Individualized, spectral domain-optical coherence tomography-guided facedown posturing after macular hole surgery: minimizing treatment burden and maximizing outcome

Macular hole surgery follow-up with spectral domain-optical coherence tomography-guided facedown posturing

PURPOSE

The main treatment for macular hole (MH) is pars plana vitrectomy, with or without internal limiting membrane (ILM) peeling, followed by gas tamponade and face-down positioning (FDP). This study aims to present the anatomical and visual outcomes following MH repair with optical coherence tomography (OCT)-guided FDP.

METHODS

Thirty-two patients who underwent surgery for idiopathic MH were enrolled. The requirement for the prone position was lifted for those with MH closure observed under gas on postoperative day one OCT. Patients with unclosed MHs were instructed to maintain FDP until the 3rd day. Best-corrected visual acuity at preoperative, postoperative 1st month, and the last visit, closure time post-surgery, duration of prone position, and surgical success rate were recorded.

RESULTS

Among the patients, 21 underwent phacovitrectomy + ILM peeling + gas tamponade, while 11 had vitrectomy + ILM peeling + gas tamponade. On postoperative day one, 28 out of 32 MHs closed, with 3 closures on day 3 and one on day 5. There were 18 stage two (56.3%), 13 stage three (40.6%) and 1 stage four (3.1%) MHs. The mean minimum MH diameter was 381.75 ± 68.07 (min 260-max 517) microns. All patients with MH closure time over postoperative day one had non-combined vitrectomy instead of phacovitrectomy. No late complications were observed.

CONCLUSIONS

OCT-guided FDP approach yields excellent closure rates with no late complications and ensures good patient comfort.

Swept Source-Optical Coherence Tomography-Guided Facedown Posturing to Minimize Treatment Burden and Maximize Outcome after Macular Hole Surgery

We evaluated the closure of full-thickness macular holes (MHs) the day after surgery in minimizing the burden and maximizing patient outcomes. Herein, 25-gauge pars plana vitrectomy, internal limiting membrane peeling, and fluid-gas (20% sulfur hexafluoride) were performed for the treatment. Patients were instructed to remain in the facedown position until the confirmation of MH closure, and the position was discontinued in cases where the closure was confirmed. In total, 43 eyes of 43 patients, whose average age was 69.7 ± 8.6 years, were enrolled in this study. We used swept source (SS)-optical coherence tomography (OCT) for the confirmation of MH closure for gas-filled eyes and used spectral domain (SD)-OCT for the reconfirmation of MH closure after the gas volume was reduced to less than half of the vitreous cavity. MH closure was confirmed in 40 eyes (93%, the closure group) on the next day after surgery. The time from surgery to SS-OCT imaging was 24.7 h. Although facedown positioning was terminated in cases where MH closure was confirmed, there were no cases in which the MH was re-opened afterward. The basal and minimum MH size was significantly larger in the non-closure group than that in the closure group (p = 0.027, p = 0.043, respectively). Therefore, checking with SS-OCT the day after surgery and terminating facedown positioning in cases where MH closure was confirmed would be a useful method, removing a great burden for the elderly without sacrificing the MH closure rate.

Macular Holes: Main Clinical Presentations, Diagnosis, and Therapies

Macular holes are a spectrum of retinal diseases that comprehends full-thickness macular holes (FTMHs), refractory/recurrent macular holes, lamellar macular holes (LMHs), myopic macular holes (MMHs), traumatic macular holes, and macular holes secondary to other retinal pathologies or injuries. There are various classifications of the subtypes of macular hole, and only in recent times researchers defined a common nomenclature, especially thanks to the evolution in retinal imaging, offered by new instruments like the swept-source OCT. The proposed therapies for macular holes are different and range from a “wait-and-see” approach to the vitrectomy, with different results in each subtype of macular hole. This narrative review has the purpose to investigate the available evidence in literature to give a summary of the knowledge about these retinal pathologies.

