EFFICACY OF THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE WITH VITRECTOMY FOR RETINAL DETACHMENT ASSOCIATED WITH MYOPIC MACULAR HOLES

Macular hole retinal detachment in extensive myelinated retinal nerve fiber and high myopia with Straatsma syndrome: A case report

Purpose

We present a case of macular hole retinal detachment (MHRD) in a patient with Straatsma syndrome, a rare condition characterized by extensive unilateral myelinated retinal nerve fibers (MRNF), high myopia, and amblyopia. This study aimed to highlight the clinical presentations, diagnostic challenges, and success of surgical interventions.

Observation

A 32-year-old Asian woman with a history of high myopia and poorly corrected vision in her right eye since childhood presented with a sudden loss of vision in the right eye. Examination revealed extensive MRNF and retinal detachment with a macular hole. A standard three-port pars plana vitrectomy was performed, and tight vitreous retinal adhesions were observed. PFCL-assisted inverted internal limiting membrane (ILM) flap technique was performed. Silicone oil was used owing to its tight vitreous retinal adhesion. Postoperatively, the macular hole was closed, the retina was reattached, and partial disappearance of the MRNF was observed.

Conclusion and importance

This case report describes a successful surgical intervention for MHRD associated with Straatsma syndrome. The PFCL-assisted inverted ILM flap technique is effective for managing complicated cases of MHRD. The partial disappearance of MRNF after vitrectomy suggests potential nerve fiber layer damage, possibly due to retinal detachment or the use of silicone oil. This case highlights the unique features of MHRD, a rare disease associated with Straatsma syndrome.

Surgical Outcomes of Retinal Detachment in Knobloch Syndrome

PURPOSE

To describe the rate, characteristics, and outcomes of rhegmatogenous retinal detachment (RD) in patients with Knobloch syndrome.

DESIGN

A single-center retrospective cohort study.

PARTICIPANTS

Fifty patients with Knobloch syndrome diagnosed clinically, with or without molecular confirmation of recessive pathogenic COL18A1 variants.

METHODS

A retrospective chart review of all patients diagnosed with Knobloch syndrome from November 1, 1983 to March 31, 2023. Demographic data, ophthalmic evaluation at baseline and follow-up, interventions, and final anatomic and visual outcomes were collected.

MAIN OUTCOME MEASURES

Rate, time of onset, characteristics, and treatment outcomes of RD.

RESULTS

Fifty patients with Knobloch syndrome were included. Males constituted 56% of cases. The diagnosis was confirmed with molecular genetic testing in 37 (74%) patients. Twenty-two patients (44%) had documented occipital bony defects or scalp lesions. Forty-eight of 100 eyes (48%) developed RD at a mean (standard deviation [SD]) age of 6.5 (6.1) years. The mean (SD) follow-up was 7.7 (5.6) years (range, 6 months to 24.3 years). Macular hole-related RD comprised 33% of RD cases. The overall single-surgery success rate was 36% and the final anatomic success rate was 70%. Macular hole-related RD carried a slightly worse prognosis with a 58% final anatomic success rate. Vitrectomy with adjunct scleral buckle and silicone oil tamponade provided the highest single-surgery success (62.2%). In eyes with measurable best-corrected visual acuity (BCVA), the mean preoperative BCVA was 1.2 logarithm of the minimum angle of resolution (Snellen equivalent, 20/320). After successful repair, mean visual acuity was 1.3 logarithm of the minimum angle of resolution (Snellen equivalent, 20/500).

CONCLUSIONS

Retinal detachment in Knobloch syndrome is frequent and occurs in young children. Macular hole-related RD comprises one third of RD cases and requires careful macular evaluation. Vitrectomy, combined with scleral buckling and silicone oil tamponade, appears to provide the best anatomic outcomes.

FINANCIAL DISCLOSURES

The authors have no proprietary or commercial interest in any materials discussed in this article.

Inverted Internal Limiting Membrane Flap Coverage With Autologous Blood Technique After Air-Fluid Exchange and Silicone Oil Tamponade for Extensive Macular Hole Retinal Detachment in Highly Myopic Eyes

PURPOSE

To report a technique consisting of inverted internal limiting membrane (ILM) flap coverage with autologous blood after air-fluid exchange and silicone oil tamponade in treating extensive retinal detachment secondary to a myopic macular hole (MH).

METHODS

This was a retrospective case series. 18 eyes with MHRD extending beyond the equator were included in this study with a minimum follow-up of 6 months. The procedures for pars plan vitrectomy (PPV) included the following: 1) The ILM was peeled to the superior and inferior arcade margins and, except for the ILM in the temporal region, was hinged toward the edge of the MH. 2) Air-fluid exchange was then performed to drain the subretinal fluid through the MH with a flute needle, ensuring that a small amount of subretinal fluid remained to facilitate ILM flap inversion. 3) The ILM flap was used to cover the MH with the assistance of autologous blood.

RESULTS

Six months after surgery, the MH was successfully anatomically closed, and retinal reattachment was observed in all 18 eyes of 18 patients. The mean best-corrected visual acuity logarithm of the minimum angle of resolution (logMAR) improved from 2.03 ± 0.61 (ranging from hand motion [2.6] to finger counting [2.3]) to 1.23 ± 0.63 (ranging from hand motion [2.6] to 20/28 [0.15]) ( P < 0.01) at 6 months.

