Surgical repair of full-thickness idiopathic macular holes associated with significant macular drusen

MACULAR HOLE IN A PATIENT WITH PENTOSAN POLYSULFATE MACULOPATHY

PURPOSE

Pentosan polysulfate (PPS), a drug used for interstitial cystitis, has recently been detected to cause maculopathy in a dose-dependent manner. Outer retinal atrophy is the hallmark of this condition.

METHODS

History, examination, and multimodal imaging were used to guide diagnosis and management.

RESULTS

We report a case of PPS-related maculopathy in a 77-year-old lady, who presented with florid retinal atrophy at the posterior pole in both eyes, and a concurrent macular hole in the left eye. She had been diagnosed with interstitial cystitis several years before for which she was prescribed PPS (Elmiron). She had noticed a drop in vision 5 years after initiation of PPS and self-discontinued the drug after 24 years of use. A diagnosis of PPS-related maculopathy with a macular hole was made. She was counselled regarding the prognosis and was advised to avoid PPS. Surgery for macular hole was deferred in view of the severe retinal atrophy.

CONCLUSION

Pentosan polysulfate-related maculopathy can lead to severe retinal atrophy and a subsequent degenerative macular hole. A high index of suspicion is required for early detection and cessation of drug to prevent this irreversible vision loss.

Full-Thickness Macular Hole Caused by Acute Subretinal Hemorrhage From Wet Age-Related Macular Degeneration

Purpose: To present a case of full-thickness macular hole (MH) that developed in association with acute subretinal hemorrhage from wet age-related macular degeneration (AMD). Methods: A retrospective observational review of a single case was performed. Results: An 84-year-old man with wet AMD presented with central vision loss and floaters and was noted to have a subretinal hemorrhage and an associated MH, which subsequently progressed to MH-associated macular detachment. The patient had a pars plana vitrectomy with internal limiting membrane peeling, gas tamponade, and prone positioning, resulting in closure of the MH and improvement in visual acuity. Conclusions: A full-thickness MH developed as a result of foveal dehiscence from an acute hemorrhage caused by choroidal neovascularization in wet AMD.

FULL-THICKNESS MACULAR HOLE IN AGE-RELATED MACULAR DEGENERATION PATIENTS WITH TWO DISTINCT ENTITIES: A Multicenter Study

PURPOSE

To describe optical coherence tomography characteristics of full-thickness macular holes (FTMHs) in age-related macular degeneration patients.

METHODS

A multicenter, retrospective, observational case series of patients diagnosed with age-related macular degeneration and FTMHs seen between January 1, 2009, and January 3, 2020. Clinical charts and spectral-domain optical coherence tomography images were reviewed. Optical coherence tomography findings included FTMH-inverted trapezoid or hourglass appearance, central macular thickness (CMT), complete retinal pigment epithelium and complete retinal outer retinal atrophy, and presence of pigment epithelium detachment and epiretinal membrane. The mean outcome was the morphologic and functional characterization of different subtypes of FTMHs.

RESULTS

A total of 86 eyes of 85 consecutive patients, with mean age of 80.31 ± 8.06 and mean best-corrected visual acuity of 1.17 ± 0.58 logarithm of the minimal angle of resolution. Two different subtypes of FTMHs were identified: tractional and degenerative. Fifty (58%) degenerative FTMHs characterized with inverted trapezoid appearance and 36 (42%) tractional FTMHs characterized with hourglass appearance. Degenerative FTMHs presented with 66% of CMT < 240 µm, 14% of CMT > 320, and 70% of complete retinal outer retinal atrophy, in comparison with 41% of CMT < 240 µm, 42.9% of CMT > 320%, and 20% of complete retinal outer retinal atrophy in the tractional FTMH group (P = 0.002, 0.003, <0.001, respectively). The presence of epiretinal membrane and pigment epithelium detachment where significantly higher in tractional FTMHs (P = 0.02, 0.03, respectively).

CONCLUSION

Degenerative and tractional FTMHs may be two distinct clinical entities. Discerning degenerative from tractional FTMHs is possible by using optical coherence tomography features including shape of the FTMHs, CMT, internal-external ratio of FTMHs, and presence of complete retinal outer retinal atrophy, pigment epithelium detachment, and epiretinal membrane.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Flap technique-assisted surgeries for advanced retinitis pigmentosa complicated with macular hole: a case report and literature review

Background

Full-thickness macular hole (FTMH) is a rare complication in retinitis pigmentosa (RP) patients and may increase intraoperative challenges. Furthermore, lens capsular flap transplantation and inverted internal limiting membrane (ILM) flap were reported to close complicated FTMH successfully. Here, we present a case of bilateral advanced RP complicated by a FTMH treated with a novel lens capsular flap transplantation and inverted internal limiting membrane flap.