Factors Associated with Anatomic Failure and Hole Reopening after Macular Hole Surgery

A macular hole (MH), particularly an idiopathic macular hole (IMH), is a common cause of central vision loss. Risk factors for nonidiopathic MH include high myopia, cystoid macular edema, inflammation, and trauma. MH is primarily diagnosed using slit-lamp microscopy and optical coherence tomography (OCT). Half of the patients with stage I MHs are treated conservatively and may show spontaneous resolution. The main treatment methods for MHs currently include vitrectomy and stripping of the internal limiting membrane (ILM). However, in some patients, surgery does not lead to anatomical closure. In this review, we summarize the factors influencing the anatomical closure of MHs and analyze the potential underlying mechanisms.

A structured exercise to relieve musculoskeletal pain caused by face-down posture after retinal surgery: a randomized controlled trial

Face-down posture after vitrectomy physically burdens patients. Despite being of significant concern for patients, the intraoperative pain and discomfort has not been of great interest to retinal surgeons or researchers. This randomized controlled trial evaluated the effect of a 3-day novel structured exercise on reducing musculoskeletal pain from the face-down posture in 61 participants (31 in the exercise group) who underwent vitrectomy. Among the subjects, the median age was 62 years, 42 were female, 42 had macular holes, and 19 had retinal detachments. Participants in the exercise group received initial education on the exercise and performed three daily active exercise sessions. After the sessions, the exercise group had median numeric pain scores of 2, 1, and 1 at the back neck, shoulder, and lower back, respectively, while the control group had corresponding scores of 5, 3, and 4, respectively. The exercise group reported significantly lower pain scores (P = .003, .039, and .006 for the back neck, shoulder, and lower back, respectively). Application of the structured exercise would alleviate the patients' position-induced postoperative physical burden, by reducing pain and discomfort.

Intraoperative Observation of a Macular Holes Using Optical Coherence Tomography

PURPOSE

This study aimed to observe intraoperative changes in macular hole (MH) form using intraoperative optical coherence tomography (iOCT).

METHODS

A total of 10 eyes from 10 patients with MH who underwent vitrectomy using iOCT from May 2015 to October 2015 at the Yamagata University Hospital were retrospectively evaluated. Accordingly, 25-gauge pars plana vitrectomy using iOCT with internal limiting membrane (ILM) peeling and sulfur hexafluoride gas tamponade was performed on each patient. During surgery, MHs were observed using iOCT over four points, namely, before posterior vitreous detachment (PVD) formation, after PVD formation, after ILM peeling, and after fluid-gas exchange. Thereafter, basal MH diameter and minimum aperture MH diameter were postoperatively analyzed.

RESULTS

Before PVD formation, after PVD formation, after ILM peeling, and after fluid-gas exchange, the mean basal MH diameters were 690.7 ± 268.4, 683.3 ± 274.2, 683.7 ± 269.5, and 668.3 ± 261.4 μm, while the mean minimum aperture MH diameters were 278.3 ± 165.2, 283.0 ± 170.2, 257.0 ± 127.8, and 188.0 ± 105.0 μm, respectively. The mean minimum aperture MH diameter decreased significantly after fluid-gas exchange (one-way repeated measures ANOVA, p < 0.05). None of the patients exhibited intraoperative closure of the MHs. However, MH closure was confirmed in all patients after the surgery.

CONCLUSION

None of the patients demonstrated intraoperative MHs closure. Accordingly, the minimum aperture MH diameter was the first change formation to close after fluid-gas exchange.

[Biomarkers in full-thickness and lamellar defects of the macula]

BACKGROUND

Biomarkers are characteristic biological measurable signs and objective parameters to detect the state of health. Besides functional and temporal factors, imaging biomarkers play an increasingly important role. In full-thickness and lamellar defects of the macula numerous imaging parameters have been described. This knowledge resulted in new classifications for both clinical pictures, which are based on important biomarkers of these clinical pictures and characteristic features of described subtypes.