CONCLUSION

This surgical technique using an inverted ILM flap combined with autologous blood provides an option for the treatment of extensive MHRD.

PRETREATED LYOPHILIZED HUMAN AMNIOTIC MEMBRANE GRAFT COVERING FOR RETINAL DETACHMENT WITH POSTERIOR RETINAL BREAKS ABOVE CHORIORETINAL ATROPHY IN PATHOLOGIC MYOPIA

PURPOSE

To compare the surgical results of vitrectomy with untreated or pretreated lyophilized human amniotic membrane grafts covering in treating retinal detachment related to posterior retinal breaks above chorioretinal atrophy in pathologic myopia.

METHODS

Nineteen patients with retinal detachment related to macular hole (MH) located above macular atrophy and/or posterior paravascular retinal breaks (PRBs) located above patchy chorioretinal atrophy in pathologic myopia were included. The eyes of these patients underwent vitrectomy with untreated lyophilized human amniotic membrane covering (n = 10) or perfluorocarbon liquid (PFCL)-assisted pretreated lyophilized human amniotic membrane covering (n = 9; grafts were pretreated in 0.125% indocyanine green and 50% hypertonic glucose solution for 15-20 minutes). The closure of the MH or PRBs, reattachment of the retina, and best-corrected visual acuity were measured postoperatively.

RESULTS

Postoperatively, graft dislocation or shift was only found in two eyes (20%) in the untreated group. The closure rate of the MH or PRBs was 80% (8/10) and 100% (9/9) in the untreated group and the pretreated group, respectively. The occurrence rate of excessive gliosis was 40% and 11% in the untreated group and the pretreated group, respectively. In both groups, best-corrected visual acuity was improved and the retinal reattachment rate was 100% at the final visit.

CONCLUSION

Perfluorocarbon liquid-assisted pretreated lyophilized human amniotic membrane graft covering was effective in treating retinal detachment related to MH and/or PRBs situated above macular atrophy or patchy chorioretinal atrophy in pathologic myopia. This technique appeared to reduce graft dislocation or shift, promote the closures of MHs/PRBs, and reduce the occurrence of gliosis.

Visual Improvement Despite Macular Pucker After Inverted Internal Limiting Membrane Flap Technique for Idiopathic Macular Hole

Purpose: To report a case of a macular pucker forming after macular hole (MH) repair with the inverted internal limiting membrane (ILM) flap technique, with resolution after secondary inverted ILM flap peeling. Methods: A single case was evaluated. Results: A 76-year-old woman presented with reduced central vision (28 letters) in the right eye. Optical coherence tomography (OCT) identified an idiopathic full-thickness MH measuring 629 µm in diameter. The patient had pars plana vitrectomy with inverted ILM flap formation. One month postoperatively, the visual acuity (VA) in the right eye was 47 letters and OCT confirmed MH closure. However, the patient developed deterioration in the central vision 10 months postoperatively. A macular pucker in the inverted ILM flap region was found on OCT. Repeat vitrectomy with inverted ILM flap peeling was performed. Postoperatively, the VA in the right eye improved to 60 letters and OCT showed resolution of the macular pucker. Conclusions: A complication of the inverted ILM flap technique for MH is formation of a macular pucker in the region of the inverted ILM flap. Secondary inverted ILM flap peeling results in resolution of the macular pucker.

Macular buckling alone versus combined inverted ILM flap on macular hole-associated macular detachment in patients with high myopia

PURPOSE

To compare the efficacy of macular buckling (MB) alone against a combined internal limiting membrane (ILM) inversion flap for full-thickness macular hole (FTMH)-associated macular detachment (MD) in patients with high myopia.

METHODS

This was a prospective interventional case series of patients with high myopia surgically treated with MB alone or combined with an inverted ILM flap for FTMH- associated MD. Best-corrected visual acuity (BCVA) at the 24-month postoperative follow-up, rate of initial retinal reattachment and macular hole closure were measured.

RESULTS

A total of 62 eyes from 62 participants (33 in the MB group, 29 in the combination group) were studied. Postoperative BCVA improved significantly in both the combination group (P < 0.001) and the MB group (P = 0.027). The postoperative BCVA at 12 months (P = 0.021) and 24 months (P = 0.041) was significantly better in the combination group than in the MB group. The postoperative BCVA was not significantly different between the eyes with closed and unclosed MH at each follow-up time point (P > 0.05). In the combination group, we observed earlier retinal reattachment and closure of the MH as well as a higher rate of MH closure (82.8% vs. 66.7%) than in the MB group, although this difference was insignificant (P = 0.248).

CONCLUSION

MB combined with the ILM flap inversion technique achieved better postoperative BCVA and a higher success rate of MH closure than MB alone. We believe that combination surgery should be preferentially recommended.

EXCESSIVE GLIOSIS AFTER VITRECTOMY FOR THE HIGHLY MYOPIC MACULAR HOLE: A Spectral Domain Optical Coherence Tomography Study

PURPOSE

To investigate different modes of foveal regeneration after the closure of idiopathic macular hole (IMH) or highly myopic macular hole (HMMH) by vitrectomy with internal limiting membranes peeling or flap techniques.

