SCLERAL IMBRICATION COMBINED WITH VITRECTOMY AND GAS TAMPONADE FOR REFRACTORY MACULAR HOLE RETINAL DETACHMENT ASSOCIATED WITH HIGH MYOPIA

Vitrectomy for retinal detachment associated with macular hole: Prognostic factor analysis under different axial length conditions

PURPOSE

To identify prognostic factors for complete anatomical success (CAS) under different axial length (AL) conditions after vitrectomy plus internal limiting membrane (ILM) peeling for retinal detachment associated with macular hole (MHRD).

METHODS

This retrospective study included 243 patients (251 eyes) with MHRD who underwent primary vitrectomy plus ILM peeling. Multivariate logistic regression explored prognostic factors for CAS in AL <30 mm and ≥ 30 mm groups.

RESULTS

Overall, 113 eyes (45.0% of 251) exhibited complete CAS after initial surgery. Eyes with CAS had greater best-corrected visual acuity improvement than eyes without CAS (p < 0.001). CAS was more common in eyes with AL < 30 mm (50.3% of 155) than in eyes with AL ≥ 30 mm (36.5%, 35/96; p = 0.032). In the AL < 30 mm group, CAS was associated with ILM insertion (odds ratio [OR], 2.824, 95% confidence interval [CI], 1.189-6.710; p = 0.019), silicone oil (SO)/perfluoropropane (C3F8) tamponade (SO: OR, 0.408, 95% CI, 0.191-0.873; C3F8: OR, 2.448, 95% CI, 1.145-5.234; p = 0.021) and staphyloma (OR, 0.318, 95% CI, 0.143-0.707; p = 0.005). In the AL ≥30 mm group, CAS was associated with ILM insertion (OR, 11.621, 95% CI, 2.557-52.813; p = 0.001), SO /C3F8 tamponade (SO: OR, 5.305, 95% CI, 1.206-23.334; C3F8: OR, 0.188, 95% CI, 0.043-0.829; p = 0.027) and age (OR, 0.928, 95% CI, 0.876-0.983; p = 0.011).

CONCLUSION

Vitrectomy plus ILM peeling can effectively treat MHRD but has limited efficacy in eyes with AL ≥ 30 mm. ILM insertion was associated with more frequent CAS at any AL. C3F8 tamponade yielded better outcomes with AL < 30 mm; SO tamponade yielded better outcomes with AL ≥ 30 mm.

Features of a well-timed macular hole closure related retinal regmatogenous detachment complicated by macular hole

The literature review deals with the analysis of the timing and surgical techniques of macular hole closure in patients with retinal detachment complicated by macular hole. Modern concepts of treatment tactics for this disease, its efficacy are analyzed. Benefits and drawbacks of each of the discussed surgical treatment methods are specified.

Are we facing an increasing surgical demand for high myopic traction maculopathies? A 12-year study from Hong Kong

PURPOSE

We aimed to investigate the longitudinal change in the number of surgically operated myopic traction maculopathies (MTM) cases at a tertiary eye centre.

METHODS

A retrospective study of all consecutive cases of surgically operated MTM over 12 years (2009-2020) was conducted in a myopia prevalent region. We compared outcomes among three groups: (1) myopic macular hole (MH), (2) myopic macular hole with retinal detachment (MHRD), and (3) myopic foveoschisis with retinal detachment (MFRD).

RESULTS

Fifty-one cases were included in the study (8 cases of MH, 33 cases of MHRD and 10 cases of MFRD). The overall mean age was 63.8 +/- 8.7 with a female preponderance (2:1). The mean age of the MH group (58.6) was significantly younger than the MHRD group (64.2) and MFRD group (66.6) (p = 0.02). Subgroup analysis using ATN classification did not show its correlation with both visual improvement and anatomical success. When comparing the first 6-year period (2009-2014) with the second 6-year period (2015-2020), there was a significant increase in the number of cases (p = 0.01).

CONCLUSION

We observe an increase in the number of surgically operated MTM. This follows the trend of the global rise in the prevalence of myopia and baby boomers entering retirement.

Human amniotic membrane for the treatment of large and refractory macular holes: a retrospective, multicentric, interventional study

Background

The purpose of the current study is to report the anatomical and functional results of off-label human amniotic membrane graft as primary intervention to repair large to giant macular holes and in reoperations when wide internal limiting membrane peeling was unsuccessful.

Methods

Retrospective chart review was carried out in five different centers to identify all cases that had undergone off-label human amniotic membrane graft for the treatment of large or failed macular holes (MH). Data collected included age, gender, other concomitant diagnosis, symptoms duration, lens status, number of previous surgeries, macular hole measurements (minimum and base linear diameters), mean post-operative follow-up (months), and pre- and post-operative best corrected visual acuity (BCVA). Main outcome measures were anatomical MH closure rates and final BCVA (in logMAR). Nonparametric Wilcoxon rank-sum test was used because the data was not normally distributed, a P values < 0.05 were considered statistically significant.

