Optical coherence tomographic characteristics and surgical outcome of eyes with myopic foveoschisis

Vitreoretinal Interface Changes After Anti-vascular Endothelial Growth Factor Treatment in Highly Myopic Eyes: A Real-World Study

INTRODUCTION

To investigate changes in the vitreoretinal interface after anti-vascular endothelial growth factor (anti-VEGF) treatment in highly myopic eyes.

METHODS

Eyes with myopic choroidal neovascularization (mCNV) treated with intravitreal injection of anti-VEGF in a single-center were retrospectively reviewed. Fundus abnormalities and features of optical computed tomography were studied.

RESULTS

A total of 295 eyes from 254 patients were recruited to the study. Prevalence of myopic macular retinoschisis (MRS) was 25.4%, and the rates of progression and onset of MRS were 75.9% and 16.2%, respectively. Outer retinal schisis (β = 8.586, p = 0.003) and lamellar macular hole (LMH) (β = 5.015, p = 0.043) at baseline were identified risk factors for progression and onset of MRS, whereas male sex (β = 9.000, p = 0.039) and outer retinal schisis at baseline (β = 5.250, p = 0.010) were risk factors for MRS progression. Progression of MRS was first detected in outer retinal layers in 48.3% of eyes. Thirteen eyes required surgical intervention. Spontaneous improvements of MRS were observed in five eyes (6.3%).

CONCLUSION

Changes in the vitreoretinal interface, such as progression, onset, and improvement of MRS, were observed after anti-VEGF treatment. Outer retinal schisis and LMH were risk factors of progression and onset of MRS after anti-VEGF treatment. Intravitreal injection of ranibizumab and retinal hemorrhage were protective factors for surgical intervention for vision-threatening MRS.

Anatomical and visual outcomes of fovea-sparing internal limiting membrane peeling with or without inverted flap technique for myopic foveoschisis

BACKGROUND

Vitrectomy and peeling of the internal limiting membrane (ILM) was an effective therapeutic approach for myopic foveoschisis with progressive visual loss. This study investigated the anatomical and visual outcomes of fovea-sparing ILM peeling with or without the inverted flap technique for patients with symptomatic myopic foveoschisis (MF).

METHODS

We retrospectively reviewed the clinical data of patients with MF. Vitrectomy with fovea-sparing ILM peeling and air tamponade was performed in all patients. The primary outcome measures included best-corrected visual acuity (BCVA), mean macular thickness (MMT), and central foveal thickness (CFT). Depending on whether an inverted ILM flap technique was utilized, further subgroup comparisons between the inverted flap group and the non-inverted flap group were conducted.

RESULTS

Twenty-six eyes of 22 patients were included. Fifteen eyes were underwent fovea-sparing ILM peeling without inverted ILM flap and 11 of the 26 eyes were treated with fovea-sparing ILM peeling and an inverted ILM flap technique. In the mean follow-up period of 10.74 ± 4.58 months, a significant improvement in BCVA was observed from 0.97 ± 0.45 logMAR to 0.58 ± 0.51 logMAR (P < 0.01), during which the BCVA of 20 eyes (76.92%) improved and remained stable in 5 eyes (19.23%). Moreover, a positive correlation was also found between the preoperative BCVA and the postoperative BCVA (r = 0.50, P = 0.01). At the last visit, the final MMT decreased from 492.69 ± 209.62 μm to 234.73 ± 86.09 μm, and the CFT reduced from 296.08 ± 209.22 μm to 138.31 ± 73.92 μm (all P < 0.01). A subgroup analysis found no significant differences in BCVA, MMT, or CFT between the inverted and non-inverted flap groups (all P > 0.05).

CONCLUSION

Fovea-sparing ILM peeling with or without inverted flap technique resulted in favorable visual and anatomical outcomes for the treatment of MF. An important factor affecting the postoperative visual outcome was the preoperative visual acuity. Our study found no significant difference between the presence and absence of the inverted ILM flap.

Non-vasogenic cystoid maculopathies

Besides cystoid macular edema due to a blood-retinal barrier breakdown, another type of macular cystoid spaces referred to as non-vasogenic cystoid maculopathies (NVCM) may be detected on optical coherence tomography but not on fluorescein angiography. Various causes may disrupt retinal cell cohesion or impair retinal pigment epithelium (RPE) and Müller cell functions in the maintenance of retinal dehydration, resulting in cystoid spaces formation. Tractional causes include vitreomacular traction, epiretinal membranes and myopic foveoschisis. Surgical treatment does not always allow cystoid space resorption. In inherited retinal dystrophies, cystoid spaces may be part of the disease as in X-linked retinoschisis or enhanced S-cone syndrome, or occur occasionally as in bestrophinopathies, retinitis pigmentosa and allied diseases, congenital microphthalmia, choroideremia, gyrate atrophy and Bietti crystalline dystrophy. In macular telangiectasia type 2, cystoid spaces and cavitations do not depend on the fluid leakage from telangiectasia. Various causes affecting RPE function may result in NVCM such as chronic central serous chorioretinopathy and paraneoplastic syndromes. Non-exudative age macular degeneration may also be complicated by intraretinal cystoid spaces in the absence of fluorescein leakage. In these diseases, cystoid spaces occur in a context of retinal cell loss. Various causes of optic atrophy, including open-angle glaucoma, result in microcystoid spaces in the inner nuclear layer due to a retrograde transsynaptic degeneration. Lastly, drug toxicity may also induce cystoid maculopathy. Identifying NVCM on multimodal imaging, including fluorescein angiography if needed, allows guiding the diagnosis of the causative disease and choosing adequate treatment when available.