METHODS

This retrospective observational study followed 47 IMH and 50 HMMH eyes for at least 6 months. Twenty four IMH and 25 HMMH eyes underwent internal limiting membrane peeling, whereas 23 IMH and 25 HMMH eyes received inverted internal limiting membrane flap technique. Spectral domain optical coherence tomography was used to analyze macular hole closure, foveal microstructures, and excessive gliosis as a foveal "peak-like" protuberance.

RESULTS

A single procedure closed all IMH (n = 47). For HMMH, the inverted group (n = 25, 100%) closed more macular hole than the peeling group (n = 14, 56.00%) (P < 0.001). Excessive gliosis only occurred in the inverted group, and there was a significant difference (P = 0.005) in incidence between IMH (three in 23 eyes, 13.04%) and HMMH (13 in 25 eyes, 52.00%). The axial length more than 29.985 mm enhanced the risk of excessive gliosis.

CONCLUSION

The inverted internal limiting membrane flap efficiently treated refractory MHs but was prone to cause excessive gliosis in highly myopic eyes. Excessive elongation of the globe (axial length > 29.985 mm) was linked to excessive gliosis growth.

Treatment of recurrent high myopic macular hole associated with retinal detachment using a human amniotic membrane

PURPOSE

To determine the efficacy of using a human amniotic membrane to close macular hole retinal detachment in highly myopic eyes.

STUDY DESIGN

Prospective, consecutive, nonrandomized interventional study.

METHODS

We included 19 high myopic eyes from 19 patients affected by macular hole retinal detachment who had already undergone vitrectomy with internal limiting membrane peeling. The patients underwent vitrectomy with amniotic membrane transplant.

RESULTS

Primary success was achieved after 3 months in 89.5% (17 of 19 eyes) and final macular hole closure was obtained in 94.7% (18 of 19 eyes) of the patients. The final retinal reattachment rate was 100%. The final 12-month mean BCVA improved from 20/2000 (2 logMAR) to 20/250 (1.1 logMAR). OCT-angiography revealed a high correlation between the superficial and deep capillary plexus and the final BCVA.

CONCLUSION

Human amniotic membrane patches can effectively repair macular hole retinal detachment in high myopic eyes in terms of anatomic results and BCVA recovery.

Glial-Plug Proliferation after Inverted Internal Limiting Membrane Flap Technique for Idiopathic Macular Hole

Purpose

This study aimed to analyze the effect of multiple folded internal limiting membrane (ILM) flap in the inverted ILM flap technique on postoperative outcomes of patients with full-thickness macular hole (FTMH).

Methods

This retrospective study included 41 eyes of 41 patients with FTMH treated with vitrectomy using the inverted ILM flap technique. Complete ophthalmic examination was performed preoperatively, at 1 week, and at 1, 3, 6, 9, and 12 months after surgery.

Results

Postoperative SD-OCT confirmed macular hole (MH) closure in all patients. The mean BCVA improved from 0.7 LogMAR (20/100) preoperatively to 0.5 LogMAR (20/63) postoperatively. In two cases, 7 days after vitrectomy, flap closure was noted. At the final visit after 12 months, the following foveal contours were noted: 14 U-shape (34.1%), 12 irregular (W-shape) (29.3%), and 6 V-shape (14.6%). We observed a type of “plug closure” in 9 (22%) eyes in which hyperproliferation was noted in one eye.

Conclusions

The surgeons should be aware of potential hyperproliferation on the retinal surface after the multi-layered flap technique.

Modified superior inverted internal limiting membrane flap technique with vitrectomy versus vitrectomy with internal limiting membrane peeling for retinal detachment with myopic macular hole

PURPOSE

To evaluate the efficacy of the modified superior inverted internal limiting (ILM) membrane flap technique in retinal reattachment, macular hole closure and external retinal layers restoration in macular hole associated retinal detachment compared to ILM peeling.

METHODS

Retrospective case series of 10 patients that required pars plana vitrectomy for retinal detachment with macular hole followed for more than 12 months. Data from medical records were retrospectively collected and patients were divided into the superior inverted flap (5 patients) and ILM peeling group (5 patients). We compared best corrected visual acuity (BCVA) before and after surgery, retinal attachment, macular hole closure rate and external retinal layer restoration between groups.

RESULTS

There were significant improvements in BCVA in both groups before and after surgery, with no differences between the two groups at 12 months after surgery (p=0.9). The macular hole closed in 100% of cases in the inverted flap group and 80% of the ILM peeling group with no significant differences between groups. The retina was reattached in 100% of cases in both groups. Only 2 patients in the inverted flap group (40%) had external retinal layer restoration and none in ILM peeling group (p=0.62).

CONCLUSIONS

ILM peeling and superior inverted flap techniques are useful for treating retinal detachment with macular hole in myopic eyes.

