ECCENTRIC MACULAR HOLES AFTER VITRECTOMY WITH PEELING OF EPIMACULAR PROLIFERATION

Time course of eccentric macular hole formation after pars plana vitrectomy for epiretinal membrane detected by optical coherence tomography

Purpose

This case report aims to describe the detailed time course of eccentric macular hole (MH) formation following pars plana vitrectomy (PPV) for epiretinal membrane (ERM) treatment, using optical coherence tomography (OCT) images.

Observations

A 60-year-old male patient presented to our hospital with complaints of blurred vision and distortion in his left eye. He was diagnosed with an ERM in the affected eye and subsequently underwent PPV with internal limiting membrane peeling. The patient's initial postoperative course was unremarkable; however, one month later, macular edema worsened, as evidenced by OCT findings. Initially, the edema was observed in both nasal and temporal to the fovea. However, four months postoperatively, the retina fluid in the area nasal to the fovea resolved, and the resolution was delayed in the area temporal to the fovea. At 18 months postoperatively, an eccentric macular hole was detected in the temporal to the fovea. The patient remained asymptomatic, and at the two-year follow-up, the eccentric macular hole demonstrated no signs of enlargement.

Conclusions and Importance

This case demonstrates the progression of an unusual asymptomatic parafoveal full-thickness retinal hole after PPV for ERM treatment. Since the development of this condition may occur over a more extended postoperative period than previously reported, long-term patient monitoring is essential following ERM or MH surgery.

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.

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.

EFFECT OF LASER PHOTOCOAGULATION ON MACULAR EDEMA ASSOCIATED WITH MACULAR HOLES

PURPOSE

To report the outcomes of laser therapy to barricade eccentric full-thickness macular hole with associated cystoid macular edema.

METHODS

We report two patients who developed an eccentric full-thickness macular hole with persistent cystoid macular edema after pars plan vitrectomy with and without internal limiting membrane peel for epiretinal membrane and the results of argon laser therapy.

RESULTS

Barricade argon laser therapy was applied concentric to the full-thickness macular hole. Associated cystoid macular edema was noted to resolve within 1 to 3 months of therapy in both cases.

CONCLUSION

Barricade laser therapy surrounding a macular hole can lead to resolution of associated cystoid macular edema. Pathogenic mechanisms to explain this favorable outcome are discussed.

Postoperative eccentric macular holes after surgery for vitreomacular interface diseases

PURPOSE

To assess the incidence, clinical characteristics, and outcome of postoperative eccentric macular hole (ECMH) after epiretinal membrane (ERM), macular hole (MH), and idiopathic vitreomacular traction (VMT) surgery and discuss the underlying possible mechanisms.

METHODS

A retrospective study was carried out for 711 eyes of 711 consecutive patients who underwent 25-gauge pars plana vitrectomy (PPV) with ERM (396 eyes), MH (268 eyes), and VMT (47 eyes) surgery between 2010 and 2016. Mean follow-up time was 19 months.

RESULTS

Eight patients developed ECMH (1.12%). Four of the patients were ERM, three patients were idiopathic full thickness MH, and one patient was ERM and lamellar pseudohole. There was no ECMH in patients with VMT. The average time of hole formation after vitrectomy was 7.25 weeks with a range from 2 to 15 weeks. Three patients developed 2 ECMH, and others had 1 ECMH. The location of the ECMH was mostly in the temporal of fovea. All patients were asymptomatic. No retinal detachment or choroidal neovascularization occurred in any patient and no additional intervention was attempted in the postoperative period in any case.

CONCLUSION

Postoperative ECMH may be seen after vitreomacular interface surgery. They are mostly asymptomatic, usually do not require additional intervention and often located in the parafoveal area. ILM peeling-induced muller cell damage, residual ILM contraction, and iatrogenic trauma may play a role as the underlying cause in our case series.

TO PEEL OR NOT TO PEEL THE INTERNAL LIMITING MEMBRANE IN IDIOPATHIC EPIRETINAL MEMBRANES

BACKGROUND

Epiretinal membranes (ERMs) have been described for more than 150 years. Currently, they are a common indication for vitreoretinal surgery. Recently, there has been an increasing trend to peel the internal limiting membrane (ILM). Although ILM peeling has generally been accepted as a fundamental step in macular hole repair, its current role in ERM remains controversial.

METHODS

Literature review.

RESULTS

Proponents of ILM peeling argue that peeling of the ILM reduces the recurrence rate and facilitates a greater resolution of retinal folds. Opponents of ILM peeling show that the visual outcomes between eyes that undergo ILM peeling and those that do not have their ILM peeled are the same. Stripping of the ILM removes the Müller cell footplates, so it is reasonable to expect some Müller cell dysfunction. Adverse events such as eccentric paracentral macular holes, macular microscotomata, and retinal dimpling have been associated with ILM peeling.

