitrectomy (PPV) and gas tamponade for primary idiopathic MH >400 µm with either conventional ILM peeling or with inverted ILM flap technique at The Royal Liverpool University Hospital between January 2016 and April 2018. Main outcome measures were closure of MH, best-corrected visual acuity (BCVA) at 3, 6, and 12 months, and restoration of external limiting membrane and ellipsoid zone (EZ) using optical coherence tomography.

RESULTS

Macular hole closure rate was significantly higher in patients with an ILM flap (67/68; 98.53%) than in those with conventional ILM peeling (43/49; 87.76%) (P = 0.02). Both groups showed significant improvements in their preoperative to postoperative BCVA at 3 months from 1.07 (0.43) logarithm of the minimum angle of resolution (logMAR) (20/235 Snellen) to 0.71 (0.34) logMAR (20/103 Snellen) (P <0.001), but there was no significant difference between the two groups (P = 0.45, P = 0.71). We found significant associations between postoperative BCVA and preoperative BCVA (P < 0.01) and the integrity of the EZ (P < 0.01). In 35 patients who had follow-up to 12 months, there was a significant improvement in BCVA between 3, 6, and 12 months from 0.73 (0.45) logMAR (20/107 Snellen) to 0.53 (0.24) logMAR (20/68 Snellen) and to 0.35 (0.18) logMAR (20/45 Snellen), respectively (P < 0.01). There was no significant difference at these time periods between the two groups (P = 0.62, P = 0.21, P = 0.31). The integrity of the EZ also improved significantly between 3, 6, and 12 months (P = 0.01), irrespective of the presence of an ILM flap (P = 0.58), but with a trend toward delay in restoration in those patients with an ILM flap. The improvement in BCVA at 12 months, taking into account the age of the patient, size and duration of the MH, presence of an ILM flap, and preoperative BCVA was dependent on the state of the EZ (P = 0.01).

CONCLUSION

In patients undergoing primary pars-plana vitrectomy for MH >400 µm, the presence of an inverted ILM flap was associated with a significantly higher closure rate than a conventional ILM peeling. Best-corrected visual acuity showed a strong correlation with the integrity of the EZ and both improved significantly between 3, 6, and 12 months, irrespective of the presence of an ILM flap.

Long-term follow-up of retinal sensitivity assessed by microperimetry in patients with internal limiting membrane peeling

PURPOSE

To evaluate anatomical and functional changes in patients with vitreomacular interface disease after internal limiting membrane (ILM) peeling, using microperimetry along with usual clinical and multimodal retinal imaging.

METHODS

Patients with vitreomacular interface disease requiring vitrectomy underwent multimodal retinal evaluation, including visual acuity assessment, fundus color photograph, Spectral-Domain Optical Coherence Tomography, Optical Coherence Tomography-Angiography, and microperimetry. They were examined at baseline (M0), 6 months (M6) and 18 months (M18) after surgery. Retinal sensitivity was subdivided into three concentric polygons: Large, Medium, Small.

RESULTS

Eleven eyes of 11 patients were analyzed, including 10 epiretinal membranes (ERMs). Best-corrected visual acuity (BCVA) improved in all patients from 0.51 logarithm of the minimal angle of resolution (logMAR) to 0.067 (p = 0.0074). Retinal sensitivity improved between M0 and M6 in all polygons and continued to improve between M6 and M18 for polygons Medium (M) and Small (S) with no statistical significance. At M18, BCVA and retinal sensitivity were similar in the operated eye compared with the fellow eye for all patients. Dissociated optic nerve fiber layer appearance was observed in 8 patients at M18. It was not correlated with either retinal sensitivity or BCVA or microscotomas. No recurrence of ERM or macular hole occurred during follow-up.

CONCLUSION

After surgery, the retinal sensitivity assessed by microperimetry gradually improved until the 18th month and was not different from the values of the fellow eye. These results seemed to confirm that ILM peeling can be an effective and safe technique to treat patients with vitreomacular interface disease.

Results of Pars Plana Vitrectomy for Different Types of Macular Holes

Purpose

To compare different types of macular holes regarding the anatomic and functional success following pars plana vitrectomy (PPV) and internal limiting membrane (ILM) removal.

Methods

A retrospective review of all patients with macular holes treated by PPV, ILM removal with gas tamponade from January 2014 to July 2017 in Magrabi Eye Hospital.

Results

One hundred fifty-seven eyes of 153 patients were analyzed. The eyes were classified according to the etiology of macular hole into four groups: 79 eyes with idiopathic macular hole (IMH), 51 eyes with traumatic macular hole (TMH), 16 eyes with macular hole in diabetic patients (DMH) and 11 eyes with myopic macular hole (MMH). We classified the IMH group based on the International Vitreomacular Traction Study Classification according to size into 3 subgroups; subgroup 1: ≤250µ, subgroup 2: >250 to 400µ and subgroup 3: ≥400 µ. All types of macular hole showed statistically significant postoperative improvement in BCVA compared to the baseline except cases with MMH. Anatomic postoperative hole closure was achieved in 86.1%, 60.7%, 43.65%, an 45.46% of eyes with IMH, TMH, DMH and MMH, respectively. In eyes with IMH, closure rate in subgroup 1 was significantly higher than in subgroups 2, and 3.