METHODS

Imaging biomarkers for full-thickness and lamellar macular defects are described with respect to the classification and their functional prognostic importance. The importance of these biomarkers is presented.

RESULTS

The current classification of full-thickness and lamellar macular defects is based on structural biomarkers. Biomarkers are important for prognostic and therapeutic evaluation and they have an impact on the surgical strategy. There are various surgical strategies for treatment of full-thickness macular holes depending on the size of the foramen and other biomarkers. The inverted ILM flap technique improves the closure rate of large macular holes. In lamellar macular holes showing signs of progression an early surgical intervention results in a good anatomical and functional prognosis.

CONCLUSION

Multimodal diagnostics provide important preoperative, intraoperative, and postoperative features for macular holes and lamellar macular holes, which are essential biomarkers for the exact classification, the therapeutic strategy and for assessment of the prognosis.

Surgical Treatment of Idiopathic Macular Hole Using Different Types of Tamponades and Different Postoperative Positioning Regimens

Purpose

To compare the effect of different types of intraocular tamponade and different types of postoperative positioning on the closure of idiopathic macular hole (IMH).

Methods

Prospective randomized clinical trial enrolling 104 eyes of 100 patients (age, 57–87 years) undergoing MH surgery. All patients were operated on by an experienced surgeon using 25-gauge pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peeling. Patients were randomized according to the type of intraocular tamponade and postoperative positioning into the following four groups: SF6 + nonsupine reading position (n = 26) (group 1), air + nonsupine reading position (n = 25) (group 2), air + prone position (n = 26) (group 3), or SF6 + prone position (n = 27) (group 4). The follow-up period was 6 months.

Results

MH closure was achieved in 87 eyes (83.7 %) in the overall sample after the first surgery, with closure rates of 100%, 56%, 84.6%, and 92.6% in groups 1, 2, 3, and 4, respectively. The group 2 was significantly less successful compared to the other three groups (p < 0.05). MH of sizes ≤400 µm was closed in 97.2% of cases after the first surgery, with no significant differences between groups (p = 0.219). MH with sizes over 400 µm was closed in 70.9% of cases after the first surgery, with both groups with air tamponade being significantly less successful than group 1. The nonsupine reading position was subjected to a better subjective evaluation in terms of postoperative comfort and quality of sleep, with no differences between air and SF6 tamponade tolerance.

Conclusion

PPV with ILM peeling, intraocular tamponade, and positioning remains the basic surgical approach in the treatment of IMH. For MH ≤ 400 µm, a high closure rate can be achieved by combining air tamponade and nonsupine reading position. For macular holes >400 µm, the greatest anatomical success can be achieved by using the SF6 tamponade in combination with the nonsupine reading position.

Literature Review of Surgical Treatment in Idiopathic Full-Thickness Macular Hole

Purpose

To summarize current surgical techniques for treating primary macular holes (MHs).

Methods

We reviewed publications detailing surgical approaches to primary MHs, briefly described their protocols, and outlined their results.

Results

Currently, the technique for primary MH repair is pars plana vitrectomy, removing the posterior cortical vitreous, stripping the epiretinal membranes, and ending with intraocular gas tamponade. The evident benefit of peeling off the internal limiting membrane (ILM) was clearly shown for MHs at stages 2 to 4 by achieving an anatomical closure rate of >90%, even in large MH up to 650 µm. Newer MH surgical techniques include modification of ILM flap techniques, placing an autologous scaffolding of tissue within the hole, and cell therapy has shown to increase the closure rate of large and chronic macular holes, resulting in modest functional improvement in complicated MHs.

Conclusion

Since the turn of the century, the success rate of modern macular surgery has increased, even for large and chronic MHs. There seems to be no limit to novel concepts in MH surgery, which range from anatomical closure to those proposing natural restoration of visual function via stem cell therapy.

iOCT-assisted macular hole surgery: outcomes and utility from the DISCOVER study

BACKGROUND/AIMS

This study aimed to characterise the clinical outcomes and utility of intraoperative optical coherence tomography (iOCT)-assisted macular hole (MH) repair.