Vitrectomy with internal limiting membrane peeling and gas tamponade for myopic foveoschisis

Background

We evaluated the effect of vitrectomy with internal limiting membrane (ILM) peeling and gas tamponade for myopic foveoschisis (MF), and analysed prognosis with different gas tamponade.

Methods

Retrospective, non-randomized study. The records of patients with MF treated by vitrectomy, were reviewed. Patients were followed up postoperatively mean 16.74 months, to record changes of Best-corrected visual acuity (BCVA) and central foveal thickness (CFT).

Results

Sixty-two eyes (59 patients) were analysed in total, with mean age of 55.29 ± 10.34 years, 49 females (83.1%). Foveoschisis completely resolved in all eyes at least 6 months post vitrectomy, except for two postoperative full-thickness macular holes (FTMH). Final BCVA improved significantly from 0.69 ± 0.39 to 0.44 ± 0.42 logMAR, and CFT from 502.47 ± 164.78 to 132.67 ± 52.26 μm. Patients were subdivided into three subgroups based on the different endotamponades used (C3F8, C2F6, and air). Baseline BCVA, baseline CFT and foveal detachment (FD) were not significantly different among the three groups. Eyes treated with air tamponade had better visual outcomes than eyes with C3F8 tamponade (P = 0.008). Baseline BCVA and FD were significant risk factors for postoperative BCVA (P < 0.001 and P = 0.013, respectively).

Conclusions

Vitrectomy with ILM peeling and gas tamponade results in good functional and anatomic outcomes in the treatment of most MF. Good vision and no-FD pre-surgery are related with good visual prognosis. Air tamponade can provide as good visual recovery as expansive gas, and reduce postoperative complications.

Long-term surgical outcomes and prognostic factors of foveal detachment in pathologic myopia: based on the ATN classification

BACKGROUND

To investigate the long-term surgical outcomes and prognostic factors of foveal detachment (FD) in pathological myopia.

METHODS

This retrospective observational study included 59 patients with FD (61 eyes) who underwent pars plana vitrectomy at Shanghai General Hospital between June 2017 and July 2018 with follow-up for at least 24 months. Comprehensive ophthalmic examinations, including best-corrected visual acuity (BCVA) and swept-source optical coherence tomography, were assessed. Preoperative myopic maculopathy was evaluated according to the ATN classification.

RESULTS

FD completely resolved in 59 of 61 eyes (96.7%). Mean duration of retinal reattachment was 12.10 ± 8.10 months. Mean logMAR BCVA improved from 1.34 ± 0.52 to 0.83 ± 0.43 at 24 months postoperatively (P < 0.001). Secondary macular hole occurred in 8 eyes (13.1%) with a mean period of 3.4 ± 4.1 weeks after primary surgery. In regression analyses, baseline myopic atrophy maculopathy (MAM) (B = 0.213, P = 0.005) and vitreomacular traction (VMT) (B = 0.292, P = 0.007) were adverse prognostic factors for postoperative BCVA. A more severe MAM revealed a delay in retinal reattachment (B = 5.670, P = 0.002). FD eyes with VMT (OR = 1.309, P = 0.003) or outer lamellar macular hole (O-LMH) (OR = 1.369, P < 0.001) were risk factors for postoperative secondary macular hole.

CONCLUSIONS

Vitrectomy was effective in the long-term for treating FD. Careful consideration is needed for those with VMT or O-LMH due to the high risk of secondary macular hole after vitrectomy. FD eyes with more severe MAM tended to have poorer postoperative BCVA and extended periods of retinal reattachment.

Myopic Traction Maculopathy: A New Perspective on Classification and Management

ABSTRACT

Myopic traction maculopathy (MTM) is a complex disease affecting approximately 30% of eyes with pathologic myopia. A review of the history of treatment of MTM with success rates and limitations of different surgical techniques are reported.The pathogenesis, the definition and the management were clarified in a recent study(cit). The MTM Staging System (MSS) table summarizes all the stages of MTM offering insights on the pathogenesis and natural evolution of the disease.Guidelines of management of MTM were therefore proposed, but customized for each stage.Initial stages 1a and 2a, which define maculoschisis in the inner or inner-outer or only outer layers of the retina, should be observed. Stages 3a and 4a, defining macular detachment with and without associated schisis, should be treated with a macular buckle (MB).Stage 1b, which is a lamellar macular hole in a myopic eye, should be treated with pars plana vitrectomy (PPV) only in symptomatic cases. Stages 2b, 3b, and 4b should be treated with a MB and PPV should be added in a second step only if the presence of a lamellar macular hole requires intervention to improve visual function.Stage 1c, which is a full thickness macular hole in a myopic eye, should be treated with PPV. Stages 2c, 3c and 4c should be treated with a combination of simultaneous MB + PPV to treat both the retinal pattern of schisis or detachment and the full thickness macular hole.

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.

INTRAVITREAL GAS INJECTION WITH LASER PHOTOCOAGULATION FOR HIGHLY MYOPIC FOVEOSCHISIS: Technique and Outcome

This article documented the effects of intravitreal perfluoropropane (C₃F₈) injection combined with macular laser photocoagulation 1 week later for patients with highly myopic foveoschisis. This modified combined therapy can yield an acceptable success rate.

Purpose:

To evaluate the effects of gas tamponade combined with laser photocoagulation without vitrectomy in patients with highly myopic foveoschisis.