Conclusion

PPV, ILM peel and C2F6 technique yielded variable anatomic and functional outcomes in different types of macular holes. Anatomic results were most favorable in IMH and least favorable in MMH. The smaller the diameter of the hole the better the results. The underlying pathogenetic mechanisms that lead to different types of macular holes are pivotal in determining the final outcome.

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.

VITRECTOMY WITH INTERNAL LIMITING MEMBRANE PEELING AND AIR TAMPONADE FOR MYOPIC FOVEOSCHISIS

PURPOSE

To evaluate the functional and anatomical outcomes of 23-gauge or 25-gauge pars plana vitrectomy with internal limiting membrane peeling and air tamponade for the treatment of myopic foveoschisis.

METHODS

Retrospective, noncomparative, interventional case series. The records of 29 patients (32 eyes), with myopic foveoschisis who were treated by 23-gauge or 25-gauge 3-port pars plana vitrectomy with internal limiting membrane peeling and air tamponade, were reviewed. At each visit, a complete ophthalmic examination, intraocular pressure, best-corrected visual acuity, and central foveal thickness measured using optical coherence tomography were assessed.

RESULTS

Twenty-five eyes of 23 patients (M:F = 4:19) matched the inclusion criteria, whereas 7 eyes of 6 patients were excluded. The mean logarithm of the minimum angle of resolution best-corrected visual acuity (Snellen equivalent) was 0.62 (20/80) (SE: 0.061), and the mean preoperative central foveal thickness was 619.5 µm (SE: 16.38) at baseline. Visual acuity significantly improved of 5 Early Treatment Diabetic Retinopathy Study letters (45 letters) at the 1-month follow-up (P < 0.001), 2 lines (50 Early Treatment Diabetic Retinopathy Study letters) at the 6-month follow-up (P < 0.001), and it reached 55 Early Treatment Diabetic Retinopathy Study letters at the 1-year follow-up visit (P < 0.001). Central foveal thickness decreased to 292.4 µm (SE: 15.93), to 227.3 µm (SE: 14.05), and to 208.8 µm (SE: 12.86), respectively, at the 1-, 6-, and 12-month follow-ups (for each P < 0.001). There were no differences in best-corrected visual acuity or central foveal thickness changes between the foveal detachment group and the nonfoveal detachment group (P > 0.05).

CONCLUSION

Small-gauge vitrectomy with internal limiting membrane peeling and air tamponade results in favorable anatomical and functional outcomes for patients affected by myopic macular foveoschisis.

Comparative study of 1 DD and 2 DD radius conventional internal limiting membrane peeling in large idiopathic full-thickness macular holes: a randomized controlled trial

OBJECTIVE

To compare the surgical outcomes of 1-disc diameter (DD) and 2-DD conventional internal limiting membrane peeling (C-ILMP) in large full-thickness macular holes (FTMHs).

MATERIALS AND METHODS

A prospective randomized controlled trial. One hundred patients with large idiopathic full-thickness macular hole (FTMH) were randomized into C-ILMP and extended C-ILMP (EC-ILMP) groups. The primary outcome was closure rate at 6 months after surgery. Secondary outcomes were visual acuity (VA), closure type, consequence of ILMP and complications.

RESULTS

The mean symptom duration was 12.19 ± 9.64 months. Mean preoperative VA was 1.25 ± 0.37 logMAR. The average minimum linear diameter was 633.05 ± 129.82 µm and basal linear dimension was 1158.49 ± 249.07 µm. The two groups did not differ in term of demographic data. Closure rate was significantly higher in the EC-ILMP group (76.47% vs. 51.02%, 95% CI 7.24-43.66; p = 0.008). There were also no significant differences in closure type, central foveal thickness, dissociated optic nerve fibre layer detection, or change in fovea-to-disc distance. There were also no significant differences in postoperative VA (p = 0.069) or visual improvement (mean 0.39 ± 0.43 logMAR; p = 0.286). According to subgroup analysis, EC-ILMP resulted in a higher closure rate in patients with chronic FTMH for >6 months, (p = 0.008). Furthermore, EC-ILMP resulted in better anatomical closure and visual result in patients with FTMH with macular hole closure index ≤0.5, p = 0.003 and p = 0.010, respectively.

CONCLUSION

Extended C-ILMP yielded a significantly higher closure rate in large FTMHs, but visual outcome did not differ significantly. According to subgroup analysis, extended C-ILMP was more effective in chronic large FTMH with MHCI ≤ 0.5.

Outcomes of Idiopathic Full-Thickness Macular Hole Surgery: Comparing Two Different ILM Peeling Sizes

Purpose

This study aimed to show the impact of different extents of internal limiting membrane (ILM) peeling on visual and anatomical outcomes following idiopathic full-thickness macular hole (FTMH) surgery.

Methods

In this single-center prospective study, patients with idiopathic FTMH underwent standard pars plana vitrectomy with two different extents of ILM peeling: 2-disc diameters (DD) or 4 DD. The main outcome measures were the closure rate of the holes based on optical coherence tomography (OCT) findings at three months after surgery.