Results

Nineteen eyes of 19 patients were identified and included in the study. Mean age was 66.21 ± 14.96 years and predominantly females (84%). All eyes had successfully closed MH with a single intervention with no recurrences during a mean of 9 ± 3.87 months follow-up. The median BCVA in logMAR preoperative was 1.30 ± 0.44 (0.80–2.0), approximately 20/400 on Snellen chart and the median BCVA in logMAR postoperative was 1.0 ± 0.72 (0.4–3.0) approximately 20/200 (p < 0.0001) with median of three lines of visual improvement.

Conclusion

The use of human amniotic membrane graft seems to be a viable and effective alternative for the treatment of large and persistent macular holes. However, further larger prospective controlled studies are necessary to confirm our preliminary results of this new surgical technique.

Topical Review: Causes of Refractive Error After Silicone-oil Removal Combined with Cataract Surgery

SIGNIFICANCE

This review summarizes the main factors of refractive error after silicone oil removal combined with cataract surgery.The post-operative refractive results of silicone oil removal combined with cataract surgery are closely related to the patient's future vision quality. This report summarizes the factors that influence the difference between the actual post-operative refractive power and the pre-operatively predicted refractive power after silicone oil removal combined with cataract surgery, including axial length, anterior chamber depth, silicone oil, commonly used tools for measuring intraocular lens power, and intraocular lens power calculation formulas, among others. The aim of the report is to assist clinical and scientific research on the elimination of refractive error after silicone oil removal combined with cataract surgery.

Autologous full-thickness retinal transplant for refractory large macular holes

Background

Despite the constant refinement of techniques and surgical aids, extremely large and refractory macular holes continue to have poor surgical outcomes with the current standard of care. The objective of the present study is to assess the anatomical and functional outcomes, as well as the structural change through time, of the optical coherence tomography of patients with refractory macular holes treated with a full-thickness autologous retinal transplant.

Methods

Prospective, case series. We include patients with a clinical diagnosis of refractory macular holes with a minimum diameter of at least 500 µm. All the patients had a comprehensive ophthalmological examination, which included a best-corrected visual acuity assessment, fundus examination, and optical coherence analysis. All the patients underwent a 23-gauge pars plana vitrectomy with a full-thickness retinal transplant and silicone oil tamponade (5000 cs<). Follow-up was done at 1, 3, 6, and 12 months. Statistical analysis was done with a test for repeated measurements and Bonferroni correction, with an alpha value of 0.05 for statistical significance and a Mann-Whitney U test for nonparametric continuous variables.

Results

We enrolled 13 eyes from 13 patients (mean age: 67.15 years) with refractory macular holes, with a mean base diameter of 1615.38 ± 689.19 µm and a minimum diameter of 964.08 ± 709.77 µm. The closure rate after 12 months of follow-up was 76.92%. Six patients with a closed macular hole at the end of the follow-up had complete recovery of the myoid/ellipsoid layer. The remaining showed a 44.9% reduction of the initial gap. Most patients formed a pseudofovea and normalization of the internal retinal layers. Despite a positive trend toward visual recovery (p = 0.034), after the correction of the alpha value, the change lost its statistical significance. During follow-up, one patient developed mild proliferative vitreoretinopathy and epiretinal membrane without anatomical or functional consequences.

Conclusions

An autologous full-thickness retinal transplant may improve the anatomical and structural outcome of patients with refractory macular holes. The full safety profile of this new technique is still unknown. More studies are needed in order to assess functional changes through time.

Comparison of Internal Limiting Membrane Peeling and Flap Removal to Flap Insertion on Visual Outcomes in Highly Myopic Eyes with Macular-Hole Retinal Detachment

INTRODUCTION

To compare the morphological and visual outcomes after pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling and flap removal to that with flap insertion in eyes with myopic macular-hole retinal detachment (MHRD).

METHODS

Forty-six eyes of 45 patients with MHRD were studied. Eighteen eyes were treated by PPV with ILM peeling and flap removal and 28 eyes by flap insertion, respectively. The baseline characteristics and postoperative findings were compared between the 2 groups.

RESULTS

The average age of the cases was 70.0 ± 8.5 years. The best-corrected visual acuity (BCVA) improved, from 1.51 ± 0.14 to 1.31 ± 0.20 logMAR units in the flap removal group, and from 1.20 ± 0.10 to 0.88 ± 0.10 logMAR units in the flap insertion group (p = 0.049). A significantly larger number of MHs were closed in the flap insertion group (96 vs. 50% in the removed group; p < 0.001). Restoration of the ellipsoid zone (EZ) and external limiting membrane (ELM) was also better in the flap insertion group than in the flap removal group (EZ 14 vs. 6%, p = 0.003; ELM 36 vs. 6%, p < 0.001).