Case presentation

A 46-year-old presented to our hospital with a complaint of progressively blurred vision and metamorphopsia in both eyes. Spectral-domain optical coherence tomography revealed a FTMH with retinoschisis in the right eye and another FTMH in the left eye. ILM peeling with inverted ILM flap technique was performed on the right eye and ILM peeling with anterior lens capsular flap technique was performed on the left eye. Post-operative follow-up showed successful closure of the FTMH and improved vision in both eyes.

Conclusions

In our present case, flap-assisted techniques for retinitis pigmentosa with macular hole result in excellent visual and anatomic outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-021-02082-3.

Surgical Treatment for a Full-Thickness Macular Hole That Developed on a Large Drusenoid Pigment Epithelial Detachment

Full-thickness macular hole (FTMH) and age-related macular degeneration (AMD) can affect the same eyes in the older population. Previously reported phenotypes of AMD concurrent with FTMH include early/intermediate AMD and serous pigment epithelial detachment (PED). A 68-year-old woman presented to our clinic with decreased vision due to a cataract and a large drusenoid PED in both eyes. After ruling out choroidal neovascularization, she underwent cataract surgery. Three days after the cataract surgery, an FTMH was found in the left eye. Although the FTMH was not closed after the initial pars plana vitrectomy (PPV) with the inner limiting membrane (ILM) peeling and air tamponade, it was closed after reoperation with additional ILM peeling, retinal massage, and SF6 gas tamponade. Best-corrected visual acuity (BCVA) was improved from 20/60 before the first PPV to 20/40 at six months after the reoperation. Some large soft drusen in the macula were fused after surgeries in the operated eye, but not in the fellow eye. An FTMH concurrent with a large drusenoid PED is rare. It can be closed surgically, and postoperative visual function can improve.

Application of subretinal fluid to close refractory full thickness macular holes: treatment strategies and primary outcome: APOSTEL study

INTRODUCTION

Persisting macular holes (PMH) after surgical release of any epiretinal traction of the vitreous and adjacent membrane may rely on secondary firm adhesions between the retracted retina and adjacent retinal pigment epithelium. Secondary application of subretinal (SR)-fluid may release these adhesions followed by an anatomical closure.

METHODS

Twelve surgeons applied in a consecutive case series SR-fluid in 41 eyes with PMH and reported retrospectively their initial surgical, anatomical and functional experience with this approach.

RESULTS

The mean duration of the MH prior to SR-fluid application was 17 months (6-96 months). The mean age of the patients at the time of surgery was 72 years (54-88). The mean preoperative aperture diameter of the opening was 1212 μm (239-4344 μm), base diameter 649 μm (SD 320 μm). The mean preoperative BCVA prior to surgery was 0.1 (0.01-0.3). All patients (41/41) complained about reduced BCVA and a significant central scotoma (negative scotoma) in their central field of vision. The secondary closure rate for our PMH was 85.36% (35 out of 41 eyes) at 6 weeks after surgery. The postoperative BCVA improved to 0.22 (0.02-0.5). The application of SR-fluid was not associated with major intraoperative adverse effects.

CONCLUSION

Remaining SR-adhesions may inhibit PMH closure. Their release by application of SR-fluid will lead to a fast and immediate anatomical closure in many cases without serious adverse events.

Vitrectomy with the inverted internal limiting membrane flap technique in eyes with full-thickness macular hole and dry age-related macular degeneration

PURPOSE

To present effects of the inverted internal limiting membrane flap technique in full-thickness macular holes coexisting with dry age-related macular degeneration.

METHODS

Our database was retrospectively reviewed in order to spot patients with the simultaneous diagnosis of dry age-related macular degeneration and full-thickness macular hole. Vitrectomy with the inverted internal limiting membrane flap technique was performed. Inclusion criteria were full-thickness macular hole, drusen, vitrectomy performed, and spectral domain optical coherence tomography (Copernicus HR, Optopol, Poland) or swept source optical coherence tomography (Triton, Topcon, Japan) before surgery, then 1 week (±3 days), 1 month (±1 week), 3 months (±1 month), 6 months (±1 month), 12 months (±2 months), and 18 months to 12 years after surgery.

MAIN OUTCOME MEASURES

Closure of macular hole and visual acuity at the final control.

RESULTS

A total of 18 eyes of 12 patients (mean age: 68 years) were included. Mean minimum macular hole diameter was 493 μm. Mean maximum macular hole diameter was 1072 μm. Macular hole was closed in 16 eyes after first surgery and in all eyes after second surgery. Improvement of visual acuity was statistically significant (P = 0.05), but there was no statistical significant correlation observed between initial macular hole diameters and final visual acuity (P > 0.1).