Methods:

This retrospective noncomparative case series included 30 eyes of 23 patients with highly myopic foveoschisis who were treated by intravitreal injection of 0.5 to 0.7 mL C₃F₈ combined with laser photocoagulation 1 week later, and remained in the face-down position for 3 weeks. The patients were followed up for at least 6 months after the treatment. The refractive status, best-corrected visual acuity, and anatomical parameters of retina observed with the optical coherence tomography before and after the treatment were recorded.

Results:

The mean age of the 23 patients (6 men and 17 women) was 50.4 ± 15.1 years. The average follow-up duration was 20.8 ± 20.6 months. At the final follow-up, 23 eyes (76.7%) completely (17 eyes) or partially (6 eyes) resolved. Seventeen eyes had complete data of optical coherence tomography parameters, the mean central foveal thickness decreased significantly from 505.24 ± 466.22 μm to 186.41 ± 95.36 μm (P = 0.01), and the mean maximal macular thickness from 687.88 ± 397.00 μm to 313.65 ± 83.07 μm (P = 0.001). The mean final logarithm of the minimum angle of resolution best-corrected visual acuity (Snellen equivalent) of the 30 eyes ranged from 1.6 (20/800) to 0.2 (20/32), showing a slight improvement from 0.91 ± 0.44 (20/163) preoperatively to 0.90 ± 0.39 (20/160) postoperatively (P = 0.87).

Conclusion:

C₃F₈ tamponade combined with laser photocoagulation could be an alternative treatment for highly myopic foveoschisis.

Visualizing the dynamic change of Ocular Response Analyzer waveform using Variational Autoencoder in association with the peripapillary retinal arteries angle

The aim of the current study is to identify possible new Ocular Response Analyzer (ORA) waveform parameters related to changes of retinal structure/deformation, as measured by the peripapillary retinal arteries angle (PRAA), using a generative deep learning method of variational autoencoder (VAE). Fifty-four eyes of 52 subjects were enrolled. The PRAA was calculated from fundus photographs and was used to train a VAE model. By analyzing the ORA waveform reconstructed (noise filtered) using VAE, a novel ORA waveform parameter (Monot1-2), was introduced, representing the change in monotonicity between the first and second applanation peak of the waveform. The variables mostly related to the PRAA were identified from a set of 41 variables including age, axial length (AL), keratometry, ORA corneal hysteresis, ORA corneal resistant factor, 35 well established ORA waveform parameters, and Monot1-2, using a model selection method based on the second-order bias-corrected Akaike information criterion. The optimal model for PRAA was the AL and six ORA waveform parameters, including Monot1-2. This optimal model was significantly better than the model without Monot1-2 (p = 0.0031, ANOVA). The current study suggested the value of a generative deep learning approach in discovering new useful parameters that may have clinical relevance.

Correlation Between the Myopic Retinal Deformation and Corneal Biomechanical Characteristics Measured With the Corvis ST Tonometry

Purpose

We previously reported that the retinal deformation due to myopia was represented by the peripapillary retinal arteries angle (PRAA). In this study, we investigated the relationship between the PRAA and biomechanical properties measured with Corvis ST (CST) tonometry.

Methods

Thirty-four normative eyes of 34 subjects who underwent CST measurement were enrolled. The PRAA was calculated from a fundus photograph. Variables related to the PRAA were identified from age, axial length, spherical equivalent refractive error, and 10 CST parameters using model selection with the second-order bias-corrected Akaike information criterion index.

Results

The PRAA was best described with axial length (coefficient = −5.66, P < 0.0001), maximum deflection amplitude (mm; coefficient = 130.5, P = 0.0004), and deflection amplitude ratio (DA ratio) 2 mm (coefficient = −25.8, P = 0.0032), where mm was the amount of the maximum corneal apex movement and DA ratio 2 mm was the ratio between the deformation amplitudes at the apex and 2 mm away from the apex. The optimal model was significantly better than the model only with axial length (P = 0.0014, analysis of variance).

Conclusions

The PRAA was significantly better described with the CST parameters compared to the axial length model only; eyes with small PRAA (larger myopic retinal deformation) showed narrow and shallow maximum corneal deflection.

Translational Relevance

The Corvis ST parameters, which represents corneal biomechanical characteristics, were associated with myopic retinal deformation.

Long-term results and risk factors influencing outcome of gas tamponade for myopic foveoschisis with foveal detachment

OBJECTIVE

To evaluate the long-term results of gas tamponade without vitrectomy in patients with myopic foveoschisis (FS) and foveal detachment (FD).

METHODS

Twenty eyes of 20 patients with myopic foveoschisis and foveal detachment were analysed retrospectively. All patients received an intravitreal injection of 0.2-0.3 mL C3F8 as an initial treatment. The patients were followed up for at least 18 months after the procedure. The refractive status, best-corrected visual acuity (BCVA), and anatomical abnormalities in macular area before and after the treatment were assessed and recorded.

RESULTS

After initial gas tamponade, FD resolved completely (defined as responders) in 14 eyes, resolved partially in 2 eyes (defined as partial responders), and worsened in 4 eyes (non-responders) at the 3-month follow-up visit. Vitrectomy was performed in four eyes that showed increased detachment (two cases) or developed macular hole (two cases). Repeated gas injection was performed in two recurrent cases after initial success at the 3-month follow-up, and the foveal detachment once again resolved. Overall, 70% of our cases demonstrated resolution of FD at the 3-month follow-up and the long-term responders to gas injection was 65%. The risk factors for treatment failure were: (1) The presence of optical coherence tomography (OCT)-evident premacular membranes (p = 0.03) and (2) the height of FS measured >588 µm (p = 0.009).