DISCUSSION

The technique of ILM peeling with flap insertion is more effective in closing the MH, and results in better BCVA and better restoration of the outer retinal microstructures than flap removal.

Pathologic myopia: an overview of the current understanding and interventions

Pathologic myopia is a major cause of low vision and blindness worldwide. Its social and economic burden has been demonstrated by epidemiological studies. There have been recent advances in the classification system for myopic maculopathy that enables clinicians to describe different types of lesions, including tessellated fundus, diffuse/patchy chorioretinal atrophy, macular atrophy, lacquer cracks, choroidal neovascularization (CNV), and Fuchs' spot, in a standardized format. From a therapeutic point of view, anti-vascular endothelial growth factor therapy has been established as first-line choice for myopic CNV. For myopic retinoschisis and macular holes with/without retinal detachment, pars plana vitrectomy has been generally accepted as an efficient strategy. Studies are being conducted to determine how to avoid the development of a postoperative macular hole and to improve the quality of vision after surgery. In recent years, studies have revealed preventive measures that can be taken against myopia progression, including low-dose atropine eyedrops and contact lens wearing with peripheral myopic defocusing.

A customized posterior scleral reinforcement for myopic macular hole with retinal detachment and posterior staphyloma: A case report

The author describes a customized posterior scleral reinforcement, its manufacturing method, the rationale of its therapeutic effect, and the surgical technique of its implantation. A 54-year-old female patient with a case history of myopic macular hole with retinal detachment and posterior staphyloma, refractory to pars plana vitrectomy and peeling of internal limiting membrane, underwent posterior scleral reinforcement treatment. Retinal reattachment and macular hole closure were obtained. Best corrected visual acuity increased from light perception to 20/160 Snellen. The pars plana vitrectomy is mandatory to remove vitreoretinal tractions and epiretinal membranes; furthermore, the internal limiting membrane peeling makes retina less rigid. However, it may not be sufficient to allow retinal reattachment and it plays no preventive role in limiting posterior staphyloma progression. The rationale of posterior scleral reinforcement is to reduce retinal stretching, to contain posterior staphyloma, and to limit its progression over time.

The effectiveness and safety of posterior scleral reinforcement with vitrectomy for myopic foveoschisis treatment: a systematic review and meta-analysis

PURPOSE

To investigate the effectiveness and safety of posterior scleral reinforcement (PSR) combined with vitrectomy for myopic foveoschisis (MF) treatment.

METHODS

We conducted a systematic review and meta-analysis. We evaluated the improvement of best-corrected visual acuity (BCVA) in logMAR unit, the percentage of patients with improved or stabled BCVA, benefit on axial length (AL), the retinal reattachment rate, the macular hole (MH) closure rate, as well as the complication rate.

RESULTS

Fourteen studies (311 eyes) were included. Overall, patients' BCVA improved - 0.46 (95% confidence interval [CI] - 0.52, - 0.40) logMAR unit, with 80% (95%CI 74%, 85%) benefiting from BCVA improvement and 6% (95%CI 3%, 10%) suffering from BCVA loss. Patients' AL was shortened by - 1.74 (95%CI - 2.92, - 0.57) mm, and for patients whose AL was ≥ 30 mm, the average benefit reached - 3.68 (95%CI - 4.59, - 2.77) mm. Ninety-three percent (95%CI 89%, 96%) of the patients achieved retinal reattachment, and 65% (95%CI 47%, 80%) of the MH was closed. Patients' central foveal thickness decreased; the MD was - 187.32 (95%CI - 206.25, - 168.40) mm. The pooled complication rate was 9% (95%CI 8%, 19%), with extrusion, choroidal atrophy, and choroidal neovascularization being the most common complications. Subgroup analysis indicated no statistical difference in BCVA improvement, AL change, retinal reattachment rate, and complication rate between patients with or without MH. Subgroup analysis indicated no statistical difference in the above four outcomes between the primary and the recurrent patients either. There was no statistical difference in the above four outcomes no matter ILM peeling was combined or not.

CONCLUSION

PSR combined with vitrectomy helps improve 80% MF patients' BCVA; the average benefit on BCVA is - 0.46 logMAR unit. The average change in AL is - 1.74 mm; patients with AL ≥ 30 mm benefit much more than the patients with AL < 30 mm. The retinal reattachment rate is up to 93%; the MH closure rate is 65%. About 9% patients will suffer from extrusion, choroidal atrophy, choroidal neovascularization, and other complications. The outcomes were not influenced by presence of MH, disease recurrence, or ILM peeling.

Vitrectomy with inverted internal limiting membrane flap versus internal limiting membrane peeling for macular hole retinal detachment in high myopia: a systematic review of literature and meta-analysis

PURPOSE

To evaluate the effect of vitrectomy with inverted internal limiting membrane (ILM) flap for the treatment of macular hole retinal detachment (MHRD) in high myopia compared with that of ILM peeling.