Results

Forty eyes from 39 patients were enrolled in the study. After three months, anatomical closure was achieved in 78% and 76% eyes in 2 DD peel and 4 DD peel groups, respectively. From 29 eyes with macular hole index (MHI) ≤ 0.5, type 1 closure was achieved in 42% eyes receiving a 2 DD ILM peel, compared to 66% eyes receiving a 4 DD peel (p=0.041). In comparison, this significant difference was not seen in the subgroup of MHI > 0.5 (p=061). In the subgroup of subjects with baseline MHI ≤ 0.5, visual improvement was significantly more in eyes with 4 DD ILM peeling (p=0.034), which was not seen in the MHI > 0.5 subgroup (p=0.61).

Conclusion

In patients with idiopathic full‐thickness macular hole (MHI ≤ 0.5), a larger ILM peel of 4 DD appears to yield better anatomical outcomes than a more limited 2 DD peel.

Evaluation of primary internal limiting membrane peeling in cases with rhegmatogenous retinal detachment

Background

Epiretinal membranes (ERMs) have been reported after pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD). Peeling of the internal limiting membrane (ILM) can prevent post-PPV ERM formation but has a potential negative impact on macular structure and function.

Purpose

To investigate the anatomical and functional outcomes of ILM peeling during PPV for primary RRD.

Methods

This was a prospective nonrandomized study that included 60 eyes of 60 patients with a primary macula-off RRD and less than grade C proliferative vitreoretinopathy (PVR). Eyes were allocated into 2 groups; Group A underwent PPV without ILM peeling and Group B had ILM peeling. At postoperative month 6, all patients underwent retinal imaging using spectral domain optical coherence tomography (OCT) and OCT angiography and macular function was assessed using multifocal electroretinogram (mfERG). Baseline characteristics and postoperative anatomical and visual outcomes were recorded and statistically analyzed.

Results

We enrolled 30 eyes of 30 patients in each group. In Group A, mean age was 44.6 years, while the mean age of Group B patients was 49.9 years. Postoperative LogMAR visual acuity was significantly better in Group A than in Group B (p < 0.001). ERMs were demonstrated on OCT in 13.3% of Group A and none of Group B patients (p = 0.04). Retinal dimples were found in 53.3% of Group B and none of Group A eyes (p < 0.001). OCTA showed a greater vessel density of the superficial capillary plexus (SCP) in Group A compared to Group B eyes (p = 0.046), while no difference was found regarding deep capillary vessel density (p = 0.7). Mean amplitude of mfERG P1 wave was significantly higher in Group A eyes than in Group B (p = 0.002). Both the SCP vessel density and P1 amplitude were positively correlated with visual acuity (p < 0.001).

Conclusion

This study suggests that ILM peeling prevents ERM development in eyes undergoing PPV for uncomplicated macula-off RRD, but potential damage to macular structure and function were found.

Trial registration Retrospectively registered on 09/24/2019 on ClinicalTrials.gov with an ID of NCT04139811.

Outcomes of Vitrectomy for Long-Duration Macular Hole

: The present study investigated the functional and anatomical outcomes of idiopathic chronic macular hole (MH) surgery with different surgical approaches related to the chronicity and diameter of the MH. A comparative retrospective study between three groups of patients who underwent vitrectomy for long-duration MH (mean: 13.5 months) was conducted. In the first group of patients (G1 or IP), the internal limiting membrane (ILM) was systematically peeled; in the second group (G2 or IPEP), the ILM and epiretinal membrane (ERM) were peeled; and in the third group (G3 or IF), patients underwent inverted ILM flap technique surgery. Pre- and post-operative best corrected visual acuities (pre- and post-op BCVA) were studied. Macular optical coherence tomography (OCT) scans were performed to measure the MH minimum and maximum diameter pre-operatively, as well as to confirm its post-op closure and evaluate the integrity of the ellipsoid zone (EZ). Fifty eyes of 48 patients (33 female and 15 male) were retrospectively evaluated. MH closure rate was 100% in IP group, 66.7% in IPEP, and 95.2% in IF group. All three groups had a statistically significant improvement of BCVA. EZ post-op was restored in 88.2% of the cases from G1, 41.6% from G2, and 23.8% from G3. No statistically significant relationship between the smaller or larger MH diameter and the visual acuity improvement was found. Patients with chronic MH and ERM have worse functional and anatomical outcomes after surgery. Treatment of chronic MHs without ERM results in a better closure rate with either an inverted ILM flap approach or systematic ILM peel.

SURGICAL OUTCOMES IN EYES WITH EXTREMELY HIGH MYOPIA FOR MACULAR HOLE WITHOUT RETINAL DETACHMENT

PURPOSE

The authors evaluated surgical outcomes in eyes with extremely high myopia for macular hole (MH) without retinal detachment.

METHODS

In this retrospective study, 14 eyes with axial lengths of ≥30.0 mm underwent vitrectomy and internal limiting membrane (ILM) peeling with or without inverted ILM flap insertion for MH without retinal detachment (October 2009-June 2016). Outcome measures were MH closure confirmed by optical coherence tomography, best-corrected visual acuity, and complications.

RESULTS

The mean axial length was 30.69 ± 0.76 mm. The overall final closure rate was 85.7% (12/14 eyes); the mean follow-up was 17.29 (±20.20) months. Primary anatomical MH closure after 1 operation was achieved in three of eight eyes (37.5%) without an inverted ILM flap and was achieved in six of six eyes (100%) with inverted ILM flap insertion (P = 0.031). There was no reopening of MH during follow-up. Mean visual acuity improved significantly from 1.10 ± 0.43 logarithm of the minimum angle of resolution (Snellen equivalent, 20/254) to 0.84 ± 0.50 logarithm of the minimum angle of resolution (Snellen equivalent, 20/138) (P = 0.046; 2-tailed, paired t-test). Only 1 eye developed an MH-associated retinal detachment 4.5 years after previously failed MH surgery; reattachment was achieved after a second operation.