CONCLUSION

Our data supported that gas tamponade may be effective as an alternative treatment for selected cases of myopic FS with FD. The procedure may be especially beneficial in patients without OCT-evident premacular membranes and have low height of FS.

Morphologic and functional outcomes of different optical coherence tomography patterns of myopic foveoschisis after vitrectomy and inner limiting membrane peeling

OBJECTIVE

To evaluate the morphologic and functional outcomes of different optical coherence tomography (OCT) patterns of myopic foveoschisis after vitrectomy with Inner Limiting Membrane (ILM) peeling.

METHODS

In this prospective non-randomised study, 62 consecutive eyes with Myopic Foveoschisis were categorised into three groups according to OCT pattern: retinoschisis type (Rt) Group (23/62), foveal detachment type (FDt) Group (20/62) and macular hole type (MHt) Group (19/62). All patients underwent 25-Gauge vitrectomy and ILM peeling. Air or gas tamponade was used. All patients were observed at month 1, 2, 4 and 6 after surgery.

MAIN OUTCOMES MEASURES

surgical success as resolution of myopic foveoschisis, central retinal thickness (CRT), IS/OS junction recovery and best-corrected visual acuity (BCVA) measurement. Any complication was reported.

RESULTS

In all eyes OCT showed a resolution of the retinoschisis, foveal detachment and macular hole pattern, respectively. CRT significantly decreased in all Groups (p < .001), mainly in MHt. IS/OS junction recovery was mainly observed in MHt. BCVA significantly increased in all Groups (p < .01). A functional gain ≥2 Snellen lines occurred in 70, 85 and 68% in the Rt, FDt and MHt Group, respectively. Final BCVA was correlated with preoperative BCVA (R 0.74, p < 0.0001), postoperative CRT (R -0.49, p < 0.0001), and the recovery of IS/OS junction at 6 months (R 0.76, p < 0.0001). Few postoperative complications occurred.

CONCLUSIONS

Vitrectomy with ILM peeling results in favourable anatomic and functional outcomes for different patterns of myopic foveoschisis.

A Review of Current Myopic Foveoschisis Management Strategies

Myopic foveoschisis (MF) is common in highly myopic eyes with posterior staphyloma, and optical coherence tomography is essential for establishing the diagnosis and monitoring disease progression. Untreated MF may lead to significant visual loss due to secondary complications. Vitrectomy with or without internal limiting membrane peeling followed by gas tamponade is the standard treatment; however, in recent years, new techniques, including macular buckling, have been introduced. We selected a total of 41 articles with 30 describing various modifications of pars plana vitrectomy, six describing the macular buckling technique, and five reporting combined surgery. The present review describes current MF treatment strategies, including outcomes, and provides a comprehensive understanding of current therapeutic options. Early detection and surgical intervention in eyes with specific risk factors may contribute to both improved visual recovery and more favorable anatomical outcomes.

Relationship Between the Shift of the Retinal Artery Associated With Myopia and Ocular Response Analyzer Waveform Parameters

PURPOSE

We have recently reported that the retinal stretch due to myopia is closely related to the peripapillary retinal arteries angle (PRAA) (Yamashita et al., Invest Ophthalmol Vis Sci 2013;54:5481-5488). The purpose of the current study was to investigate the relationship between retinal artery position and Ocular Response Analyzer (ORA) waveform parameters.

METHODS

In 43 eyes of 41 healthy subjects, ORA measurements were carried out and the PRAA was calculated from fundus photographs. Then, the variables related to PRAA were identified from 40 variables of age, axial length (AL), keratometry, ORA corneal hysteresis (CH), ORA corneal resistant factor (CRF), and 35 ORA waveform parameters, using the Lasso regression and model selection with the second-order bias-corrected Akaike information criterion index.

RESULTS

The optimal model for PRAA included AL, CRF, and three ORA waveform parameters (aindex, w2, and slew1). This optimal model was significantly better than the model with AL-only, the model only with AL and CH, and the model only with AL and CRF (P < 0.0001, P < 0.0001, P < 0.0001, respectively; analysis of variance).

CONCLUSIONS

The PRAA was significantly better represented by using AL and ORA parameters including waveform parameters, compared with AL alone, with AL and CH alone, and with AL and CRF alone.

TRANSLATIONAL RELEVANCE

ORA waveform, which represents corneal biomechanical properties, was associated with myopic retinal stretch.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-term outcome of highly myopic foveoschisis treated by vitrectomy with or without gas tamponade

AIM

To evaluate the long-term safety and efficacy of vitrectomy and internal limiting membrane (ILM) peeling with or without gas tamponade for highly myopic foveoschisis.

METHODS

We performed an open-label, observer-blinded clinical trial of 85 patients with myopic foveoschisis between 2000 and 2012. Patients were randomly allocated to one of two groups, those who received vitrectomy and ILM peeling without gas tamponade (no-gas group) or those who with gas tamponade (gas group) and follow up at least 5y.