METHODS

PubMed, EMBASE, Web of Science, MEDLINE, Ovid, Wan Fang and CNKI were systematically reviewed. The primary outcome parameters were the MH closure rate, retinal reattachment rate and postoperative BCVA. Secondary outcome parameters, included intraoperative or postoperative complications.

RESULTS

Seven retrospective comparative studies including 228 eyes were selected. No significant difference was detected in either postoperative BCVA (MD -0.07; 95% CI: -0.17 to 0.03; p = 0.16) or the improvement in postoperative BCVA (MD -0.17; 95% CI: -0.50 to 0.16; p = 0.32) between the ILM flap group and ILM peeling group. The retinal reattachment rate using inverted ILM flap was not significantly different from that using ILM peeling (odds ratio (OR) 2.24; 95% CI: 0.75-6.73; p = 0.15). The MH closure rate was higher with inverted ILM flap than with ILM peeling (OR 11.86; 95% CI: 5.65 to 24.92; p < 0.00001). There was no significant difference in intraoperative or postoperative complications, including concomitant cataract rate (OR 1.22; 95% CI: 0.42-3.58; p = 0.71).

CONCLUSION

The inverted ILM flap technique could contribute to a higher MH closure rate than ILM peeling, but visual improvement was similar. Both surgical methods could obtain a high-retinal reattachment rate with fewer intraoperative and postoperative complications.

Autologous Retinal Transplant for Refractory Macular Holes: Multicenter International Collaborative Study Group

PURPOSE

To report the structural and functional outcomes of autologous neurosensory retinal transplant for closure of refractory large macular holes (MHs).

DESIGN

Multicenter, retrospective, consecutive case series.

PARTICIPANTS

A total of 41 eyes of 41 patients with a full-thickness MH refractory to prior vitrectomy with internal limiting membrane (ILM) peel and tamponade.

METHODS

All patients underwent pars plana vitrectomy, autologous neurosensory retinal transplant with gas, silicone oil tamponade, or short-term perfluoro-n-octane heavy-liquid tamponade. All patients had at least 6 months' follow-up.

MAIN OUTCOME MEASURES

Anatomic closure of MH, change in ellipsoid zone (EZ) and external limiting membrane (ELM) defect on OCT, visual acuity (VA) recovery, and surgical complications were analyzed.

RESULTS

Mean number of prior surgeries was 1.5±0.94 (range, 1-3), and patients were followed for a mean of 11.1±7.7 months (range, 6-36 months). Complete anatomic closure of MH by OCT was achieved in 36 of 41 eyes (87.8%). Mean corrected VA (logarithm of the minimum angle of resolution [logMAR]) improved (P = 0.03) from 1.11±0.66 (range, 0.48-3) to 1.03±0.51 (range, 0.1-2) at the last postoperative visit. The VA improved (≥0.3 logMAR units) in 15 eyes (36.6%), was stable in 17 eyes (41.5%), and worsened in 9 eyes (21.9%). Among eyes with anatomic closure, VA improved in 52.3% and worsened in 13.8%, whereas in those without closure, VA worsened in 40% and improved in none. Mean preoperative largest basal diameter was 1468.1±656.4 μm (range, 621-2600 μm), and mean inner-opening diameter was 825±422.5 μm (range, 336-1649 μm). Mean preoperative EZ defect was 1777.3±513.8 μm (range, 963-2808 μm), which decreased to 1370±556.9 μm (range, 288-2000 μm) at final follow-up (P = 0.007). Mean preoperative ELM was 1681.5±429 μm (range, 1172-2606 μm), which decreased to 1408.5±571.2 μm (range, 200-2000 μm) at final follow-up (P = 0.017). Major postoperative complications were retinal detachment (n = 1) and vitreous hemorrhage (n = 1). There were no cases of proliferative vitreoretinopathy, endophthalmitis, suprachoroidal hemorrhage, or choroidal neovascularization.

CONCLUSIONS

The autologous retinal transplant technique offers a high degree of anatomic success and proved safe in this initial experience for closure of refractory MHs.

Autologous Neurosensory Retinal Free Flap Treatment for a Large Macular Hole

A patient presented with a large chronic macular hole (MH) of 700 μm. Best-corrected visual acuity (BCVA) was 20/200. Since the MHs edges were attached and stiff, an autologous neurosensory retinal flap was harvested and placed into the MH to close it. Perfluoro-n-octane heavy liquid (PFC) was instilled over the flap and exchanged with silicone oil (1,000 cs). Seven days postoperatively, the MH was closed, with a BCVA of 20/80 that improved to 20/60 at months 1 and 3. Optical coherence tomography and angiography showed patch incorporation with fovea formation and normal circulation. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e89-e92.].

Macular buckle technique in myopic traction maculopathy: a 16-year review of the literature and a comparison with vitreous surgery

PURPOSE

The aim of this study is to review anatomical and functional outcomes following macular buckling (MB) in high myopia and to compare such results with those obtained by pars plana vitrectomy (PPV).