CONCLUSION

The inverted internal limiting membrane flap technique improves anatomical and functional results in eyes with coexisting dry age-related macular degeneration and full-thickness macular holes. Final development of choroidal neovascularization or geographic atrophy is possible in rare cases.

To Peel or Not to Peel: Pars Plana Vitrectomy with Macular Membrane Peel in Eyes with Abnormalities of Vitreomacular Interface and Coexisting Dry Age-Related Macular Degeneration

Purpose

To evaluate the outcome of macular surgery with ILM- and epiretinal membrane peel associated with significant dry age-related macular degeneration (AMD) as defined by the Age-Related Eye Disease Study (AREDS).

Patients and Methods

Institutional. Retrospective case-control study. A total of 42 pseudophacic eyes of 39 patients (7 with full thickness macular hole and 35 with epiretinal membrane) with coexisting dry AMD underwent pars plana vitrectomy (PPV) with internal limiting membrane (ILM) and epiretinal membrane peel. Preoperative and postoperative data including best corrected visual acuity (BCVA), AMD grade according to AREDS, central retinal thickness (CRT), development of choroidal neovascularization (CNV), and central retinal atrophy have been evaluated. Twenty-eight fellow eyes with dry AMD of the included 39 patients served as a control group.

Results

A significant improvement in the visual acuity could be observed after surgery (initial BCVA 0.47±0.31 logarithm of the minimal angle of resolution (logMAR) vs 0.33±0.29logMAR 9 months postoperatively; p=0.006). CRT decreased significantly after surgery (p<0.001). In the surgery group, there were 4 eyes (9.5%) with CNV and 1 eye (2.5%) with new central retinal atrophy development after surgery. All these eyes had preoperative AREDS 3 (4 eyes) or AREDS 4 (1 eye) AMD category. In the control group, there was 1 eye (4%) with CNV and 4 eyes (14%) with new central retinal atrophy development during the follow-up of 9 months. These eyes had initially AREDS 2 (1 eye), AREDS 3 (3 eyes) or AREDS 4 (1 eye) AMD category.

Conclusion

Eyes with dry AMD of AREDS 3 and AREDS 4 with coexisting VMI abnormalities improve significantly after PPV with membrane peel. While there is a higher risk of CNV development after surgery (9.5%) in these eyes, the vitrectomy does not seem to accelerate central retinal atrophy progression compared to the fellow eyes course.

OUTCOMES OF ANTI-VEGF THERAPY IN CHOROIDAL NEOVASCULARIZATION AFTER MACULAR SURGERY

PURPOSE

To report treatment outcomes of anti-vascular endothelial growth factor (VEGF) therapy in choroidal neovascularization (CNV) presenting after macular surgery.

METHODS

Retrospective analysis of 7 eyes of 7 patients, who were diagnosed to have CNV after macular surgery and were treated with anti-vascular endothelial growth factor therapy. Collected data included demographic details; history of present illness; surgical procedure; and clinical examination including visual acuity at presentation and follow-up with imaging and management. Main outcome measures were resolution of CNV activity at the last follow-up. Secondary outcomes included change in visual acuity at final follow-up from baseline, number of injections, treatment free interval, and adverse events.

RESULTS

Seven eyes of 7 patients (2 females and 5 males), which underwent macular surgery (4 macular hole repairs and 3 epiretinal membrane (ERM) removal), were included in this study. Two eyes had drusen at the time of surgery; however, five eyes had no preexisting conditions. Mean interval between surgery and CNV development was 21.07 ± 38.55 months (range, 2 months-9 years). All patients had undergone intravitreal anti-vascular endothelial growth factor injections (range, 2-15; mean number: 5.85) with one eye requiring additional photodynamic therapy (PDT) and focal laser. Visual acuity was unchanged with inactive CNV at the last visit in all eyes after anti-vascular endothelial growth factor therapy. The mean follow-up duration after the development of CNV was 35.5 months (range, 6.5 months-8 years).

CONCLUSION

Choroidal neovascularization occurring after otherwise successful macular surgery is uncommon with unknown predisposing factors. This entity appears to have poor visual outcome with currently available anti-vascular endothelial growth factor therapy.

Predictors of Visual Acuity Outcomes Following Vitrectomy for Idiopathic Macular Hole

BACKGROUND AND OBJECTIVE

To investigate predictors of visual outcomes in patients who underwent vitrectomy for full-thickness macular hole (FTMH) with at least 1 year of follow-up.