RESULTS

Visual acuity of gas group improved from 0.82±0.33 to 0.79±0.73 in 6mo, improved to 0.71±0.67 in 1y and within this range in the following 4y. Visual acuity of no-gas group improved from 0.81±0.46 to 0.78±0.66 in 6mo, improved to 0.70±0.65 in 1y. The finial visual acuity of two groups were significantly increased compared with the baseline (P<0.05). The visual acuity was improved in 35 of 40 eyes (87.5%) in gas group and 29 of 33 eyes (87.9%) in no-gas group, while there were no significant differences between gas group and no-gas group in the visual acuity. The foveoschisis on optical coherence tomography (OCT) completely resolved in 5 of 40 eyes in 1mo, 14 eyes in 6mo and 40 eyes in 1y in the gas group. While the foveoschisis completely resolved in 4 of 33 eyes in 1mo, 10 eyes in 6mo and 33 eyes in 1y in the no-gas group.

CONCLUSION

Vitrectomy and ILM peeling without gas tamponade appears to be as effective in the treatment of myopic foveoschisis as vitrectomy and ILM with gas tamponade. However, eyes treated with no-gas tamponade showed more rapid resolution of myopic foveoschisis.

Internal limiting membrane peeling and gas tamponade for myopic foveoschisis: a systematic review and meta-analysis

Background

Myopic foveoschisis (MF) is among the leading causes of visual loss in high myopia. However, it remains controversial whether internal limiting membrane (ILM) peeling or gas tamponade is necessary treatment option for MF.

Methods

PubMed, EMBASE, CBM, CNKI, WANFANG DATA and VIP databases were systematically reviewed. Outcome indicators were myopic foveoschisis resolution rate, visual acuity improvement and postoperative complications.

Results

Nine studies that included 239 eyes were selected. The proportion of resolution of foveoschisis was higher in ILM peeling group than non-ILM peeling group (OR = 2.15, 95% CI: 1.06–4.35; P = 0.03). The proportion of postoperative complications was higher in Tamponade group than non-Tamponade group (OR = 10.81, 95% CI: 1.26–93.02; P = 0.03). However, the proportion of visual acuity improvement (OR = 1.63, 95% CI: 0.56–4.80; P = 0.37) between ILM peeling group and non-ILM peeling group and the proportion of resolution of foveoschisis (OR = 1.80, 95% CI: 0.76–4.28; P = 0.18) between Tamponade group and non-Tamponade group were similar.

Conclusions

Vitrectomy with internal limiting membrane peeling could contribute to better resolution of myopic foveoschisis than non-peeling, however it does not significantly influence the proportion of visual acuity improvement and postoperative complications. Vitrectomy with gas tamponade is associated with more complications than non-tamponade and does not significantly influence the proportion of visual acuity improvement and resolution of myopic foveoschisis.

Electronic supplementary material

The online version of this article (10.1186/s12886-017-0562-8) contains supplementary material, which is available to authorized users.

Insight into high myopia and the macula

The incidence of myopia is constantly on the rise. Patients of high myopia and pathological myopia are young and can lose vision due to a number of degenerative changes occurring at the macula. With the emergence of new technologies such as swept-source optical coherence tomography (OCT) and OCT angiography, our understanding of macular pathology in myopia has improved significantly. New conditions such as myopic traction maculopathy have been defined. Early, noninvasive detection of myopic choroidal neovascularization and its differentiation from lacquer cracks is possible with a greater degree of certainty. We discuss the impact of these new exciting and promising technologies and management of macular pathology in myopia. Incorporation of OCT in the microscope has also improved macular surgery. New concepts such as fovea-sparing internal limiting membrane peeling have emerged. A review of literature and our experience in managing all these conditions are discussed.

RETINAL PHENOTYPE IN A CASE OF LCHAD/TFP DEFICIENCY WITH LATE-STAGE DIAGNOSIS

PURPOSE

To report the retinal phenotype of a rare case of long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD)/trifunctional protein (TFP) deficiency diagnosed in his late 40s with ocular findings of diffuse chorioretinal atrophy and bilateral retinoschisis.

METHODS

An acylcarnitine profile assay revealed LCHAD/TFP deficiency in a 45-year-old man with a history of high myopia, bilateral decreased vision, episodic rhabdomyolysis, and peripheral neuropathy. Ocular findings were evaluated with spectral domain optical coherence tomography (Spectralis OCT; Heidelberg Engineering, Heidelberg, Germany) and color fundus photography.

RESULTS

Spectral domain optical coherence tomography revealed severe bilateral macular retinoschisis. Subretinal fibrosis was noted in the left temporal macula with an associated lamellar macular hole. Fundus photographs demonstrated diffuse, symmetric chorioretinal atrophy characteristic of end-stage retinopathy, as previously reported in younger patients. Myopic staphylomas were evident in the posterior pole of both eyes. A trial of topical dorzolamide for 3 months resulted in no change in the retinal profile.

CONCLUSION

We report the retinal phenotype of a patient with LCHAD/TFP deficiency diagnosed later in life. To date, this is the oldest patient reported with LCHAD/TFP-associated retinopathy. Macular retinoschisis may represent a feature of the end-stage retinopathy due to the progressive myopia. The diagnosis of LCHAD/TFP deficiency should be considered in adult patients with a history rhabdomyolysis, neuropathy, and retinopathy, as they would not have undergone routine newborn screening before the late 90s.

Long-term follow-up of vitrectomy in patients with pathologic myopic foveoschisis

AIM

To report the long-term surgical outcomes of pathologic myopic foveoschisis (MF) following vitrectomy.

METHODS

We performed a retrospective case series analysis of 50 consecutive patients diagnosed with MF who experienced vision loss due to progression of foveoschisis. The 50 patients (67 eyes) were treated in our hospital with vitrectomy with internal limiting membrane (ILM) peeling from December 2004 to September 2010. Best corrected visual acuity (BCVA), refractive error, optical coherence tomography (OCT), and routine examination results were analysed. The changes of BCVA, foveal anatomical features on OCT scan, and complications were the main outcome measures.