Inverted multi-layer internal limiting membrane flap for macular hole retinal detachment in high myopia

To investigate the surgical outcomes of pars plana vitrectomy (PPV) combined with inverted multi-layer internal limiting membrane (ILM) flap for the treatment of macular hole retinal detachment in high myopia. We retrospectively analysed the medical records of macular hole retinal detachment (MHRD) patients with high myopia. The patients were divided into two groups with different surgical procedure: inverted multi-layer ILM flap group (group 1, 27 eyes) and the ILM peeling group (group 2, 29 eyes). Retinal reattachment rate, macular hole closure rate at last follow-up and BCVA at 6 months post-operation were compared between the two groups. After primary PPV and silicone oil removal, the retinal reattachment rate was 96.3% in group 1 and 93.1% in group 2 respectively at last follow-up, showing no statistically significant difference (odds ratio = 0.525, P = 1.000). All eyes in group 1 had type I macular closure (100%, 27/27), while only 7 eyes (24.1%, 7/29) in group 2 have type I macular hole closure. The difference was statistically significant (odds ratio = 0, P < 0.05). The mean logMAR BCVA both improved significantly at 6 months post-operation compared with pre-operation (t = 4.181, P < 0.001; t = 3.217, P < 0.001), however the difference of post-operation BCVA between the two groups was not statistically significant (t = 0.906, P > 0.05). PPV combined with inverted multi-layer ILM flap could achieve better anatomical outcomes than ILM peeling technique with no significant advantage in functional outcomes.

Inverted internal limiting membrane flap technique for retinal detachment due to macular holes in high myopia with axial length ≥ 30 mm

To compare the efficacy of internal limiting membrane (ILM) flap covering to that of ILM flap insertion for the treatment of macular hole retinal detachment (MHRD) in highly myopic eyes with axial length (AL) ≥ 30 mm. We retrospectively analysed the medical records of 48 MHRD patients with high myopia (AL ≥ 30 mm). According to different surgical methods, the patients were divided into a covering group (23 eyes) and an insertion group (25 eyes). The rate of retinal reattachment and MH closure were compared between the two groups, and the related factors affecting the initial anatomical results were analysed. After primary vitrectomy and single silicone oil removal, there were 18 eyes (78.3%) in the covering group, and 20 eyes (80.0%) in the insertion group had retinal reattachment (P = 1.000). Moreover, 16 eyes (69.6%) in the covering group and 17 eyes (68.0%) in the insertion group had their MHs sealed (P = 0.907). The best-corrected visual acuity (BCVA) at 12 months and the improvement in BCVA postoperatively in the two groups were not statistically significant (P = 0.543, 0.955). Logistic regression analysis showed that elongated AL (OR = 1.844, 95% CI 1.037–3.280, P = 0.037) and higher choroidal atrophy (OR = 2.986, 95% CI 1.011–8.821, P = 0.048) were risk factors affecting initial anatomical success. For extremely high-myopia MHRD with AL ≥ 30 mm, ILM flap covering and insertion can both effectively seal the MH and promote retinal reattachment, but the visual function improvement may still be limited. The longer the AL and the higher the choroidal atrophy, the greater is the risk of initial anatomical failure.

A Comparison of Face-Down Positioning and Adjustable Positioning After Pars Plana Vitrectomy for Macular Hole Retinal Detachment in High Myopia

Purpose

To compare the anatomical and functional outcomes of macular hole retinal detachment (MHRD) in high myopia after pars plana vitrectomy (PPV) with face-down positioning and adjustable positioning.

Methods

Fifty-three eyes from 53 patients with MHRD were analyzed in this study. All patients received PPV with silicon oil for tamponade and then subdivided into 2 groups: 28 were included in a face-down positioning group and 25 were included in the adjustable positioning group. Patients were followed up for at least 6 months. The main outcome was the rate of anatomical macular hole (MH) closure and retinal reattachment. Secondary outcome measures were the best-corrected visual acuity and postoperative complications.

Results

There was no significant difference in the rate of MH closure (53.6 vs. 72.0%, p = 0.167) and retinal reattachment (100 vs. 96%, p = 0.472) between the face-down group and adjustable group. Compared with the mean preoperative best-corrected visual acuity (BCVA), the mean postoperative BCVA at the 6-month follow-up improved significantly in both groups (p = 0, both). But there was no significant difference in the mean postoperative BCVA (p = 0.102) and mean BCVA improvement (p = 0.554) at 6 months after surgery between the two groups. There was no significant difference in the high intraocular pressure (IOP) after surgery between the two groups (53.6 vs. 44%, p = 0.487). There were no other complications that occurred during the follow-up.

Conclusion

Adjustable positioning after PPV with silicon oil tamponade for MHRD repair is effective and safe. Face-down positioning does not seem to be necessary for all patients with MHRD.

The Role of Internal Limiting Membrane Flap for Highly Myopic Macular Hole Retinal Detachment: Improving the Closure Rate but Leading to Excessive Gliosis

Purpose: To investigate the surgical outcomes of the inverted internal limiting membrane (ILM) flap technique for macular hole retinal detachment (MHRD) in high myopia.

Methods: This was a retrospective interventional study on 45 highly myopic eyes with MHRD after ILM peeling (n = 24, peeling group) or the inverted ILM flap technique (n = 21, inverted group). The inverted group was consisted of autologous blood (AB) subgroup (n = 10) and perfluorocarbon liquid (PFCL) subgroup (n = 11). MH closure, best-corrected visual acuity (BCVA), foveal microstructures, and excessive gliosis were analyzed during a follow-up of over 12 months.

Results: The inverted group achieved a higher MH closure rate (95.24%) than the peeling group (41.67%; p < 0.001). No significant difference was found in postoperative BCVA between the two groups (p = 0.98) or between the closed MH with or without excessive gliosis (p = 0.60). Excessive gliosis was identified in 9 eyes in the inverted group, and there was no difference in the incidence of excessive gliosis between the AB subgroup (4 in 10 eyes, 40%) and the PFCL subgroup (5 in 11 eyes, 45.45%) (p > 0.999).