METHODS

PubMed articles on MB in high myopia (2000-2016) were reviewed. Main outcomes included retinal reattachment and macular hole (MH) closure rates, resolution of myopic foveoschisis (MFS), and postoperative visual acuity.

RESULTS

Thirty-one articles included 16 in patients with retinal detachment due to MH (MHRD group), 11 in MFS with or without foveal detachment (MFS group), and 4 in MH patients with MFS (MH-MFS group). Surgical techniques mainly differed in the type of buckle, rectus muscles involvement, and concurrent PPV. In eyes with persistent MH, prognosis in the MHRD and MH-MFS groups differed between eyes receiving MB compared to PPV: functional outcome was markedly poorer and there was a higher risk of retinal redetachment associated with PPV. In the MSF group, secondary MHs were more likely to develop in eyes treated with PPV and internal limiting membrane peeling than those undergoing MB alone or combined with PPV. Retinal pigment epithelium changes, malpositioning, perforation, and choroidal detachment were the main complications.

CONCLUSIONS

Although different approaches are used, complete resolution of foveoschisis, retinal reattachment, and MH closure seem to be achieved more frequently with MB than PPV.

Posterior scleral reinforcement using genipin-cross-linked sclera for macular hole retinal detachment in highly myopic eyes

Background/aims

To investigate the surgical outcomes of posterior scleral reinforcement (PSR) using genipin-cross-linked sclera to treat macular hole retinal detachment (MHRD) in highly myopic eyes.

Methods

Nineteen patients with high myopia (19 eyes) with MHRD were treated sequentially with genipin-cross-linked PSR and were followed at least for 1 year after the surgery. The best corrected visual acuity (BCVA), axial length (AL), optical coherence tomography (OCT) outcomes and the complications were evaluated.

Results

Macular hole was closed in 73.7% of the eyes, foveal reattachment rate was 100%. The mean logMAR BCVA improved from 1.27±0.55 preoperatively to 0.88±0.55 postoperatively. The preoperative AL (29.88±1.97 mm) was decreased (27.73±1.84 mm) after the operation (p<0.001).

Conclusions

For at least a 1-year period of follow-up, PSR with genipin-cross-linked sclera should be considered as a preferred surgical approach to treat MHRD in highly myopic eyes, especially when foveal retinoschisis is also documented.

Vitrectomy with a modified temporal inverted limiting membrane flap to reconstruct the foveolar architecture for macular hole retinal detachment in highly myopic eyes

PURPOSE

We investigated the surgical results of macular hole retinal detachment (MHRD) with a modified C-shaped temporal inverted internal limiting membrane (ILM) flap to reconstruct the foveolar architecture in highly myopic eyes.

METHODS

Eighteen highly myopic eyes with MHRD in 17 patients who underwent a vitrectomy with a modified C-shaped temporal inverted ILM flap were followed for 12 months. Anatomic outcomes were evaluated by fundus examinations and optical coherence tomography. The preoperative and postoperative best-corrected visual acuities (BCVAs) were compared as functional outcomes.

RESULTS

Women accounted for 88% of the MHRD patients. The mean age was 60.2 ± 8.2 years. The mean axial length was 29.25 ± 2.10 mm. Type 1 and type 2 MHRD was present in four eyes and 14 eyes, respectively. After a single surgery, the hole was closed in 18 eyes (100%). Retinal attachment was achieved in 95%. Persistent shallow subretinal fluid (SRF) was noted in one case, which was resolved at follow-up. The surgery significantly improved BCVAs (from 1.7 ± 0.6 to 0.72 ± 0.4 logarithm of the minimum angle of resolution units [p < 0.001]) at the last visit. In total, 94.4% of the eyes had restored foveolar architecture. Ellipsoid zone recovery within the foveola was found in 77.8% of the eyes.

CONCLUSION

A vitrectomy and modified C-shaped inverted temporal ILM flap is effective for closing MHs, reattaching the retina, restoring the foveolar architecture and significantly improving the postoperative BCVA in MHRD patients. This technique is feasible, and we propose 'presumed' Müller cell cone repair in MHRD surgery.

Vitrectomy with internal limiting membrane peeling versus inverted internal limiting membrane flap technique for macular hole-induced retinal detachment: a systematic review of literature and meta-analysis

BACKGROUND

To evaluate the effects on vitrectomy with internal limiting membrane (ILM) peeling versus vitrectomy with inverted internal limiting membrane flap technique for macular hole-induced retinal detachment (MHRD).

METHODS

Pubmed, Cochrane Library, and Embase were systematically searched for studies that compared ILM peeling with inverted ILM flap technique for macular hole-induced retinal detachment. The primary outcomes are the rate of retinal reattachment and the rate of macular hole closure 6 months later after initial surgery, the secondary outcome is the postoperative best-corrected visual acuity (BCVA) 6 months later after initial surgery.