RESULTS

The mean follow-up duration was 42±17mo (range 24 to 93mo). BCVA improved significantly postoperatively (0.76±0.65 logMAR) compared with preoperative baselines (1.31±0.78 logMAR, P<0.0001), and in 53 eyes (79%) including 3 lines gain in 44 eyes (66%) at the last follow-up visit. OCT scans showed that central retinal thickness decreased from 580.0±270.0 µm preoperatively (n=67) to 179.7±84.7 µm postoperatively (n=58, P<0.0001). Total resolution of foveoschisis occurred in 41 eyes (61%). Preoperative BCVA correlated well with postoperative BCVA, whereas other factors such as age, axial length, and refractive error were not correlated. The most common complications were cataract and full-thickness macular hole formation in 14 and 9 cases, respectively.

CONCLUSION

Patients with progressive vision loss due to MF who were treated with vitrectomy with ILM peeling show favourable outcomes. In most eyes, visual acuity and foveal structure remain stable during long-term observation.

VITRECTOMY WITHOUT INNER LIMITING MEMBRANE PEELING FOR MACULAR RETINOSCHISIS IN HIGHLY MYOPIC EYES

PURPOSE

To determine if it is necessary to peel inner limiting membrane during vitrectomy for macular retinoschisis in highly myopic eyes.

METHODS

This retrospective noncomparative interventional case series included 112 eyes of 84 patients with myopic foveoschisis who were treated by 23-gauge 3-port pars plana vitrectomy. During vitrectomy, triamcinolone acetonide was injected into the vitreous cavity to visualize the vitreous. The inner limiting membrane was not peeled, but the posterior hyaloid membrane was removed from the macular surface with active suction or a flute needle. A fluid-gas exchange was carried out using 16% perfluoropropane gas.

RESULTS

A total of 106 eyes (95%) exhibited collapse of the foveoschismatic intermediary zone after surgery. Best-corrected visual acuity at baseline and at the end of the follow-up did not differ significantly (1.06 ± 0.74 logarithm of the minimum angle of resolution versus 0.92 ± 0.56 logarithm of the minimum angle of resolution, P = 0.18). An improvement in best-corrected visual acuity of greater than 2 lines was achieved in 84 eyes (75%). A macular hole with retinal detachment was found in 6 eyes (5%) 1 to 8 months after surgery. Intraoperatively, all 112 eyes exhibited vitreous liquefaction. The posterior hyaloid membranes were tightly adherent to the posterior retinal surface and vessels except for 1 eye that had a complete posterior vitreous detachment. There were no or only a very small amount of triamcinolone acetonide particles attached to the surface of posterior retina in 38 eyes, which seemed that a completely posterior vitreous detachment had happened. But these membranes on the surface of the posterior retina can be removed easily, which indicated these membranes were posterior hyaloid membranes instead of internal limiting membranes.

CONCLUSION

In the treatment of macular retinoschisis in highly myopic eyes, vitrectomy associated with posterior hyaloid membranes peeling may achieve successful anatomical results. Internal limiting membrane peeling seems unnecessary.

Clinical utility of intraoperative optical coherence tomography

PURPOSE OF REVIEW

To explore the clinical utility of intraoperative optical coherence tomography (iOCT) for the management of vitreoretinal conditions.

RECENT FINDINGS

The role of iOCT in guiding surgical decision-making and surgical manipulations during vitreoretinal procedures has been evaluated by multiple studies. This imaging modality is emerging as a valuable asset during procedures for vitreoretinal interface disorders, retinal detachments, submacular surgeries and therapeutics, and in pediatric conditions such as retinopathy of prematurity. iOCT allows the surgeon to assess completion of surgical goals and to directly monitor the architectural impact of instrument-tissue interactions that may correlate with eventual prognosis. The technology has gone through numerous iterations with the eventual goal being the development of a user-friendly, efficient, and integrated system that provides surgeons with 'real-time' feedback during ophthalmic surgeries to allow for a comprehensive image-assisted vitreoretinal surgery platform.

SUMMARY

The role of iOCT in ophthalmic surgery has been evolving with the help of ongoing research to define its utility in the operating room and to develop integrative technologies. Advancements in OCT-friendly surgical instrumentation and in integrative capabilities of this technology may help achieve more widespread adoption of this technology in the vitreoretinal surgical theater. Although the evidence appears clear that this technology impacts surgical decision-making, additional research is needed. However, further research is needed to determine the influence of this technology on overall patient outcomes.

RISK FACTORS FOR DEVELOPMENT OF MACULAR HOLE RETINAL DETACHMENT AFTER PARS PLANA VITRECTOMY FOR PATHOLOGIC MYOPIC FOVEOSCHISIS

PURPOSE

To identify the risk factors for the development of macular hole retinal detachment (MHRD) after vitrectomy without internal limiting membrane peeling for pathologic MF.

METHODS

We retrospectively reviewed the records of 131 eyes (115 patients) treated with vitrectomy for pathologic MF from 2009 to 2014. The best-corrected visual acuity (BCVA), refractive error, axial length, and spectral-domain optical coherence tomography findings were analyzed.