CONCLUSION

Patients with extremely high myopia obtained anatomical and functional improvements from MH surgery; inverted ILM flap insertion achieved significantly higher primary success rates in MH closure.

The impact of extent of internal limiting membrane peeling on anatomical outcomes of macular hole surgery: results of a 54-week randomized clinical trial

PURPOSE

To compare the anatomical outcomes of different extents of internal limiting membrane (ILM) peeling in idiopathic macular hole surgery.

METHODS

Prospective, parallel-group, randomized clinical trial. A total of 121 eyes of 121 patients with idiopathic macular hole underwent pars plana vitrectomy, and peeling of the ILM with a diameter of two disk diameters (DD) or 4DD based on randomization. The main outcome was the proportion of eyes with complete hole closure at 12 months. The second outcome was the hole closure grading stratified by macular hole closure index (MHCI) at each visit.

RESULTS

At 12 months, there was no significant difference in anatomical outcomes with complete closure achieved in 52 (82.5%) of 63 eyes in the 2DD group and 53 (91.4%) of 58 eyes in the 4DD group (p = 0.15). For subjects with MHCI ≤0.5 (n = 24), complete closure rate was significantly lower in the 2DD group compared to the 4DD group (p = 0.012; 18.2% versus 75.9%, respectively). Average BCVA was lower in 2DD group than 4DD group (p = 0.014). By contrast, when MHCI was >0.5, the complete closure rate between the two groups showed no significant difference: 96.2% (50 patients) versus 95.6% (43 patients), respectively (p = 0.185).

CONCLUSION

In patients with idiopathic full-thickness macular hole and MHCI ≤0.5, a larger ILM peel of 4DD tends to achieve better anatomical outcomes than a more limited 2DD peel.

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.

Clinical observations of vitreoretinal surgery for four different phenotypes of X-linked congenital retinoschisis

AIM

To evaluate the outcomes of vitreoretinal surgery for four different phenotypes of X-linked retinoschisis (XLRS).

METHODS

This study included thirty-one eyes of 25 patients who developed XLRS with severe complications. Among the 31 eyes, there were 7 eyes with vitreous hemorrhage, 8 eyes with retinal detachment and vitreous hemorrhage, and 16 eyes with rhegmatogenous retinal detachment. All of the patients underwent standard three-port pars plana vitrectomy. All of the eyes were divided into 4 groups before surgery according to a modified classification scheme, with the first three groups as follows: group A, with foveal cystic schisis; group B with macular lamellar schisis; and group C with foveolamellar changes. Peripheral schisis was not present in these 3 groups; however, group D was a complex group with both macular and peripheral changes. One year after surgery, we analyzed the best corrected visual acuity and postoperative anatomical and functional outcomes of these 4 groups.

RESULTS

There were 7 eyes in group A (22.6%), 1 eye in group B (3.2%), 15 eyes in group C (48.4%) and 8 eyes in group D (25.8%). Postoperative anatomical and functional outcomes were satisfactory at the last visit, while the mean visual acuity was increased to 0.27±0.11, with a significant difference (t=-1.049, P=0.000) compared with the results before surgery (0.1±0.08). Visual acuity was improved in 23 eyes (74.2%). Complications were found in three eyes: two eyes with proliferative vitreoretinopathy and traction retinal detachment 10 and 12mo after surgery, respectively; and one eye with vitreous hemorrhage 15mo after surgery. These eyes were in groups C and D. The retinas remained attached in these 3 eyes after reoperation.

CONCLUSION

We should pay greater attention to XLRS with foveolamellar changes because it is the most changeable phenotype. Once complications occur, vitreoretinal surgery can significantly improve visual acuity and restore the anatomic structure of the retina.

A Review of Surgical Outcomes and Advances for Macular Holes

The surgical outcomes of macular holes (MHs) have improved greatly in recent years. The closure rate is as high as 90-100%, but the outcomes of some special types of MHs remain unsatisfactory. Internal limiting membrane (ILM) peeling dramatically improves the anatomic success rate, but recent studies have found that it could also cause mechanical and subclinical traumatic changes to the retina. Dyes are widely used, and apart from indocyanine green (ICG), the toxicities of other dyes require further research. Face-down posturing is necessary for MHs larger than 400 μm, and the duration of this posture is determined by the type of tamponade and the case. The ellipsoid zone has been shown to be highly correlated with visual outcome and recovery. New surgical methods include the inverted ILM flap technique and the ILM abrasion technique. However, they require further research to determine their effectiveness.

Modified technique of internal limiting membrane staining in idiopathic macular hole surgery

PURPOSE

To describe a new method of ILM staining with TB under perfluorocarbon in cases of full thickness idiopathic macular hole using the inverted ILM flap technique.

METHODS

This study was a prospective interventional case series that included 42 eyes of 42 patients who had full thickness idiopathic macular hole with a minimum diameter more than 400 µm. Patients consecutively underwent vitrectomy with inverted ILM flap technique using the modified ILM staining method.