CONCLUSION

Internal limiting membrane peeling does not improve the functional outcomes after ERM surgery. Internal limiting membrane peeling reduces ERM recurrences, but many recurrences are not clinically significant. It remains unclear what the long-term effects of ILM peeling are. We should err on the side of caution and avoid routine ILM peeling in primary idiopathic ERM cases and should reserve it for recurrent and high risk of recurrence cases.

Multiple extrafoveal macular holes following internal limiting membrane peeling

Objective

Internal limiting membrane (ILM) peeling has been the standard of treatment for macular holes. Besides, causing retinal nerve fiber layer surface abnormality, postoperative extrafoveal multiple retinal holes is a rare phenomenon following ILM peeling. We report an unusual complication of eight extrafoveal macular holes occurring following ILM peeling.

Case presentation

A 60-year-old male presented with complaints of decreased and distorted vision in the right eye. He was diagnosed as having epiretinal membrane with lamellar macular hole. He underwent 23G pars plana vitrectomy, brilliant blue assisted ILM peeling and fluid gas exchange. Intraoperatively, ILM was found to be adherent to the underlying neurosensory retina. One month after cataract surgery, he underwent YAG capsulotomy in the right eye. He complained of visual distortion. His fundus evaluation in the right eye showed multiple (eight) extrafoveal retinal holes temporal to the macula clustered together.

Conclusion

This case demonstrated that peeling of ILM, especially when it is adherent to the underlying neurosensory retina, may cause unwanted mechanical trauma to the inner retina. Glial apoptosis and neuronal degeneration may presumably play a role in delayed appearance of multiple (eight) extrafoveal macular holes, which has not been reported earlier.

Eccentric Macular Hole after Pars Plana Vitrectomy for Epiretinal Membrane Without Internal Limiting Membrane Peeling: A Case Report

Introduction

Postoperative eccentric macular hole formation is an uncommon complication after pars plana vitrectomy (PPV) without internal limiting membrane (ILM) peeling for the treatment of epiretinal membrane (ERM). We present a case of eccentric macular hole formation after PPV for ERM without ILM peeling.

Case report

A 68-year-old male patient presented with ERM and visual acuity of 6/24 in his left eye. He underwent 23-gauge PPV without ILM peeling for treatment of ERM. One week postoperatively the retina was attached and the epiretinal membrane was successfully removed, while visual acuity was 6/9. One month after PPV, a single eccentric retinal hole below the macula was detected using fundoscopy and subsequently confirmed by optical coherence tomography. At this time the visual acuity was 6/9 and the patient reported no symptoms. No further intervention was attempted and at the 9-month follow-up, the visual acuity and the size of the eccentric macular hole remained stable.

Conclusion

Eccentric macular holes can be developed after PPV even without ILM peeling and are usually managed conservatively by observation.

Eccentric Macular Hole after Pars Plana Vitrectomy for Idiopathic Macular Hole: A Case Report

Introduction

Postoperative eccentric macular hole (MH) formation is an uncommon complication after pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling for epiretinal membrane or MH treatment. Herein, we present a case of eccentric MH formation after PPV with ILM peeling for MH.

Case Description

A 72-year-old female patient underwent 23-gauge PPV with ILM peeling for idiopathic MH in her right eye. The visual acuity was 6/24 in the right eye. One week postoperatively the retina was attached and the MH seemed to be closed, while visual acuity was 6/12. One month after PPV, there was a single eccentric retinal hole below the macula, which was detected at the fundoscopy and was confirmed by OCT. The visual acuity was 6/9 and the patient referred no symptoms. No further intervention was attempted, and at the 6-month follow-up the visual acuity and the size of the eccentric MH remained stable.

Conclusions

Eccentric MHs can develop after PPV and are usually managed conservatively by observation.

Late development of a lamellar macular hole after the spontaneous separation of vitreoretinal traction: case report

PURPOSE

To report a case of epiretinal macular membrane and a lamellar macular hole developing after the spontaneous separation of an idiopathic vitreoretinal traction.

METHODS

Retrospective, observational, long follow-up of a case evaluated and documented with optical coherence tomography and managed with current therapies including pars plana vitrectomy.

RESULTS

Good anatomic and functional results with stable 20/30 best-corrected visual acuity.

CONCLUSIONS

The natural course of idiopathic vitreomacular traction has been documented during prolonged observation after its spontaneous separation from the fovea leading to the development of an epiretinal membrane and a lamellar macular hole.