RESULTS

Four studies that included 98 eyes were selected. All the included studies were retrospective comparative studies. The preoperative best-corrected visual acuity was equal between ILM peeling and inverted ILM flap technique groups. It was indicated that the rate of retinal reattachment (odds ratio (OR) = 0.14, 95% confidence interval (CI):0.03 to 0.69; P = 0.02) and macular hole closure (OR = 0.06, 95% CI:0.02 to 0.19; P < 0.00001) after initial surgery was higher in the group of vitrectomy with inverted ILM flap technique than that in the group of vitrectomy with ILM peeling. However, there was no statistically significant difference in postoperative best-corrected visual acuity (mean difference (MD) 0.18 logarithm of the minimum angle of resolution; 95% CI -0.06 to 0.43 ; P = 0.14) between the two surgery groups.

CONCLUSION

Compared with ILM peeling, vitrectomy with inverted ILM flap technique resulted significantly higher of the rate of retinal reattachment and macular hole closure, but seemed does not improve postoperative best-corrected visual acuity.

Utility of microscope-integrated optical coherence tomography (MIOCT) in the treatment of myopic macular hole retinal detachment

Macular hole-associated retinal detachment in high myopia is described as a final stage in progression of myopic traction maculopathy (MTM).^1â€"3 Shimada et al⁴ described the progressive stages of MTM from macular retinoschisis to serous retinal detachment in high myopia. Stage 4 MTM is characterised as disappearance of retinoschisis with progression to retinal detachment due to macular hole formation. It is hypothesised that vitreoschisis and abnormal vitreo-retinal interface create the premacular tangential traction.^{5 6} Intraoperative triamcinolone acetonide is used to visualise the residual posterior vitreous cortex (PVC). We hereby describe the utility of microscope-integrated optical coherence tomography (MIOCT) in assisting complete removal of PVC and internal limiting membrane (ILM) peeling with multilayered inverted ILM flap in the treatment of myopic macular hole retinal detachment. MIOCT helped identify vitreoschisis and confirm the position of ILM flaps over the macular hole intraoperatively.

Ultra-widefield fundus imaging in gas-filled eyes after vitrectomy

Background

To evaluate the quality of the images obtained by an ultra-widefield device in gas-filled eyes after vitrectomy for a retinal detachment.

Methods

Retrospective case series. The ultra-widefield scanning laser ophthalmoscopic images (Optos 200Tx imaging system) of 40 eyes that were gas-filled with 40 to 90% of the vitreous cavity after vitrectomy for a rhegmatogenous retinal detachment were studied. The rates of detecting the rates of reattachments and the causative retinal tears that were treated and were in the superior or inferior areas in eyes with intravitreal gas of ≥60% were compared to that to eyes with intravitreal gas of <60% of the vitreous cavity. The widefield images recorded with 532 nm (green) or 633 nm (red) wavelength laser lights were compared to determine which wavelength had clearer images in 20 eyes of retinal detachment with superior retinal tears and were more than 50% gas-filled.

Results

The ultra-widefield images showed a retinal reattachment in all eyes on postoperative days 1 to 40 (mean; 8.7 ± 7.5 days). A superior retinal break was not visible in 5 of 26 eyes due to a reflection from the intravitreal gas bubbles when the gas was <60%. However, the superior retinal breaks were visible when the patients were requested to gaze downward to reduce the reflection of the gas bubble. The retinal breaks treated with laser burns and the retinal vasculature were imaged better with green laser than red laser light, and the choroidal vasculature was seen better with red laser light.

Conclusions

Ultra-widefield fundus images can be used to evaluate and document the retinal breaks and retinal reattachments in gas-filled eyes. The green and red laser lights can image different depths of the retina and choroid in gas-filled eyes.

SCLERAL IMBRICATION COMBINED WITH PARS PLANA VITRECTOMY WITHOUT INTERNAL LIMITING MEMBRANE PEELING FOR MYOPIC SCHISIS

PURPOSE

We investigated whether scleral imbrication combined with pars plana vitrectomy without internal limiting membrane peeling would be effective in treating eyes with myopic macular schisis.

METHODS

In this retrospective, interventional case series, 8 eyes of 8 patients with myopic retinoschisis without a macular hole were studied. Scleral imbrication was done with 6-mm-wide mattress sutures placed at the temporal quadrants. Pars plana vitrectomy and removal of the vitreous cortex were performed, but the internal limiting membrane was not removed. The best-corrected visual acuity was measured, and the retinal morphology was determined by spectral-domain optical coherence tomography before and at 6 and 12 months postoperatively.