PATIENTS AND METHODS

Retrospective, noncomparative, consecutive case series of 132 eyes of 122 patients who underwent surgical repair of idiopathic FTMH with at least 1 year of follow-up. Predictors of visual acuity (VA) outcomes were analyzed using linear regression.

RESULTS

Mean follow-up time was 22.2 months. Twenty-three eyes (17.4%) had age-related macular degeneration (AMD), of which 17 (73.9%) cases were mild and nonexudative. At final follow-up, poor preoperative VA (P < .001), perioperative complications (P < .001), AMD (P < .001), and delay from preoperative evaluation to surgery (P = .037) were significant predictors of final VA. In multiple regression, these variables remained significant (P < .001, P = .011, P < .001, and P = .002, respectively).

CONCLUSION

Poor preoperative VA, perioperative complications, AMD, and delay to surgery were significant predictors of final VA following FTMH repair. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:566-570.].

Case report of a secondary macular hole closure after intravitreal bevacizumab therapy in a patient with retinal pigment epithelial detachment

We describe a case of macular hole (MH) closure after intravitreal bevacizumab therapy for an underlying pigment epithelial detachment (PED) due to exudative age-related macular degeneration (AMD). The 73-year-old Caucasian female presented with reduced visual acuity (20/80) of the left eye and metamorphopsia for approximately 6 months. Spectral domain optical coherence tomography revealed a subfoveal PED due to AMD with an associated MH. To treat the exudative component of the pathology, we started intravitreal bevacizumab therapy, consecutively leading to reduction of the height of PED and allowing closure of the MH. Detachment recurred during further follow-up, but the MH remained closed. MHs and exudative AMD are common diseases, which rarely occur simultaneously. To the best of our knowledge (search via PubMed for “MH,” “PED,” “age-related macular degeneration”), no other case with the persistent closure of an MH associated with PED during intravitreal antivascular endothelial growth factor therapy and despite recurrent PED has been published to date.

Choroidal neovascularization in angioid streaks following microincision vitrectomy surgery: a case report

Background

Patients with angioid streaks are prone to developing subretinal hemorrhage after ocular or head injury due to the brittleness of Bruch’s membrane. However, there have been no reports of any angioid streak patients in whom choroidal neovascularization occurred after vitrectomy surgery. We report herein a patient with angioid streaks who developed choroidal neovascularization after vitrectomy surgery for epiretinal membrane.

Case presentation

A 76-year-old man presented with distorted vision in his left eye, with a best corrected visual acuity of 1.2 and 0.6 in his right and left eyes, respectively. Fundus examination showed angioid streaks in both eyes and epiretinal membrane only in the left eye. The patient underwent 23-gauge three-port pars plana vitrectomy with removal of the epiretinal membrane combined with cataract surgery. Internal limiting membrane in addition to the epiretinal membrane were successfully peeled and removed, with indocyanine green dye used to visualize the internal limiting membrane. His left best corrected visual acuity improved to 0.8. An elevated lesion with retinal hemorrhage due to probable choroidal neovascularization was found between the fovea and the optic disc in the left eye at 7 weeks after surgery. Since best corrected visual acuity decreased to 0.15 and the hemorrhage expanded, posterior sub-Tenon injection of triamcinolone acetonide was performed. However, no improvement was observed. Even though intravitreal bevacizumab injection was performed a total of five times, his best corrected visual acuity remained at 0.1. Subsequently, we performed a combination treatment of a standard-fluence photodynamic therapy and intravitreal ranibizumab injection, with additional intravitreal ranibizumab injections performed 3 times after this combination treatment. Best corrected visual acuity improved to 0.5 and the size of the choroidal neovascularization markedly regressed at 4 months after the combined treatment.

Conclusion

Development of choroidal neovascularization could possibly occur in elderly patients with angioid streaks after vitrectomy surgery. In such cases, a combination of photodynamic therapy and intravitreal ranibizumab injection may be considered for initial treatment of the choroidal neovascularization.

Occult choroidal neovascularization after successful macular hole surgery treated with ranibizumab

PURPOSE

To report on a case that developed an atypical form of occult choroidal neovascularization (CNV) after successful macular hole surgery.

METHODS

Visual acuity change, color fundus photographs, fluorescein and indocyanine green angiograms, and optical coherence tomography results were compared throughout the follow-up duration.

PATIENTS

A 64-year-old woman with a macular hole in the right eye and drusen in both eyes underwent pars plana vitrectomy, internal limiting membrane peeling, and gas tamponade. One month after the operation she developed occult CNV, in which pigment epithelial detachment and fine retinal pigment epithelial (RPE) layer wrinkles were observed under the completely sealed macular hole. After 3-monthly intravitreal injections of ranibizumab, the lesion did not change significantly.