METHODS

This was a post hoc analysis of eyes in the D etermination of feasibility of I ntraoperative S pectral domain microscope C ombined/integrated O CT V isualization during E n face R etinal and ophthalmic surgery (DISCOVER) study undergoing surgical MH repair with use of iOCT. Functional and surgical outcome data were collected through 12 months postoperatively. MH closure rate, postoperative visual acuity (VA), percentage of cases in which iOCT provided valuable feedback and altered surgical decision making were measured.

RESULTS

Eighty-four eyes were included in this study. The mean preoperative VA measured 20/114. The mean postoperative VA improved to 20/68 (p<0.001) at month 1, 20/48 (p<0.001) at month 3 and 20/45 (p<0.001) at month 12 or later. In 43 cases (51%), surgeons reported that iOCT provided valuable information (eg, confirming release of vitreomacular traction and identification of occult residual membranes). In 10 cases (12%), iOCT data specifically altered surgical decision making. Postoperative day 1 transtamponade OCT confirmed tissue apposition and apparent hole closure in 74% of eyes (21/26). All five open holes on postoperative day 1 closed following positioning. Single-surgery MH closure was achieved in 97.6% of cases. One persistent MH was successfully closed with a subsequent surgical repair for a final overall closure rate of 98.8%. Due to chronicity and MH size, additional repair was not recommended for the single remaining persistent MH.

CONCLUSION

This study suggests that iOCT may have important utility in MH surgery, including impacting surgical decision making. iOCT-assisted MH surgery resulted in significant improvement in VA and high single-surgery success rate.

Feasibility and Safety of Intraoperative Optical Coherence Tomography-Guided Short-Term Posturing Prescription after Macular Hole Surgery

PURPOSE

To assess closure rate and visual outcome of a court of patients with macular hole (MH) who underwent surgical repair with intraoperative optical coherence tomography (iOCT)-confirmed MH closure and short-term postoperative face-down posturing (FDP). Secondary aim was to assess the correlation between iOCT and postoperative OCT at day 1.

METHODS

Retrospective clinical study conducted in the Miulli Hospital Acquaviva delle Fonti (Italy), enrolling patients with idiopathic MH who underwent 25-G pars plana vitrectomy plus internal limiting membrane peeling. During surgery, closure of MH was confirmed by iOCT and short-term FDP (12-24 h, until day-1 visit) was prescribed. All patients had measurement of best-corrected visual acuity (BCVA) and spectral domain-OCT before the surgery and during follow-up (at 1 day, 1 month, 3 months).

RESULTS

Twenty-nine eyes of 29 patients (14 males, 62.1%) were enrolled in the study. MH mean size was 451.7 ± 139.7 µm and baseline BCVA was 0.77 ± 0.26 logarithm of the minimum angle of resolution (LogMAR). MH was confirmed to be closed in 100% of patients intraoperatively (iOCT) and at OCT during early follow-up (1-3 days). Mean time of FDP was 18 ± 2.6 h. At 3 months, MH closure rate was 93%; 2 eyes -underwent secondary MH repair surgery. Final BCVA was 0.39 ± 0.22 LogMAR (p < 0.0001).

CONCLUSION

iOCT-based confirmation of MH closure could be a safe and useful tool for prescribing short-term FDP after surgery, with high closure rate and no additional complication. The execution of an OCT in the immediate postoperative days could be potentially unnecessary.

Pathogenesis and Management of Macular Hole: Review of Current Advances

Macular hole has been believed to be a disorder of vitreomacular interface, which forms as a result of abnormal vitreous traction from incomplete vitreous detachment. However, our recent studies demonstrated that dynamic forces, caused by mobile posterior cortical vitreous with fluid currents, exist already at early stages of macular hole development. Therefore, in eyes with flexible vitreous, the contributions of tractional forces due to vitreous shrinkage are unlikely. These facts indicate that in the development of idiopathic macular holes, there is a greater contribution of dynamic forces than has been previously reported. This review also evaluates the recent findings in the assessment of the idiopathic macular holes and the recent therapeutic strategies for optimal management. Inner limiting membrane is considered to improve anatomical closure rate; however, it is still questionable if peeling is necessary in holes less than 250 µm. There are plenty of publications indicating that in the management of small and medium size hole (less than 400 µm), use of long-lasting gas and face-down position is not always required; however, it may be necessary for the treatment of large holes. Ocriplasmin and expansile gas had been reported to be successful for management of small- and medium-sized holes and vitreomacular attachment.