Conclusion: The inverted ILM flap technique was effective in MH closure but had no advantage in postoperative BCVA and microstructural restoration. Excessive gliosis was only detected in the inverted group but did not affect the postoperative BCVA. Additionally, the incidence of excessive gliosis was not affected by adjuvants.

Contractility of temporal inverted internal limiting membrane flap after vitrectomy for macular hole

We investigated the postoperative visual outcomes and morphological changes of the internal limiting membrane (ILM) flap, in patients who underwent the temporal inverted ILM flap technique for macular hole (MH). Between August 2018 and February 2020, 22 eyes of 22 patients with idiopathic or myopic MH who underwent vitrectomy with ILM flap were included in this study and followed-up for more than 6 months. Postoperative MH status, comparison of best-corrected visual acuity (BCVA) before and 6 months after surgery, changes in the ILM flap area at 1 and 6 months postoperatively, and the factors related to changes in ILM flap size, were analyzed. MH closure was achieved in all of the patients. The BCVA at 6 months postoperatively (0.18 ± 0.15) was significantly better than the preoperative BCVA of 0.63 ± 0.37 (P < 0.001, paired t test). The area of the ILM flap decreased significantly from 3.25 ± 1.27 mm² at 1 month to 3.13 ± 1.23 mm² at 6 months (P = 0.024, Wilcoxon signed-rank test). Two eyes showed an ILM flap contraction of more than 20%, and one eye required reoperation due to an increase in metamorphopsia and decreased visual acuity. Among age, sex, ILM flap area at 1 month, preoperative BCVA, and axial length, ILM flap contraction was correlated with patient age and ILM flap area. Although vitrectomy with the inverted ILM flap technique confers a good visual outcome, the ILM flap may contract in younger patients.

EVALUATION OF THE EFFICACY OF POSTERIOR SCLERAL CONTRACTION IN THE TREATMENT OF MACULAR HOLE WITH RETINAL DETACHMENT IN HIGH MYOPIA

PURPOSE

To evaluate efficacy of posterior scleral contraction for macular hole with retinal detachment in high myopia.

METHODS

Seventy-three macular hole with retinal detachment eyes were treated with posterior scleral contraction. A strip was sent across inferior-temporal scleral surface to posterior pole, then two ends were led out from nasal-inferior to temporal-superior areas. It was tightened to contract posterior sclera with designed axial length shortening ([10% of preoperative axial length-0.5] mm) after aqueous humor was drained from anterior chamber. Recovery was classified as type I (retinal reattachment with MH bridged) and II (retinal reattachment without MH bridged). Follow-up duration was 25.3 ± 18.0 months.

RESULTS

Axial length was 30.01 ± 2.27 mm at preoperation and shortened by 2.57 ± 0.82 mm intraoperatively. At final postoperation, maintained axial length shortening was 1.87 ± 0.92 mm. Forty-six eyes (63.0%) recovered as type I, 26 eyes (35.6%) as type II, and 1 eye (1.4%) unrecovered. Postoperative best-corrected visual acuity (logarithm of minimal angle of resolution) was better than preoperative one (0.85 ± 0.50 [Snellen 20/125] vs. 1.11 ± 0.56 [Snellen 20/250], P < 0.001) with correlation (r = 0.662, P < 0.001) and consistency (Kappa = 0.34, P < 0.001) between two. Best-corrected visual acuity improvement did not differ between recovery types (P = 0.206).

CONCLUSION

Macular hole with retinal detachment was successfully recovered by posterior scleral contraction with axial length shortening. Visual improvement was achieved, correlated, and consistent with preoperative best-corrected visual acuity while independent of recovery types.

Complete ILM Peeling Versus Inverted Flap Technique for Macular Hole Surgery: A Meta-Analysis

BACKGROUND AND OBJECTIVE

To compare complete internal limiting membrane (ILM) peeling with the inverted flap technique for macular hole (MH) surgery.

PATIENTS AND METHODS

An electronic database search on PubMed, CENTRAL, and ClinicalTrials.gov was performed. Inclusion criteria were comparative prospective/retrospective studies including patients with MH of any size with at least 6 months of follow-up. The primary outcome was MH closure rate. Secondary outcomes were best-corrected visual acuity improvement and surgery-related adverse events.

RESULTS

Sixteen papers enrolling 1,403 eyes were included (733 ILM peeling, 670 inverted flap). MH mean minimum diameter and time of symptomatic evolution were higher in the inverted flap group (531.1 μm ± 188.8 μm vs. 602.8 μm ± 223.8 μm; 10.4 ± 20.2 months vs. 12.0 ± 18.4 months; P < .01). Overall, MH closure rate was superior with the inverted flap technique (risk-ratio [RR]: 1.25; 95% confidence interval [CI], 1.14-1.38; P < .0001), as well as in all subgroups: idiopathic large MH (n = 362; RR: 1.12; 95% CI, 1.05-1.20; P < .001), myopic MH without retinal detachment (n = 133; RR: 1.35; 95% CI, 1.14-1.59; P < .001), and MH retinal detachment (n = 198; RR: 1.89; 95% CI, 1.31-2.73; P < .001).

CONCLUSION

This meta-analysis suggests the inverted flap technique is more effective in achieving MH closure. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:187-195.].