RESULTS

Postoperative MHRD developed in 7 eyes (5.3%). Between patients with or without secondary MHRD after vitrectomy, there were no significant differences in age, sex, axial length, preoperative BCVA, refractive error, lens status, and presence of posterior staphyloma. Spectral-domain optical coherence tomography showed all 7 eyes (100%) had foveal detachment, while only 47 patients (37.9%) of 124 eyes had foveal detachment (P = 0.004). There was no significant difference between preoperative and postoperative BCVA in the 7 eyes with MHRD. The postoperative BCVA in the 124 eyes without MHRD was significantly improved (P < 0.001). Among the 124 eyes, both preoperative and postoperative BCVA of eyes with foveal detachment was worse than the eyes without foveal detachment (P < 0.001, respectively).

CONCLUSION

Preoperative foveal detachment is a risk factor for the development of MHRD after vitrectomy for pathologic MF.

Complications of Pathologic Myopia

Pathologic myopia (PM) is one of the leading causes of visual impairment worldwide. The pathophysiology of PM is not fully understood, but the axial elongation of the eye followed by chorioretinal thinning is suggested as a key mechanism. Pathologic myopia may lead to many complications such as chorioretinal atrophy, foveoschisis, choroidal neovascularization, rhegmatogenous retinal detachment, cataract, and glaucoma. Some complications affect visual acuity significantly, showing poor visual prognosis. This article aims to review the types, pathophysiology, treatment, and visual outcome of the complications of PM.

Spontaneous resolution of foveal detachment in traction maculopathy in high myopia unrelated to posterior vitreous detachment

BACKGROUND

Foveal detachment associated with foveoschisis usually takes a progressive course, and is associated with a poor visual outcome. The purpose of this study was to report the spontaneous resolution of foveal detachment in patients with myopic traction maculopathy without posterior vitreous detachment.

METHODS

A retrospective study involving eight cases of high myopia with foveoschisis and foveal detachment in which the subfoveal fluid had spontaneously resolved. The clinical characteristics and optical coherence tomography (OCT) findings were described.

RESULTS

All cases involved predominant schisis in the outer retina, with six showing internal limiting membrane detachment. The average central foveal thickness was 445.1 μm, and the average foveal detachment height was 271.5 μm. None of the cases involved traction of the vitreomacular interface or posterior vitreous detachment (PVD), either before or after the resolution of foveal detachment. In seven cases, the mean best-corrected visual acuity improved after foveal reattachment.

CONCLUSIONS

Spontaneous reattachment not associated with PVD can occur in cases of high myopic traction maculopathy, especially in those without obvious vitreomacular traction.

Myopic foveoschisis: a clinical review

To review the literature on epidemiology, clinical features, diagnostic imaging, natural history, management, therapeutic approaches, and prognosis of myopic foveoschisis. A systematic Pubmed search was conducted using search terms: myopia, myopic, staphyloma, foveoschisis, and myopic foveoschisis. The evidence base for each section was organised and reviewed. Where possible an authors' interpretation or conclusion is provided for each section. The term myopic foveoschisis was first coined in 1999. It is associated with posterior staphyloma in high myopia, and is often asymptomatic initially but progresses slowly, leading to loss of central vision from foveal detachment or macular hole formation. Optical coherence tomography is used to diagnose the splitting of the neural retina into a thicker inner layer and a thinner outer layer, but compound variants of the splits have been identified. Vitrectomy with an internal limiting membrane peel and gas tamponade is the preferred approach for eyes with vision decline. There has been a surge of new information on myopic foveoschisis. Advances in optical coherence tomography will continually improve our understanding of the pathogenesis of retinal splitting, and the mechanisms that lead to macular damage and visual loss. Currently, there is a good level of consensus that surgical intervention should be considered when there is progressive visual decline from myopic foveoschisis.

Late recurrence of myopic foveoschisis after successful repair with primary vitrectomy and incomplete membrane peeling

PURPOSE

To report three cases of late recurrence of myopic foveoschisis (MF) after initial successful repair with pars plana vitrectomy and membrane peeling to assess the importance of internal limiting membrane peeling.

METHODS

A retrospective noncomparative case series was performed of patients who underwent a primary pars plana vitrectomy by a single surgeon with successful resolution of MF, but eventually underwent repeat pars plana vitrectomy for recurrent MF. Best-corrected visual acuity, fundus photography, and optical coherence tomography were obtained at each examination.

RESULTS

Three eyes of three patients underwent pars plana vitrectomy for recurrent MF. Myopic foveoschisis recurrence occurred 6, 3.5, and 12 years after the primary vitrectomy, respectively. Repeat vitrectomy with staining and additional peeling of the internal limiting membrane resulted in good anatomical outcome and stabilization of visual acuity in all cases.

CONCLUSION

Late recurrence of MF after successful primary vitrectomy is described. Fibrocellular proliferation on residual cortical vitreous or incomplete internal limiting membrane peeling during the initial vitrectomy may underlie recurrence.

Vitreous tamponades in highly myopic eyes

The use of endotamponade agents has gained a major role in the management of macular complications of high myopia. Myopic foveoschisis and macular hole are the main macular complication of pathologic myopia, this growing condition that is a main cause of visual loss, especially in patients at a younger age. We discuss the physical properties and advantages and disadvantages of the main ocular tamponade agents used in the treatment of these diseases.

[Foveoschisis in highly myopic eyes: clinical and tomographic features]

INTRODUCTION

Foveoschisis is a rare condition in highly myopic eyes, characterized by intra-retinal cleavage associated with abnormalities of the vitreous cortex and occasionally cortical retraction. The natural history of foveoschisis is unpredictable. The functional prognosis is often favorable after surgical treatment.