RESULTS

Anatomic success was achieved in 40 patients (95.2%). The other two patients had flat-open macular holes with bare RPE (foveal defect of neurosensory retina). Among the 40 eyes with closed holes, 25 eyes were of the U-type closure (normal foveal contour) and 15 eyes were of the V-type closure (steep foveal contour). These 40 eyes remained closed during the 6 months follow-up period.

CONCLUSION

The modified technique of ILM staining using TB under PFCL is safe and effective in cases of idiopathic macular hole combined with the inverted ILM flap technique.

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.

Does Internal Limiting Membrane Peeling Size Matter?

Purpose:

A variety of retinal topographical changes occur after internal limiting membrane (ILM) peeling for macular holes including a movement of the fovea toward the optic nerve. This study was carried out to assess the effect of the extent of ILM-peeled area on these changes and postoperative visual acuity.

Methods:

Prospective single-center study of a consecutive series of patients undergoing macular hole surgery. Preoperative and postoperative optical coherence tomography images were used to assess a variety of measures of retinal morphology. Transmission electron microscopy of the peeled ILM was used to assess residual retinal and vitreous side debris. The area of the ILM peeled was calculated from intraoperative images.

Results:

Fifty-six eyes of 56 patients were included. The mean area of ILM peeled was 9.5 mm2 (2.4-28.3 mm2). The mean disc-to-fovea distance (DFD) preoperatively was 3703 μm with a mean reduction of 52 μm postoperatively, representing a change of −1.29% with a wide range of −7.04% to 1.36%. Using stepwise linear regression, ILM-peeled area was significantly associated with a change in DFD ( P < .001), extent of a dissociated optic nerve fiber layer appearance ( P < .001), and postoperative visual acuity ( P = .025). Nasotemporal retinal thickness asymmetry was associated with the minimum linear diameter ( P < .001).

Conclusion:

The ILM-peeled area has a significant effect on changes in retinal topography and postoperative visual acuity separate from macular hole size. Further study is needed to assess the effect of ILM peeled size on visual function and to guide clinical practice.

Internal Limiting Membrane Peeling to Prevent Post-vitrectomy Epiretinal Membrane Development in Retinal Detachment

PURPOSE

To determine the efficacy of internal limiting membrane (ILM) peeling during vitrectomy for rhegmatogenous retinal detachment (RRD) regarding post-vitrectomy epiretinal membrane (ERM) development and visual outcomes.

DESIGN

Retrospective, interventional, comparative case series.

METHODS

Setting: Institutional.

STUDY POPULATION

One hundred and two consecutive eyes with RRD treated with vitrectomy and followed for at least 6 months. ILM was peeled without using dye such as indocyanine green (ICG). Observational Procedures: Patients were divided into 2 groups based on postoperative ERM development: Group 1, 81 eyes without ERM formation; Group 2, 21 eyes with ERM development. Patients also were divided into 2 subgroups: those with and without ILM peeling (58 and 44 eyes, respectively). Statistical analyses were performed between the 2 groups with/without ERM formation and between the 2 subgroups with/without ILM peeling for 5 preoperative factors including foveal involvement of the RRD, 4 intraoperative factors including ILM peeling, baseline best-corrected visual acuity (BCVA), and final BCVA.

MAIN OUTCOME MEASURES

An association of ILM peeling with ERM prevention and the influence of ILM peeling on visual outcomes.

RESULTS

ILM peeling was significantly (P < .001) associated with ERM prevention. There was no significant difference in the final BCVA between subgroups with and without ILM peeling.

CONCLUSIONS

ILM peeling without ICG staining during the initial vitrectomy for RRDs may prevent postoperative ERM formation with favorable visual outcomes.

3-DOF Force-Sensing Micro-Forceps for Robot-Assisted Membrane Peeling: Intrinsic Actuation Force Modeling

Membrane peeling is a challenging procedure in retinal microsurgery, requiring careful manipulation of delicate tissues by using a micro-forceps and exerting very fine forces that are mostly imperceptible to the surgeon. Previously, we developed a micro-forceps with three integrated fiber Bragg grating (FBG) sensors to sense the lateral forces at the instrument's tip. However, importantly this architecture was insufficient to sense the tissue pulling forces along the forceps axis, which may be significant during membrane peeling. Our previous 3-DOF force sensing solutions developed for pick tools are not appropriate for forceps tools due to the motion and intrinsic forces that develop while opening/closing the forceps jaws. This paper presents a new design that adds another FBG attached to the forceps jaws to measure the axial loads. This involves not only the external tool-to-tissue interactions that we need to measure, but also the adverse effect of intrinsic actuation forces that arise due to the elastic deformation of jaws and friction. In this study, through experiments and finite element analyses, we model the intrinsic actuation force. We investigate the effect of the coefficient of friction and material type (stainless steel, titanium, nitinol) on this model. Then, the obtained model is used to separate the axial tool-to-tissue forces from the raw sensor measurements. Preliminary experiments and simulation results indicate that the developed linear model based on the actuation displacement is feasible to accurately predict the axial forces at the tool tip.