Inverted internal limiting membrane flap technique for myopic macular hole: A meta-analysis

A macular hole (MH) may be a significant complication in patients with high myopia. The recently reported inverted internal limiting membrane (ILM) flap technique is a promising alternative to treat myopic MHs. We performed a meta-analysis of the published anatomical and functional results of the "inverted ILM flap" technique for the treatment of myopic MH with or without retinal detachment (RD). Our results showed that the inverted ILM flap technique, either covering or insertion, is an effective method for treating myopic MH with or without RD and provides high MH closure, ranging from 91.8% to 97.1%. Despite the high MH closure rate, the pooled visual acuity improvement rate was 77.3% and 66.2% in patients with myopic MH without RD, while it was 95% and 80.3% in patients with myopic MHRD, using "covering" and "insertion" ILM flap technique, respectively. Potential complications included reopening or persistence of MH, development of RD, choroidal detachment, ocular hypertension, and chorioretinal atrophy.

PERFLUOROCARBON LIQUID-ASSISTED INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE VERSUS INTERNAL LIMITING MEMBRANE PEELING FOR HIGHLY MYOPIC MACULAR HOLE RETINAL DETACHMENT

PURPOSE

To compare the efficacy of a modified perfluorocarbon liquid-assisted inverted internal limiting membrane (ILM) flap technique with the standard ILM peeling for the treatment of macular hole retinal detachment in highly myopic eyes.

METHODS

This was a retrospective, consecutive, nonrandomized comparative study. Forty-two macular hole retinal detachment eyes of 42 patients were included into either a perfluorocarbon liquid-assisted inverted ILM flap technique group (n = 22, inverted group) or standard ILM removal group (n = 20, peeling group). Outcomes measured were macular hole closure, retinal reattachment, and best-corrected visual acuity at least 6 months after surgery.

RESULTS

Macular hole closure was achieved in 20 eyes (90.9%) in the inverted group and in eight eyes (40%) in the peeling group (P < 0.01). Reattachment rates were 100% in the inverted group and 95% in the peeling group (P = 0.476). The mean best-corrected visual acuity improvement from baseline was 27.4 ± 19.9 Early Treatment Diabetic Retinopathy Study letters in the inverted group while the best-corrected visual acuity improvement was 13.6 ± 22.5 Early Treatment Diabetic Retinopathy Study letters in the peeling group (P = 0.044).

CONCLUSION

The perfluorocarbon liquid-assisted inverted ILM flap technique was effective in sealing the macular hole, reattaching retina, and improving visual function postoperatively in highly myopic macular hole retinal detachment.

Macular buckling versus vitrectomy on macular hole associated macular detachment in eyes with high myopia: a randomised trial

Aim

To compare the efficacy of macular buckling (MB) and pars plana vitrectomy (PPV) for full-thickness macular holes (FTMH) and associated macular detachment (MD) in highly myopic eyes.

Methods

Prospective interventional case series of eyes undergoing PPV or MB for FTMH and MD.

Main outcome measures

Best-corrected visual acuity (BCVA) at postoperative month 24. Other measured outcomes include the initial surgical success rate, macular hole closure rate and the progression of myopic maculopathy.

Results

A total of 53 eyes from 53 participants were included in this study (26 participants receiving MB and 27 participants receiving PPV), and finally 49 eyes from 49 participants (25 participants in the MB group and 24 participants in the PPV group) were analysed. At postoperative month 24, the BCVA had improved significantly in those that underwent either MB (p<0.001) or PPV (p=0.04). The difference between the groups was not significant (p=0.653). The surgical failure rate after the primary treatment was significantly higher in the PPV group than the MB group (25.00% vs 4.00%, respectively; p=0.04). The macular closure rate was higher in the MB group compared with the PPV group, but the difference was not statistically significant (64.00% vs 58.33%, respectively; p=0.45). Myopic maculopathy development may be more severe following PPV than following MB surgery.

Conclusion

Patients with high myopia obtained anatomical and functional improvements from either MB or PPV. However, MB achieved a significantly higher success rate in retinal reattachment compared with PPV.

Trial registration number

NCT03433547.

Superior Wide-Base Internal Limiting Membrane Flap Transposition for Macular Holes: Flap Status and Outcomes

PURPOSE

Internal limiting membrane (ILM) flap techniques are used for the management of macular holes (MHs). Status of the flap after surgery often is uncertain. The current study evaluated the status of the ILM flap after MH surgery with superior wide-base ILM flap transposition (SWIFT).

DESIGN

Retrospective consecutive case series.

PARTICIPANTS

Eyes undergoing SWIFT for MH.

METHODS

Data were collected on demographic characteristics, preoperative and postoperative visual acuity (VA), and MH status. OCT and indocyanine green (ICG) fluorescence were used to evaluate the MH and the ILM flap status.

MAIN OUTCOME MEASURES

Status of MH, ILM flap position, and ILM flap integrity.