MATERIALS AND METHODS

We report 7 cases of macular retinoschisis in highly myopic eyes. We describe the optical coherence tomographic features as well as associated signs. The correlation with visual acuity was assessed.

RESULTS

Foveoschisis was undetected on clinical exam and visualized only on optical coherence tomography (OCT) in 4 cases. Mean central foveal thickness was 540 , mean visual acuity was 1/10—P10. The thicker the macula was, the worse was the visual acuity. The presenceor absence of serous retinal detachment did not affect visual acuity, whereas an epiretinal membrane or retraction of the vitreous cortex appeared to induce visual loss.

CONCLUSION

OCT has been demonstrated to be particularly useful for the diagnosis of visual loss in the high myope, notably in the case of foveoschisis. Anatomic-functional correlations in high myopic foveoschisis are not yet well clarified. Posterior pole retinal detachment and macular hole are the most serious complications.

Natural course and surgical management of high myopic foveoschisis

PURPOSE

To describe the spectral-domain optical coherence tomographic characteristics, natural course and surgical management for eyes with myopic foveoschisis.

METHODS

The medical records of 39 consecutive patients (56 eyes) with myopic foveoschisis were retrospectively reviewed. Pars plana vitrectomy with internal limiting membrane peeling and Brilliant Blue G staining was performed on 16 symptomatic eyes (14 patients).

RESULTS

Optical coherence tomography at baseline showed an isolated foveoschisis in 62.5%, foveal detachment in 21.4%, and a lamellar hole in 16.1% of the eyes. After a mean follow-up period of 15.7 months, 1.8% of the eyes developed a full-thickness macular hole and 28.5% of the eyes required surgery. The mean preoperative visual acuity (VA) was 20/63 and the mean central retinal thickness (CRT) was 507.6 µm. The mean postoperative VA was 20/40 and the mean CRT 282.9 µm. Anatomical success was achieved in 75% of the eyes at a mean of 3.3 months after surgery, and 81.2% of the eyes had an improvement of 2 lines of VA.

CONCLUSION

Myopic foveoschisis remained stable in most eyes; however, 28.5% of the eyes had decreases in VA secondary to progression of the foveoschisis and required surgery.

Surgical outcomes of macular buckling techniques for macular retinoschisis in highly myopic eyes

PURPOSE

To report the anatomic and visual results following macular buckling for patients with macular retinoschisis related to high myopia.

METHODS

Thirty-nine highly myopic eyes (mean refractive error -16.7 D; range, -9 to -24 D) of 36 patients (mean age 59 years; range, 35-79 years) presenting with macular retinoschisis associated with a posterior staphyloma, who underwent combined vitrectomy and macular buckling were evaluated. Main outcome measures included best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) findings. Three cases were excluded due to short follow-up (less than 3 months). The mean follow-up was 16 months.

RESULTS

The mean BCVA increased from 0.76 to 0.43 LogMAR (p = 0.001). Visual acuity improved in 30 eyes (83.3%), remained stable in three eyes (8.3%) and decreased in three eyes (8.3%). OCT showed resolution of foveoschisis with foveal reattachment in all eyes. None of the evaluated patients developed a macular hole during follow-up.

CONCLUSION

Macular buckling associated with vitrectomy results in good anatomic and visual outcomes in patients with myopic foveoschisis.

The diversity of traction mechanisms in myopic traction maculopathy

PURPOSE

To identify the major traction mechanisms that cause myopic traction maculopathy and to determine whether surgery can be tailored successfully to the specific mechanism involved.

DESIGN

Nonrandomized, retrospective, interventional case series.

METHODS

We performed a chart review of consecutive patients who underwent vitreoretinal surgery for myopic traction maculopathy by a single surgeon at a tertiary referral center. Traction mechanisms were identified based on preoperative and intraoperative findings and postoperative response to a tailored surgical approach.

RESULTS

Six eyes of 6 patients with a minimum follow-up of 6 months were included. Major pathogenic traction mechanisms included perifoveal posterior vitreous detachment with vitreomacular traction in 3 eyes, noncompliance of native internal limiting membrane in 2 eyes, epiretinal membrane in 1 eye, and remnant cortical vitreous layer after posterior vitreous detachment in 1 eye. One eye exhibited 2 traction mechanisms. The surgical approach addressed only the major traction mechanism(s) identified in each eye. After surgery, the visual acuity improved by 2 lines or more in all eyes, and macular thickening resolved completely in 5 (83%) of 6 eyes and partially in the remaining eye.

CONCLUSIONS

The traction mechanisms causing myopic traction maculopathy are diverse. Vitreoretinal surgical repair for this condition is successful when the major traction mechanisms causing tautness of the inner retina are identified and relieved.

Non-full-thickness macular holes: a closer look

Lamellar macular holes and macular pseudoholes are non-full-thickness defects of retinal tissue involving the anatomic fovea, thereby affecting central visual acuity. Non-full-thickness macular holes have been associated with myriad ocular conditions. Originally, lamellar macular holes were described as secondary to diabetic macular edema and macular pseudoholes as idiopathic. The pathogenesis of secondary non-full-thickness macular defects was recently confirmed by spectral-domain optical coherence tomography. These may be mistaken for macular hole lesions, despite careful clinical examination. Careful biomicroscopic examination with a contact lens and optical coherence tomography help to ensure accurate diagnosis. Surgical management with or without air or gas tamponade improves visual acuity and foveal morphology in most eyes.