CONCLUSION

CNV can develop after otherwise successful macular hole surgery, especially in patients with pre-existing aging changes in the macula, such as drusen. Care should be taken in such patients, to prevent the development of CNV after macular hole surgery.

A rare case of choroidal neovascularization following macular hole surgery

BACKGROUND

Choroidal neovascularization occurs in a wide spectrum of conditions, including degenerative, inflammatory, traumatic and hereditary conditions, all of which are characterized by breaks in Bruch's membrane. A few cases of choroidal neovascular membrane (CNVM) have been reported in the literature following macular hole surgery.

METHOD

We present a retrospective case study of a single patient who developed CNVM after successful macular hole surgery. The 70-year-old diabetic female underwent macular hole surgery in her right eye. Posterior hyaloid was separated with suction and vitrectomy was performed. Internal limiting membrane (ILM) was stained with trypan blue under air and ILM peeling was performed. Perfluoropropane (C3F8) gas was used as the tamponade. Six weeks post-operation, closure of macular hole was seen. Six months later, she presented with defective vision. Subfoveal classic CNVM was seen in the same eye.

DISCUSSION

About 1%-3% of patients who undergo macular hole surgery develop CNVM. Age-related changes and surgical trauma are considered to be the predisposing factors in reported cases. Injury to the retinal pigment epithelium (RPE) during surgery may be an important factor in our case, since there were no pre-existing age-related changes.

CONCLUSIONS

CNVM though rare can occur after macular hole surgery, especially in the setting of age-related changes. Injuries to the RPE should be avoided during surgery. We report a case of CNVM after macular hole in which trypan blue was used as a staining agent.

CHARACTERISTICS AND OUTCOMES OF CHOROIDAL NEOVASCULARIZATION OCCURRING AFTER MACULAR HOLE SURGERY

PURPOSE

To study the characteristics and outcomes of choroidal neovascularization (CNV) developing after surgery for idiopathic macular holes.

METHODS

Retrospective, noncomparative case series. Search of diagnostic and procedure databases of four participating institutes identified nine eyes of eight patients with CNV after surgery for idiopathic macular hole. Demographic, clinical, and fundus fluorescein angiographic data were abstracted from patients' medical records.

RESULTS

Choroidal neovascularization developed 6 weeks to 30 months after macular hole surgery. The macular hole was closed in all cases. The CNV complex involved the foveal region in 9 (100%) eyes, was predominantly classic in 8 (89%) eyes, and was associated with moderate to severe leakage of fluorescein in 8 (89%) eyes. The CNV was crescent-shaped and spared the central area of retinal pigment epithelial mottling that corresponded to the site of the macular hole in 6 (67%) cases. Other fluorescein angiographic features included retinal pigment epitheliopathy in 6 (67%) eyes and presence of drusen in 7 (78%) eyes. The final visual acuity after a mean follow-up period of 11.2 months (range, 3-16 months) was 20/50 to 20/80 in 2 (22%) eyes, 20/100 to 20/200 in 1 (11%) eye, and less than 20/200 in 6 (67%) eyes.

CONCLUSION

Choroidal neovascular complexes occurring after macular hole surgery tend to share certain characteristics, including foveal involvement, frequent sparing of the central area corresponding to the site of the closed macular hole, and generally poor visual outcomes. Therapeutic modalities including photodynamic therapy and surgical options may be considered in these patients.

Detection and segmentation of drusen deposits on human retina: potential in the diagnosis of age-related macular degeneration

Assessment of the risk for the development of age-related macular degeneration requires reliable detection and quantitative mapping of retinal abnormalities that are considered as precursors of the disease. Typical signs for the latter are the so-called drusen that appear as abnormal white-yellow deposits on the retina. Segmentation of these features using conventional image analysis methods is quite complicated mainly due to the non-uniform illumination and the variability of the pigmentation of the background tissue. This paper presents a novel segmentation algorithm for the automatic detection and mapping of drusen in retina images acquired with the aid of a digital Fundus camera. We employ a modified adaptive histogram equalization, namely the multilevel histogram equalization (MLE) scheme, for enhancing local intensity structures. For the detection of drusen in retina images, we develop a novel segmentation technique, the histogram-based adaptive local thresholding (HALT), which extracts the useful information from an image without being affected by the presence of other structures. We provide experimental results from the application of our technique to real images, where certain abnormalities (drusen) have slightly different characteristics from the background. The performance of the algorithm is established through statistical analysis of the results. This analysis indicates that the proposed drusen detector gives reliable detection accuracy in both position and mass size.