Predictive Model for Macular Hole Closure Speed: Insights From Intraoperative Optical Coherence Tomography

Purpose

To establish a predictive model of macular hole (MH) closure speed.

Methods

This study was a post hoc analysis of eyes that underwent full-thickness MH repair in the prospective PIONEER intraoperative optical coherence tomography (iOCT) study. The Bioptigen SDOIS system was used for iOCT imaging. All patients underwent standard small-gauge vitrectomy with internal limiting membrane (ILM) peeling, gas tamponade, and postoperative facedown positioning. Before vitrectomy and after ILM peeling, various quantitative OCT measures related to MH were obtained, including MH geometry alterations and outer retinal features. Trans-gas OCT was performed on postoperative day 1 to evaluate MH closure. Univariate and multivariate analyses were conducted to identify predictors of early MH closure (i.e., postoperative day 1 [POD 1] closure).

Results

Thirty-two (86%) out of 37 eyes were confirmed for MH closure at POD 1. At 3 months, MH closure was achieved in 35 (95%) eyes. After multivariate logistic regression analyses, seven covariates were determined as predictors for MH closure. These seven covariates included age, ellipsoid zone-retinal pigment epithelium expansion following ILM peel, preincision minimal width, post-ILM peel MH depth, change in MH volume, change in minimum MH width, and change in MH depth. Using these seven covariates, the area under the curve was 0.974. Cross-validation analysis indicated that intraoperative change in MH volume, intraoperative change in minimal width, and preincision minimal width were the most robust predictors for early MH.

Conclusions

This study suggests that iOCT may be important in predicting MH closure speed and may be a surrogate for tissue properties/behavior. A future prospective clinical trial is needed to validate this model.

Translational Relevance

This study provides unique insights into the potential role of iOCT imaging in predicting retinal tissue behavior during MH repair.

Best surgical technique and outcomes for large macular holes: retrospective multicentre study in Japan

The purpose of this study was to compare the surgical outcomes of vitrectomy with conventional internal limiting membrane (C-ILM) peeling to that with the inverted ILM (I-ILM) flap technique for large macular holes (MHs). This was a retrospective chart review of consecutive cases with a large MH at nine hospitals in Japan. Among the 1342 eyes, 165 eyes of 165 cases met the inclusion criteria. The results for medium-large MHs with a diameter 400-550 μm were compared to that of eyes with an extra-large MH with a diameter >550 μm. In addition, the results of C-ILM peeling were compared to that of the I-ILM technique. In medium-large MHs, the closure rate was 95.2% (59/62) by C-ILM peeling and 100% (19/19) by the I-ILM technique. In extra-large MHs, the closure rate was 88.4% (38/43) by C-ILM peeling and 100% (41/41) by I-ILM. Although the difference between the two methods was not significant, the I-ILM technique was successful in 100% of the cases. Multiple logistic regression analysis showed the best-corrected visual acuity (BCVA) at 6 months was significantly associated with the preoperative BCVA, MH size, age and sex of the patient. Analyses of the eyes with extra-large MHs show that the surgical success is high, and the I-ILM technique is more effective for closure in eyes with extra-large MHs.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

INTERNAL LIMITING MEMBRANE PEELING-DEPENDENT RETINAL STRUCTURAL CHANGES AFTER VITRECTOMY IN RHEGMATOGENOUS RETINAL DETACHMENT

PURPOSE

To examine retinal changes after vitrectomy with internal limiting membrane (ILM) peeling, we used 3-dimensional optical coherence tomography (3D-OCT) in rhegmatogenous retinal detachment cases.