Complications of Macular Peeling

Macular peeling refers to the surgical technique for the removal of preretinal tissue or the internal limiting membrane (ILM) in the macula for several retinal disorders, ranging from epiretinal membranes (primary or secondary to diabetic retinopathy, retinal detachment…) to full-thickness macular holes, macular edema, foveal retinoschisis, and others. The technique has evolved in the last two decades, and the different instrumentations and adjuncts have progressively advanced turning into a safer, easier, and more useful tool for the vitreoretinal surgeon. Here, we describe the main milestones of macular peeling, drawing attention to its associated complications.

Using Adeno-associated Virus as a Tool to Study Retinal Barriers in Disease

Müller cells are the principal glial cells of the retina. Their end-feet form the limits of the retina at the outer and inner limiting membranes (ILM), and in conjunction with astrocytes, pericytes and endothelial cells they establish the blood-retinal barrier (BRB). BRB limits material transport between the bloodstream and the retina while the ILM acts as a basement membrane that defines histologically the border between the retina and the vitreous cavity. Labeling Müller cells is particularly relevant to study the physical state of the retinal barriers, as these cells are an integral part of the BRB and ILM. Both BRB and ILM are frequently altered in retinal disease and are responsible for disease symptoms. There are several well-established methods to study the integrity of the BRB, such as the Evans blue assay or fluorescein angiography. However these methods do not provide information on the extent of BRB permeability to larger molecules, in nanometer range. Furthermore, they do not provide information on the state of other retinal barriers such as the ILM. To study BRB permeability alongside retinal ILM, we used an AAV based method that provides information on permeability of BRB to larger molecules while indicating the state of the ILM and extracellular matrix proteins in disease states. Two AAV variants are useful for such study: AAV5 and ShH10. AAV5 has a natural tropism for photoreceptors but it cannot get across to the outer retina when administered into the vitreous when the ILM is intact (i.e., in wild-type retinas). ShH10 has a strong tropism towards glial cells and will selectively label Müller glia in both healthy and diseased retinas. ShH10 provides more efficient gene delivery in retinas where ILM is compromised. These viral tools coupled with immunohistochemistry and blood-DNA analysis shed light onto the state of retinal barriers in disease.

Vitreo-retinal relationship and post-operative outcome of macular hole repair in eyes with high myopia

PURPOSE

To investigate the vitreoretinal relationship in eyes with full-thickness macular hole (FTMH) without retinal schisis or detachment. Eyes with and without high myopia were compared using slit-lamp biomicroscopy, optical coherence tomography (OCT), and intraoperative observations.

METHODS

Clinical records of 34 consecutive cases of FTMH without schisis or detachment in highly myopic eyes (refractive error larger than -6.0 diopters or axial length >26 mm) were retrospectively reviewed. All eyes underwent pars plana vitrectomy between 2006 and 2013. An additional 43 consecutive cases of FTMH in eyes without high myopia were also reviewed to serve as controls. All control patients underwent surgery during the same period. Ophthalmological, OCT, and intraoperative findings, and vitreoretinal interface features were documented in both groups. Anatomical closure rate and final best-corrected visual acuity (BCVA) were compared between groups.

RESULTS

Premacular tissue was identified during surgery in 21 of 34 high myopia patients (61.8 %) and three of 43 control patients (7.0 %). The high myopia group showed two layers of premacular membranes. Two cases had a shiny, loose inner membrane, 13 cases had a tightly adherent outer membrane, and six cases had both. Only a tightly adherent membrane was found in controls. In the high myopia group, 11 of 21 eyes (52.4 %) did not have a preretinal membrane identified preoperatively. Anatomical closure was achieved in 91.2 and 95.3 % of high myopia and control patients respectively (p = 0.65). No significant intergroup difference in final BCVA was observed.

CONCLUSION

Premacular tissue was found in 61.8 % of eyes with high myopia and FTMH without retinal schisis or detachment. Anatomically successful surgical closure in high myopia patients was achieved at a rate comparable to their idiopathic counterparts.

Macular hypotrophy after internal limiting membrane removal for diabetic macular edema

PURPOSE

To compare the anatomic and functional effects of three different approaches to nontractional diabetic macular edema.

METHODS

Retrospective comparative study. Sixty eyes of 60 patients diagnosed with cystoid diabetic macular edema and treated with 1.25 mg/mL intravitreal bevacizumab (Group A), laser photocoagulation (Group B), or vitrectomy with inner limiting membrane peeling (Group C) were included in the study. Changes in number of Early Treatment Diabetic Retinopathy Study letters, central macular thickness, largest diameter of the intraretinal cysts (IC), and choroidal thickness were investigated. Analyses were performed during follow-up visits at Months 1, 3, 6, 9, and 12.

RESULTS

Visual acuity only significantly improved in Group A at the last follow-up (P = 0.004). Central macular thickness significantly decreased in every group throughout the follow-up period. Differences in central macular thickness between Groups A and B (P < 0.01), A and C (P < 0.01), and B and C (P < 0.01) were significant. Intraretinal cysts also significantly decreased in each group throughout the follow-up period. Differences in IC size between Groups A and B (P = 0.8), A and C (P = 0.1), and B and C (P = 0.1) were not significant. Choroidal thickness did not undergo any significant change in any group throughout the follow-up period. A significant correlation was also found in Group A between best-corrected visual acuity at month 12 and baseline central macular thickness (R = 0.3; P = 0.006), and in Group B between postoperative best-corrected visual acuity at month 12 and baseline IC size (R = 0.8; P < 0.01, negatively correlated at 92.4%).