RESULTS

Seventeen eyes of 17 patients with a mean age of 65.3 years and mean follow-up of 11.6 months were included in the study. Thirteen eyes had 1 or more high-risk characteristics. Four eyes (24%) were highly myopic, 6 eyes (35%) had chronic MH, and 3 eyes (18%) had a history of prior MH surgery and ILM removal. The mean MH basal diameter was 899.4 μm and the mean inner diameter was 516.1 μm. In 6 eyes, the MH inner diameter was 650 μm. The baseline mean VA equivalent was 0.88 logarithm of the minimum angle of resolution (logMAR). The MH closed in 16 eyes (94%). Indocyanine green fluorescence imaging demonstrated complete coverage of the MH by the ILM flap in 14 eyes (82%), partial coverage in 1 eye (6%), and no coverage in 2 eyes (12%). In the 2 eyes without ILM flap coverage, the MH was closed in 1 eye and remained open in 1 eye. Non-center-involving folding of the ILM flap was present in 4 eyes (24%). At the last follow-up visit, the mean VA equivalent was 0.54 logMAR.

CONCLUSIONS

Superior wide-base ILM flap transposition is a useful technique for the management of high-risk MHs, including persistent MHs with previously removed ILM. After surgery, the ILM flap may be visualized by ICG fluorescence imaging. After SWIFT, ICG imaging indicates that the ILM flap is intact and in a good position in most cases.

Autologous neurosensory retinal transplantation for recurrent macular hole retinal detachment in highly myopic eyes

PURPOSE

To investigate the morphological and functional reconstruction of the macular fovea after autologous neurosensory retinal transplantation for recurrent macular hole retinal detachment (MHRD) in highly myopic eyes.

METHODS

Ten consecutive cases of recurrent MHRD with high myopia were retrospectively reviewed. All eyes underwent pars plana vitrectomy combined with autologous neurosensory retinal transplantation and were followed up for at least 3 months after silicone oil extraction. The main outcomes were whether or not the retina was reattached and the macular hole (MH) was closed, morphological changes in the retinal graft, best-corrected visual acuity (BCVA), the sensitivity threshold and blood flow signal in the macula.

RESULTS

At the one month postoperative visit, there was an obvious boundary between the graft and the surrounding retinal tissue, and some retinal structural layers could be seen in the graft on optical coherence tomography scans. At the final follow-up, eight eyes (80%) showed retinal reattachment and closure of the MH. Optical coherence tomography revealed blurring of the boundary between the graft and surrounding retinal tissue and that the retinal structure in the graft was disordered. The MH was not closed in two eyes (20%), in one case because of partial displacement of the graft and in the other because of incomplete coverage of the MH as a result of a smaller graft. The post-BCVA was significantly better than the pre-BCVA (1.32 ± 0.33 versus 2.01 ± 0.29 logMAR; p = 0.000, paired t-test).

CONCLUSION

Autologous neurosensory retinal transplantation can be an effective treatment for recurrent MHRD in highly myopic eyes. 'Fusion' between the neurosensory retinal graft and the original retinal tissue may be the mechanism involved in the closure of the MH and reconstruction of the macular fovea.

SWEPT-SOURCE OPTICAL COHERENCE TOMOGRAPHY TO DETERMINE THE RECOVERY OF RETINAL LAYERS AFTER INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE FOR MACULAR HOLE: Correlation With Visual Acuity Improvement

PURPOSE

To analyze the recovery of retinal lines using swept-source optical coherence tomography after inverted internal limiting membrane flap technique to treat full-thickness macular hole, and the relationship between best-corrected visual acuity and retinal line repair.

METHODS

Thirty-eight eyes were evaluated for recovery of the external limiting membrane, photoreceptor inner segment/outer segment junction line, and cone outer segment tips (COST) line. Correlation between the recovery of retinal lines and best-corrected visual acuity improvement was analyzed 6 months after surgery.

RESULTS

The closure rate of full-thickness macular hole was 97%. The best recovery rates were associated with external limiting membrane line recovery (25 eyes, 65.8%), followed by inner segment/outer segment line recovery (22 eyes, 57.9%), and less frequently, COST line recovery (9 eyes, 23.7%); moreover, recovery of the COST line was apparent only in eyes with recovered external limiting membrane and inner segment/outer segment lines. Mean postoperative visual acuity in the COST line recovery group (COST+) was 20/42 (0.48, 0.33 logarithm of the minimum angle of resolution), compared with 20/95 (0.21, 0.68 logarithm of the minimum angle of resolution) without COST line recovery (COST-). Final visual acuity was significantly better in the COST+ group compared with the COST- group (P = 0.002).

CONCLUSION

Cone outer segment tips line recovery is correlated with best-corrected visual acuity improvement for eyes treated with inverted internal limiting membrane flap technique for full-thickness macular hole.

Treatment of macular hole retinal detachment with macular plug in highly myopic eyes: three-year results

PURPOSE

To investigate the long-term surgical outcomes of macular hole retinal detachment (MHRD) following vitrectomy with macular plug in highly myopic eyes.

METHODS

Thirty-five cases of highly myopic eyes with MHRD in 35 patients who underwent an initially successful vitrectomy with macular plug and were followed up for at least 3 years were reviewed. The anatomical outcomes were evaluated by fundus examination, fundus photographs and optical coherence tomography (OCT). Myopic features after the surgery were differentiated according to recommendations of the Meta-analysis of Pathologic Myopia (META-PM) Study Group. The best-corrected visual acuities (BCVAs) before and after surgery were analysed as the functional outcome. Main outcome measures time-course changes in BCVA and complications.