METHODS

The 68 eyes from 67 patients with rhegmatogenous retinal detachment were studied, including 35 detached macula cases (51%) and 33 attached macula cases. Internal limiting membrane peeling was performed with fine forceps after brilliant blue G staining. The 3D-OCT images were obtained with volume-rendering technologies from cross-sectional OCT images.

RESULTS

The 3D-OCT detected 45 eyes (66%) with ILM peeling-dependent retinal changes, including dissociated optic nerve fiber layer appearance, dimple sign, temporal macular thinning, ILM peeling area thinning, or forceps-related retinal thinning. The ILM peeled area was detectable in only 9 eyes with 3D-OCT, whereas it was undetectable in other 59 eyes. The dissociated optic nerve fiber layer appearance was detected in 8 of the total cases (12%), and dimple signs were observed in 14 cases (21%). Forceps-related thinning was also noted in eight cases (24%) of attached macula cases and in four cases (11%) of detached macula cases. No postoperative macular pucker was noted in the observational period.

CONCLUSION

The 3D-OCT clearly revealed spatial and time-dependent retinal changes after ILM peeling. The changes occurred in 2 months and remained thereafter.

Spectral domain optical coherence tomography-guided versus 1-week facedown-posturing after macular hole surgery

OBJECTIVE

To compare idiopathic full-thickness macular hole (FTMH) closure rates and postoperative best-corrected visual acuity (BCVA) between spectral domain optical coherence tomography (SD-OCT)-guided facedown posturing and conventional 1-week facedown posturing after macular hole surgery.

DESIGN

A retrospective comparative study.

PARTICIPANTS

Thirty-one consecutive eyes that underwent surgery for FTMH between July 2013 and September 2014 were divided into 2 groups.

METHODS

In the SD-OCT-guided group, SD-OCT was performed on the first day after surgery. If the macular hole was closed, the patient could assume any position but supine. If the hole was not closed on postoperative day 1, SD-OCT was performed daily for 1 week until the hole was closed, at which point the patient was asked to stop positioning. For the control group, patients were asked to keep facedown posturing for 1 week after surgery.

RESULTS

Mean length of follow-up for the SD-OCT-guided group and the control group was 188.3 (SD = 74.6) days and 216.7 (SD = 71.2) days, respectively. FTMH closure rate was 100% for both groups. Mean time for FTMH closure in the SD-OCT group was 1.2 days. There was no statistical difference in postoperative BCVA at the last visit between SD-OCT-guided (0.49 ± 0.3 logMAR) and control (0.50 ± 0.4 logMAR; p = 0.9422) groups.

CONCLUSIONS

No difference in FTMH closure rates was detected between the SD-OCT-guided facedown posturing group and the control group. SD-OCT-guided posturing may be used to shorten facedown positioning while maintaining a high success rate.

Sulfur hexafluoride (SF6) versus perfluoropropane (C3F8) tamponade and short term face-down position for macular hole repair: a randomized prospective study

Background

To compare early visual and anatomical outcomes after either sulfur hexafluoride (SF₆) or perfluoropropane (C₃F₈) tamponade for macular hole repair.

Methods

147 eyes affected by primary full-thickness macular hole underwent pars plana vitrectomy with dye assisted removal of the internal limiting membrane and gas tamponade. Prone position was prescribed for 48 h after surgery. All patients were divided into 3 groups depending on the size of the hole: small (<250 µm), medium (>250–<400 µm) or large (>400 µm). Eyes within the same group randomly received either SF₆ (70 eyes) or C₃F₈ (77 eyes). A complete ophthalmic evaluation, including best corrected visual acuity and anatomic status of the macular holes, was conducted preoperatively, at 1 week and 1 month after surgery. Macular hole volume was calculated using optical coherence tomography scans. The Wilcoxon Signed Ranks Test, the Mann–Whitney Test, the Spearman’s rank-order correlation coefficient and the study of variance for repeated measures were used for statistical analysis.