RESULTS

The mean age of the subjects was 67.1 years. The best-corrected visual acuity improved from 0.71 ± 0.25 to 0.36 ± 0.19 logarithm of the minimum angle of resolution units (Snellen equivalent: from 20/100 to 20/50) at 12 months (P = 0.028). The axial length was shortened from 29.5 ± 1.7 to 28.5 ± 2.5 at 12 months (P = 0.012). The central foveal thickness decreased from 540 ± 171 μm to 170 ± 85 μm at 12 months (P = 0.012). In the 6 macular-detached eyes, 5 eyes (83%) had a complete resolution. The curvature of posterior eye wall was flatter at 12 months (P = 0.049). No retinal complications were observed.

CONCLUSION

Scleral imbrication combined with pars plana vitrectomy can be an effective method of treating myopic schisis.

Effectiveness of combined macular buckle under direct vision and vitrectomy with ILM peeling in refractory macular hole retinal detachment with extreme high axial myopia: a 24-month comparative study

Purpose

To evaluate the efficacy of a combined macular buckle under direct vision and 23-gauge pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling in refractory macular hole retinal detachment (MHRD) with extreme high axial myopia.

Design

Prospective, randomised controlled study.

Participants

The study included 98 eyes of 98 patients of MHRD with extreme high axial (>30 mm) myopia.

Intervention

Patients were randomly assigned to undergo PPV with ILM peeling (group 1, n=52) or PPV with ILM peeling combined with macular buckle under direct vision (group 2, n=46).

Main outcome measures

Complete ocular examination included best-corrected visual acuity (BCVA) (LogMAR), applanation tonometry, optical biometry, slit-lamp biomicroscopy, colour fundus photography, ultrasound examination and optical coherence tomography at baseline and every follow-up visit.

Results

Initial retinal reattachment rate was significantly higher in group 2 than in group 1 at 12-month postoperatively (χ² test, p=0.020). Macular hole closure rate in group 2 was significantly higher than that in group 1 at 3, 12, 18 and 24 months postoperatively (Fisher's exact test, p<0.05). In initial retinal reattachment cases, the mean BCVA decreased significantly in group 2 than in group 1 at 3 months postoperatively (Wilcoxon matched pairs signed rank test, p=0.036), and had increased significantly in group 2 than in group 1 since 6 months postoperatively (Wilcoxon matched pairs signed rank test, p<0.05). Mean axial lengths in group 2 were significantly shorter than that of group 1 at each follow-up time point (Wilcoxon matched pairs signed rank test, p<0.05).

Conclusions

Combined macular buckle under direct vision and PPV with ILM peeling is more effective in treatment of MHRD with extreme high axial (>30 mm) myopia.

Clinical Investigation of the Posterior scleral contraction to Treat Macular Traction Maculopathy in Highly Myopic Eyes

Myopic traction maculopathy (MTM) can cause vision disabilities in highly myopic eyes. This retrospective case series investigated the clinical outcomes of posterior scleral contraction (PSC) using genipin-cross-linked sclera as the material to treat MTM in highly myopic eyes. In total, 32 eyes from 29 highly myopic patients who underwent PSC for MTM were recruited. The changes in best-corrected visual acuity (BCVA) and axial length were evaluated, macular reattachment and macular hole (MH) closure was assessed by optical coherence tomography, and complications were evaluated. At the final follow-up, the retina was completely reattached in 25 eyes (78.1%), essentially reattached in 4 eyes (12.5%), and partially reattached in 3 eyes (9.4%). The logMAR BCVA improved significantly from 1.18 ± 0.45 preoperatively to 0.87 ± 0.45 postoperatively (P < 0.001). The 32 eyes were further divided into the MH group (16 eyes) and the non-MH group (16 eyes) for comparison. The MH was closed in 9 eyes (56.3%). The retinal reattachment rate was 75.0% in the MH group and 81.25% in the non-MH group, and the logMAR BCVA improved significantly in both groups. The PSC using genipin-cross-linked sclera as the material can effectively treat MTM in highly myopic eyes, and significant visual improvement can be achieved with minimal complications.

Vitrectomy and scleral imbrication in patients with myopic traction maculopathy and macular hole retinal detachment

Purpose

To determine the outcomes of vitrectomy with scleral imbrication in highly myopic eyes with either myopic traction maculopathy (MTM) or macular hole retinal detachment (MHRD).

Methods

The medical records of 17 patients who had undergone vitrectomy with internal limiting membrane (ILM) peeling and scleral imbrication for MTM or MHRD were reviewed. The best-corrected visual acuities (BCVAs), the axial length, the macular hole (MH) closure rate, and the shape of the posterior segment determined by optical coherence tomography were evaluated. Three-dimensional magnetic resonance imaging (3D-MRI) was also performed on five eyes.

Results

The postoperative BCVA improved significantly from 0.76 ± 0.39 logarithm of the minimum angle of resolution (logMAR) units to 0.53 ± 0.35 logMAR units (P = 0.0004). The axial length decreased from 29.42 ± 1.81 mm to 27.97 ± 1.71 mm at 1 month. The MTM was resolved or decreased in all eyes. The MH was closed in 44 % of the MHRD eyes, and the retina was reattached in all of the MHRD eyes. The horizontal distance between the optic disc and the bottom of the posterior staphyloma was significantly decreased at 1 month (P = 0.012) but not at later times. The 3D-MRI images showed a reduction in the distance between the bottom of the posterior staphyloma and the center of the eye (P = 0.029) and a flattening of the posterior staphyloma (P = 0.010).