CONCLUSION

According to our retrospective data, diabetic macular edema with intraretinal cysts larger than 390 μm should not be treated with vitrectomy with ILM peeling, because this may induce subfoveal atrophy, defined as the "Floor Effect," and subsequent visual deterioration.

Foveal contour changes following surgery for idiopathic epiretinal membrane

PURPOSE

We evaluated the change in foveal contour in eyes with idiopathic epiretinal membrane (ERM) before and four months following pars plana vitrectomy with internal limiting and epiretinal membrane peeling, and correlated foveal contour with best corrected visual acuity (BCVA) and optical coherence tomography (OCT) parameters.

METHODS

Retrospective chart review of consecutive patients undergoing surgery with pre- and postoperative OCT. Foveal contour grading was devised according to the thickness of the fovea relative to the surrounding macula from OCT radial line scans: Grade 0, foveal depression relative to surrounding macula; Grade 1, relative flatness; and Grade 2, fovea thicker than surrounding macula. Baseline and follow-up grades were compared for change and correlated with BCVA, central retinal thickness (CRT), central subfield thickness (CST), central subfield volume (CSV), and integrity of the ellipsoid zone (EZ).

RESULTS

Among 41 eyes of 41 patients, mean follow-up was 125 days. No eyes were Grade 0 at baseline; 7 of 41 eyes were Grade 0 at follow-up. Baseline Grade 1 eyes improved CRT (P < 0.001), CST (P < 0.001), CSV (P = 0.002), and BCVA (P = 0.022). Baseline Grade 2 eyes improved CRT (P < 0.001), CST (P < 0.001), and CSV (P < 0.001), but not BCVA (P = 0.369).

CONCLUSIONS

We developed a novel foveal contour grading method to assess retinal contour in ERM eyes before and after surgery. In eyes with ERM and no foveal depression, the majority did not regain foveal depression following surgery even though retinal thickness improved.

Treatment of retinal detachment secondary to macular hole in highly myopic eyes: pars plana vitrectomy with internal limiting membrane peel and silicone oil tamponade

PURPOSE

To evaluate efficacy of vitrectomy with internal limiting membrane peel and silicone oil tamponade in highly myopic eyes with retinal detachment secondary to macular hole (MH).

METHODS

Twenty-one consecutive cases of MH-retinal detachment in highly myopic eyes were retrospectively reviewed. Eyes underwent pars plana vitrectomy, internal limiting membrane peeling, and silicone oil tamponade. A face-down or side-lying position was maintained postoperatively. Silicone oil was removed 3 months to 12 months later. Outcomes included MH closure and retinal reattachment rates, best-corrected visual acuity, and complication rates.

RESULTS

Mean patient age was 59.3 ± 6.5 years and mean spherical equivalent was -15.2 ± 4.3 diopters. After silicone oil removal, 18 eyes (86%) had MH closure with retinal reattachment and 2 eyes needed reattachment with endolaser photocoagulation and fluid/gas exchange, and 1 patient refused further treatment. At the last follow-up, median best-corrected visual acuity was +1.48 ± 0.12, up from preoperative +2.11 ± 0.17 (P = 0.03). Transient intraocular pressure elevation was observed in 11 eyes (52%). Iatrogenic retinal break occurred in one case.

CONCLUSION

Combining pars plana vitrectomy with internal limiting membrane peel and silicone oil tamponade was safe and effective in treating MH-retinal detachment in highly myopic eyes. Silicone oil tamponade may improve initial anatomical success rates because of longer tamponade duration.

Favorable anatomic and visual outcomes with 25-gauge vitrectomy for myopic foveoschisis

Purpose

To report the surgical outcomes of 25-gauge vitrectomy in eyes with myopic foveoschisis (MF).

Methods

The medical records of 40 eyes of 36 patients that had undergone 25-gauge vitrectomy with internal limiting membrane peeling for MF were studied. The main outcome measures were the best-corrected visual acuity (BCVA) and the optical coherence tomography (OCT) findings. The eyes were divided into two groups: 1) those with a foveal detachment (FD; FD group); and 2) those without a FD (no-FD group).

Results

The postoperative OCT images showed a resolution of the MF with a significant reduction in the central foveal thickness from the preoperative values in both the FD group (479±150 μm to 196±56 μm; P=0.002, mean ± standard deviation) and in the no-FD group (369±116 μm to 245±50 μm; P=0.001). The final mean BCVA significantly improved from the preoperative values in the FD group (0.96±0.53 logarithm of the minimum angle of resolution [logMAR] units to 0.70±0.56 logMAR units; P=0.009) and in the no-FD group (0.46±0.38 logMAR units to 0.34±0.36 logMAR units; P=0.007). The final BCVA in the FD group improved in 63%, remained unchanged in 31%, and worsened in 6%. In the no-FD group, the final BCVA improved in 21%, remained unchanged in 71%, and worsened in 8% of the eyes. A better final BCVA was significantly correlated with a better preoperative BCVA in both groups (P<0.001).

Conclusion

Twenty five-gauge vitrectomy results in favorable visual and anatomic outcomes for MF. We recommend that 25-gauge vitrectomy be used to treat eyes with MF.