Results

Mean best-corrected visual acuity improved from 0.92 logMAR to 0.28 logMAR (P < 0.001). A reduction of the dimensions of macular holes was observed in all cases, with a total repair of 90 % (63/70 eyes) in the SF₆ group and 91 % in the C₃F₈ group (70/77 eyes). There was a negative correlation between the initial minor diameter, the volume of the hole and the rate of anatomic success.

Conclusions

Short-term anatomical and visual outcomes were similar in eyes treated with either SF₆ or C₃F₈, independently of the stage of the macular hole. The initial volume and the minor diameter of the hole may be considered as valid tools for predicting surgical success. Age and gender did not appear to have influenced the prognosis.

Minification of fundus optical coherence tomographic images in gas-filled eye

BACKGROUND

Optical coherence tomography (OCT) is being used increasingly to evaluate and manage a variety of retinal diseases, but not much is known about the minification of the OCT images in gas-filled eyes. The purpose of this study was to investigate the effect of gas-filled eyes on the size of the OCT images.

METHODS

This was retrospective case series of 81 consecutive eyes of 79 patients who had macular hole surgery between April 2012 and September 2014. Images of the optic disc were taken with a spectral domain-OCT instrument 2 days after surgery in gas-filled, pseudophakic eyes and from the same eyes but fluid-filled one month after the surgery. The vertical length, horizontal width, and the area of the optic disc were measured in the OCT images.

RESULTS

Clear images were obtained from 50 eyes of 49 patients (mean age 66.4 ± 5.9 years). The mean vertical length and mean horizontal width of the optic disc in the gas-filled eyes were about 25 % shorter than that of fluid-filled eyes (vertical, 1213.8 ± 170.5 and 1650.6 ± 195.9 μm, P < 0.01; horizontal, 1169.4 ± 143.1 and 1526.4 ± 219.9 μm, P < 0.01). The mean area of the optic disc was 1.12 ± 0.34 mm(2) in gas-filled eyes which was significantly smaller than that in fluid-filled eyes (1.88 ± 0.37 mm(2)) by 40.4 %.

CONCLUSIONS

The fundus images of gas-filled eyes are significantly smaller than that in the same fluid-filled eyes. The minification of the OCT images should be considered when analyzing images obtained from gas-filled eyes.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

UMIN000007517 . Date of registration: 3/21/2012.

Optimal management of idiopathic macular holes

This review evaluates the current surgical options for the management of idiopathic macular holes (IMHs), including vitrectomy, ocriplasmin (OCP), and expansile gas use, and discusses key background information to inform the choice of treatment. An evidence-based approach to selecting the best treatment option for the individual patient based on IMH characteristics and patient-specific factors is suggested. For holes without vitreomacular attachment (VMA), vitrectomy is the only option with three key surgical variables: whether to peel the inner limiting membrane (ILM), the type of tamponade agent to be used, and the requirement for postoperative face-down posturing. There is a general consensus that ILM peeling improves primary anatomical hole closure rate; however, in small holes (<250 µm), it is uncertain whether peeling is always required. It has been increasingly recognized that long-acting gas and face-down positioning are not always necessary in patients with small- and medium-sized holes, but large (>400 µm) and chronic holes (>1-year history) are usually treated with long-acting gas and posturing. Several studies on posturing and gas choice were carried out in combination with ILM peeling, which may also influence the gas and posturing requirement. Combined phacovitrectomy appears to offer more rapid visual recovery without affecting the long-term outcomes of vitrectomy for IMH. OCP is licensed for use in patients with small- or medium-sized holes and VMA. A greater success rate in using OCP has been reported in smaller holes, but further predictive factors for its success are needed to refine its use. It is important to counsel patients realistically regarding the rates of success with intravitreal OCP and its potential complications. Expansile gas can be considered as a further option in small holes with VMA; however, larger studies are required to provide guidance on its use.