Postoperative eccentric macular holes after vitrectomy and internal limiting membrane peeling

The purpose of this study was to describe the incidence, clinical characteristics, and outcome of eccentric macular holes presenting after vitrectomy and internal limiting membrane (ILM) peeling for the treatment of macular pathology and discuss the pathogenesis of holes formation. A retrospective, noncomparative, interventional case-series study of five patients who developed eccentric macular holes postoperatively following vitrectomy in 198 consecutive patients who underwent ILM peeling for idiopathic macular hole and epiretinal membrane formation between 2008 and 2015. Five patients (2.5 %) developed full-thickness eccentric macular holes postoperatively. Three patients presented with a single eccentric macular hole, one patient had an eccentric hole after a failed idiopathic macular hole surgery and one patient developed four eccentric macular holes. The mean diameter of the holes was 584 μm (range 206-1317 μm) and the average time of holes formation after vitrectomy was 27.7 weeks (range 1-140 weeks). Postoperative best-corrected visual acuity ranged from "counting fingers" to 20/25. The eyes with the holes distant from the fovea had the best final visual acuity. No further intervention was attempted and no complications occurred. The mean follow-up time was 26.8 months. The postoperative macular holes after vitrectomy and ILM peeling were variable in number, size, and time of appearance but remained stable and were not associated with any complications. The pathogenesis of macular holes is most consistent with contraction of the residual ILM or secondary epimacular proliferation probably stimulated by ILM peeling.

Relationship between Peeled Internal Limiting Membrane Area and Anatomic Outcomes following Macular Hole Surgery: A Quantitative Analysis

Purpose. To quantitatively evaluate the effects of peeled internal limiting membrane (ILM) area and anatomic outcomes following macular hole surgery using spectral domain optical coherence tomography (SD-OCT). Methods. Forty-one eyes in 37 consecutive patients with idiopathic, Gass stage 3-4 macular hole (MH) were enrolled in this retrospective comparative study. All patients were divided into 2 groups according to anatomic success or failure. Basal MH diameter, peeled ILM area, and MH height were calculated using SD-OCT. Other prognostic parameters, including age, stage, preoperative BCVA, and symptom duration were also assessed. Results. Thirty-two cases were classified as anatomic success, and 9 cases were classified as anatomic failure. Peeled ILM area was significantly wider and MH basal diameter was significantly less in the anatomic success group (p = 0.024 and 0.032, resp.). Other parameters did not demonstrate statistical significance. Conclusion. The findings of the present study show that the peeled ILM area can affect the anatomic outcomes of MH surgery.

Risk factors for development of full-thickness macular holes after pars plana vitrectomy for myopic foveoschisis

PURPOSE

To identify risk factors for development of secondary full-thickness macular holes after pars plana vitrectomy with internal limiting membrane (ILM) peeling for myopic foveoschisis.

DESIGN

Retrospective, interventional case series.

METHODS

We retrospectively reviewed the records of 42 eyes (42 patients) treated with pars plana vitrectomy (vitreous separation, internal limiting membrane peeling, and gas tamponade) for myopic foveoschisis with and without a retinal detachment but without a macular hole from January 2002 through June 2012. Cataract surgery was performed in all phakic eyes. Patients were followed up for 6 months after the initial surgery, and optical coherence tomography images were obtained at every visit. The factors associated with development of postoperative full-thickness macular holes were investigated.

RESULTS

A postoperative macular hole developed in 8 (19.0%) eyes. No significant correlations of age (P = .369), axial length (P = .113), visual acuity (P = .859), foveal status (P = .331), posterior staphyloma (P = 1.000), or chorioretinal atrophy (P = .837) were found between patients with and without secondary macular holes. Among the characteristics seen on the optical coherence tomography images, the percentage of eyes with an inner segment/outer segment junction defect was significantly (P = .013, Fisher exact test) higher in patients with a macular hole than in those without a macular hole. Logistic regression analysis showed that only an inner segment/outer segment junction defect (P = .018) was a significant risk factor for development of secondary macular holes.

CONCLUSIONS

Secondary macular holes can develop in myopic foveoschisis after pars plana vitrectomy with internal limiting membrane peeling. A preoperative inner segment/outer segment junction defect can be a risk factor for development of a macular hole.

Techniques, rationale, and outcomes of internal limiting membrane peeling

BACKGROUND

The internal limiting membrane represents the structural interface between the retina and the vitreous and has been postulated to serve several essential functions. Recently, internal limiting membrane peeling has been used in the treatment of a variety of retinal disorders. We review the history, techniques, rationale, and outcomes of internal limiting membrane peeling.

METHODS

A review of the literature.

RESULTS

Internal limiting membrane peeling has been used to successfully treat a variety of retinal disorders including macular hole, epiretinal membrane, diabetic macular edema, retinal vein occlusion, and others.

CONCLUSION

Internal limiting membrane peeling may serve as an important component in the armamentarium of retinal surgery.

Pneumatic tools for vitreoretinal surgery

One of the difficulties of microsurgery is learning how to control physiological tremors. The pneumatic tool eliminates the physiological tremor, but no tactile feedback is provided. The manual tremor when closing the forceps is completely eliminated and the exact target can be more easily grabbed. Forceps closure pressure can rise up to 50 psi, whereas the scissors can be used in two modes: multicut and proportional. When performing bimanual surgery the pedal range is divided into two steps: in the first step, the forceps are controlled, and in the second step, the forceps remain closed. At the same time the scissors start to work in the preselected mode. No adverse events occurred and no iatrogenic retinal breaks were produced. Precision and control sensation were a grateful surprise.