Brilliant blue G assisted macular surgery: the effect of air infusion on contrast recognisability in internal limiting membrane peeling

BACKGROUND

To evaluate the potential efficacy and safety of inner limiting membrane (ILM) staining with brilliant blue G (BBG) under air infusion.

METHODS

63 patients, treated by one surgeon with macular hole or idiopathic epiretinal membrane were evaluated prospectively. BBG was applied under air infusion in 38 patients (group 1), and injected into the vitreous cavity in 25 (group 2). Main outcome measures were the chromaticity difference between the stained ILM and the unstained underlying retina, anatomical-functional outcomes and complications of the surgery. Chromaticity difference was measured by an objective and quantitative analysis method to describe colour contrast strengths as they are perceived by the human eye. Anatomical and functional outcomes were assessed using optical coherence tomography (OCT), visual field analyses (VFA) and multifocal electroretinography (mfERG).

RESULTS

CIELAB scores showed a significantly superior contrast for group 1 (16.72±2.36) than group 2 (10.34±1.29) (p<0.001). Visual acuity had increased in 28 eyes and remained stable in 10 eyes in group 1. In group 2, visual acuity had improved in 17 patients and remained unchanged in 8 patients. Based on postoperative OCT, anatomical success rate was 100%. During the follow-up period, mfERG and VFA demonstrated no case of BBG toxicity in either group. Cataract progression was the main postoperative complication (six eyes in group 1 and four eyes in group 2) and did not show a significant difference between the groups (p=0.45).

CONCLUSIONS

BBG under air infusion yields a significantly higher contrast staining and easy peeling of ILM associated with anatomical and functional improvement and no retinal toxicity after macular surgery.

Comparison between subjective and objective internal limiting membrane peeling area during epiretinal membrane surgery

PURPOSE

To determine the reliability of surgeons in estimating internal limiting membrane peeling area during epiretinal membrane surgery and to evaluate their ability to remove a predetermined internal limiting membrane surface.

METHODS

One senior surgeon and two junior surgeons were asked to reach a target internal limiting membrane peeling surface (ILMPS) with an eccentricity of 1 optic disk diameter (centered on the fovea) in patients undergoing epiretinal membrane surgery. The ILMPS was measured on video recordings during epiretinal membrane surgery with no dye and then after brilliant blue G staining.

RESULTS

Thirty patients were included. Median (interquartile range) ILMPS was 9.3 mm(2) (5.7-16.3 mm(2)) and 7.4 mm(2) (3.7-16.4 mm) before and after brilliant blue G, respectively (P = 0.17). The ILMPS was significantly larger in eyes operated by the senior surgeon than in those operated by the junior surgeons (P = 0.01). The senior surgeon reached the target ILMPS more often than the junior surgeons: 87% versus 47%, respectively (P = 0.02).

CONCLUSION

Subjective estimation of the ILMPS with no dye was fair, but this area was larger for the surgeon with greater surgical expertise.

Vitrectomy with internal limiting membrane peeling versus no peeling for idiopathic full-thickness macular hole

OBJECTIVE

To determine whether internal limiting membrane (ILM) peeling improves anatomic and functional outcomes of full-thickness macular hole (FTMH) surgery when compared with the no-peeling technique.

DESIGN

Systematic review and individual participant data (IPD) meta-analysis undertaken under the auspices of the Cochrane Eyes and Vision Group. Only randomized controlled trials (RCTs) were included.

PARTICIPANTS AND CONTROLS

Patients with idiopathic stage 2, 3, and 4 FTMH undergoing vitrectomy with or without ILM peeling.

INTERVENTION

Macular hole surgery, including vitrectomy and gas endotamponade with or without ILM peeling.

MAIN OUTCOME MEASURES

Primary outcome was best-corrected distance visual acuity (BCdVA) at 6 months postoperatively. Secondary outcomes were BCdVA at 3 and 12 months; best-corrected near visual acuity (BCnVA) at 3, 6, and 12 months; primary (after a single surgery) and final (after >1 surgery) macular hole closure; need for additional surgical interventions; intraoperative and postoperative complications; patient-reported outcomes (PROs) (EuroQol-5D and Vision Function Questionnaire-25 scores at 6 months); and cost-effectiveness.

RESULTS

Four RCTs were identified and included in the review. All RCTs were included in the meta-analysis; IPD were obtained from 3 of the 4 RCTs. No evidence of a difference in BCdVA at 6 months was detected (mean difference, -0.04; 95% confidence interval [CI], -0.12 to 0.03; P=0.27); however, there was evidence of a difference in BCdVA at 3 months favoring ILM peeling (mean difference, -0.09; 95% CI, -0.17 to-0.02; P=0.02). There was evidence of an effect favoring ILM peeling with regard to primary (odds ratio [OR], 9.27; 95% CI, 4.98-17.24; P<0.00001) and final macular hole closure (OR, 3.99; 95% CI, 1.63-9.75; P=0.02) and less requirement for additional surgery (OR, 0.11; 95% CI, 0.05-0.23; P<0.00001), with no evidence of a difference between groups with regard to intraoperative or postoperative complications or PROs. The ILM peeling was found to be highly cost-effective.

CONCLUSIONS

Available evidence supports ILM peeling as the treatment of choice for patients with idiopathic stage 2, 3, and 4 FTMH.