Conclusions

Vitrectomy with ILM peeling and scleral imbrication may be helpful in treating MTM and MHRD by reducing the degree of curvature of the posterior staphyloma.

Comparison of the Inverted Internal Limiting Membrane Flap Technique and the Internal Limiting Membrane Peeling for Macular Hole with Retinal Detachment

Purpose

To evaluate the efficacy of the inverted internal limiting membrane (ILM) flap technique in vitrectomy for macular hole (MH) with retinal detachment (RD) compared with vitrectomy using ILM peeling.

Methods

A retrospective case series study was performed. Twenty-two eyes of 22 patients who underwent vitrectomy for MH with RD and followed-up more than 12 months after the surgery were included in this study. We retrospectively reviewed the medical records of patients who underwent vitrectomy with inverted ILM flap technique or vitrectomy with ILM peeling. Ten patients who had been treated vitrectomy with inverted ILM flap technique, and 12 patients who had been treated vitrectomy with ILM peeling were analyzed. We evaluated changes in best-corrected visual acuity (BCVA) before and after surgery, closing rates of MH, and retinal reattachment rates and compared between both groups.

Results

MH was closed and RD was reattached postoperatively in 9 eyes (90%) in the inverted ILM flap group. In the ILM peeling group, the MH was closed in 4 eyes (33.3%) and the retinas were reattached in 6 eyes (50%) after surgery. Significant improvement in BCVA after surgery (P = 0.0017) was only found in the inverted ILM flap group.

Conclusions

Higher rates of closed MH and retinal reattachment, and small but significant improvement in BCVA were found in the inverted ILM flap group. Based on our data, the inverted ILM flap technique may be useful in vitrectomy for MH with RD.

The efficacy and safety of posterior scleral reinforcement using genipin cross-linked sclera for macular detachment and retinoschisis in highly myopic eyes

BACKGROUND/AIMS

To evaluate the efficacy and safety of posterior scleral reinforcement (PSR) using genipin cross-linked sclera as the material to treat macular detachment and retinoschisis, both without macular hole, in highly myopic eyes.

METHODS

Twenty-one patients with highly myopic eyes (24 eyes) with macular detachment and retinoschisis were treated sequentially with genipin cross-linked PSR and were followed for at least 1 year after surgery. The best-corrected visual acuity (BCVA), spherical equivalent (SE) power, axial length (AL), optical coherence tomography, and the complications were evaluated.

RESULTS

The mean SE decreased from -13.81±4.67 D preoperatively to -9.64±4.86 D postoperatively, while the improvement in the logMAR BCVA values was from 1.24±0.57 before surgery to 1.03±0.57 after surgery. The preoperative AL (29.73±2.31 mm) was decreased (28.08±2.08 mm) after the operation. The retina in 21 eyes (87.5%) was successful reattached and the macular detachment was significantly decreased in two eyes; a macular hole occurred in one eye.

CONCLUSIONS

For at least a 1 year period of follow-up, PSR with genipin cross-linked sclera was safe and effective to treat macular detachment and retinoschisis in high myopia when a macular hole was not present. The reinforcement effect tended to be stabilised and maintained for 6 months after treatment.

Inverted Internal Limiting Membrane Insertion for Macular Hole-Associated Retinal Detachment in High Myopia

PURPOSE

To investigate the surgical outcomes of inverted internal limiting membrane (ILM) insertion in macular hole (MH)-associated retinal detachment (RD) in high myopia.

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

This study was conducted at 2 medical centers. Consecutive cases of highly myopic eyes with MH-associated RD were included. Forty eyes were divided into 2 groups: Group 1 (20 eyes) received vitrectomy, ILM peeling within the arcade area, and air-fluid exchange, and Group 2 (20 eyes) received vitrectomy, inverted ILM inserted into the macular hole, and air-fluid exchange. Optical coherence tomography was used to observe the closure of the macular hole. Corrected visual acuity (VA) was also recorded. Two-sample t test and Mann-Whitney U test were used for statistical analysis to compare differences between the 2 groups.

RESULTS

MH was closed in 35% of the eyes in Group 1 and in all eyes in Group 2 (P < .001). Significant improvement in VA in logarithm of minimal angle of resolution (logMAR) was achieved in both groups. There was no difference in the initial, final, or improvement of logMAR VA in the 2 groups.

CONCLUSION

Inverted ILM insertion into a macular hole effectively helps close the macular hole in MH-associated RD in high myopia. This may prevent the possible re-detachment from the MH. A prospective study with a larger number of cases and longer follow-up may help validate our findings.