RESULTS

The mean patient age was 61.0 ± 11.4 years. The follow-up was 45.2 ± 8.6 months (ranged from 36 to 71 months). The mean axial length was 29.3 ± 1.2 mm. All eyes demonstrated attached retina, but 2 eyes (5.7%) developed reopened macular holes until the last follow-up. Complications of postoperative rhegmatogenous retinal detachment were detected in 2 eyes (5.7%) within 1 year and retina reattached after the secondary vitrectomy. Three cases (8.6%) of prolonged subretinal fluid lasting more than 1 year were detected but finally absorbed completely. Comparing 1-3 years postoperatively, myopic features showed significant progression of myopic maculopathy category (p = 0.035). Functionally, significantly improved BCVA could be maintained postoperatively between 6 months and 3 years. However, vision of 14 eyes (40.0%) worsened within 1-3 years postoperatively, and visual deterioration was associated with progression of myopic maculopathy (p = 0.004) and pre-existing disease of glaucoma (p = 0.006).

CONCLUSIONS

A vitrectomy combined with macular plug provided favourable outcomes in the long term, over the ≥3-year follow-up period.

Inverted internal limiting membrane flap technique in the surgical treatment of macular holes: 8-year experience

PURPOSE

To evaluate the ellipsoid zone (EZ) structural recovery, hole closure rate, and visual acuity improvement after inverted internal limiting membrane (ILM) flap technique.

METHODS

Retrospective cohort of eyes affected by idiopathic macular holes (MH) that underwent pars plana vitrectomy combined with inverted ILM flap technique in a tertiary center, over an 8-year period (2011-2019). The main outcomes were the postoperative qualitative analysis of EZ structure on spectral-domain optical coherence tomography, hole closure rate, and best-corrected visual acuity (BCVA) improvement of ≥ 0.3 units in the logarithm of minimal angle of resolution (logMAR) scale.

RESULTS

Our study included 76 eyes of 72 patients; 65% were female, with a mean age of 70 ± 8 years-old. Median (range) follow-up was 21 (3-92) months. Hole closure rate was 92%. Structural defects in EZ were observed in 66% of closed holes (EZ atrophy in 33%, EZ disruption in 22%, and EZ thinning in 11%). The mean final BCVA was 0.5 ± 0.4 logMAR (Snellen 20/63), but visual acuity improvement occurred in 80% of the eyes. Final BCVA was significantly worse in eyes with EZ atrophy compared with eyes with EZ disruption (0.75 vs. 0.36 logMAR, p = 0.004) and EZ thinning (0.75 vs. 0.32 logMAR, p = 0.015). In multivariate regression, minimum linear diameter (OR 1.01; IC 95% 1.01-1.02) independently predicted a final BCVA (logMAR) < 0.3 units.

CONCLUSION

Inverted ILM flap technique provided a hole closure rate above 90%, similar to previous studies. Although the modest value of the final BCVA, a significant visual acuity improvement occurred in most eyes. Structural defects of EZ were found in more than half of closed MHs after surgery. Evidence of postoperative retinal atrophy was associated with a worse visual outcome.

Inverted Internal Limiting Membrane Flap Technique versus Internal Limiting Membrane Peeling for Vitrectomy in Highly Myopic Eyes with Macular Hole-Induced Retinal Detachment: An Updated Meta-Analysis

BACKGROUND

The aim of this meta-analysis was to compare morphological and functional outcomes between vitrectomy with the inverted internal limiting membrane (ILM) flap technique and vitrectomy with internal limiting membrane peeling in highly myopic eyes with macular hole- (MH-) induced retinal detachment (MHRD).

METHODS

The PubMed, Web of Science, Embase, and Cochrane Library databases were comprehensively searched from inception to November 10, 2019, for published studies comparing the two techniques for the treatment of MHRD. The outcomes in the collected articles included the postoperative MH closure rate, retinal reattachment rate, and best-corrected visual acuity (BCVA). Review Manager (version 5.3) was used for analyses.

RESULTS

In total, seven retrospective studies comparing the inverted ILM flap technique with ILM peeling for the treatment of MHRD were included. The MH closure rate was significantly higher in the inverted ILM flap group than in the ILM peeling group at 6 and 12 months after initial surgery (OR = 15.39; 95% CI: 6.68 to 35.43;P < 0.00001 and OR = 12.58, 95% CI: 3.51 to 45.08; P=0.0001), while the retinal reattachment rate was similar in both groups at 6 months after initial surgery (OR = 2.40; 95% CI: 0.89 to 6.50; P=0.08). Besides, the postoperative BCVA was significantly better in the inverted ILM flap group than in the ILM peeling group at 12 months after initial surgery (MD = -0.35; 95% CI: -0.52 to -0.18; P < 0.0001).

CONCLUSIONS

Thus, the MH closure rate and postoperative BCVA may be better with the inverted ILM flap technique than with ILM peeling for myopic MHRD, while the postoperative retinal reattachment rate appears to be similar with both techniques. Therefore, in the future, vitrectomy with the inverted ILM flap technique should be preferred over standard ILM peeling technique for the treatment of MHRD in highly myopic eyes.

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.

Internal limiting membrane flap technique in macular hole surgery

Vitrectomy combined with internal limiting membrane (ILM) peeling is popular for the treatment of macular hole (MH). However, the improvements of MH closure rate and postoperative visual acuity are not satisfactory especially in large and refractory MHs. Currently, the ILM flap technique has gradually been applied for the treatment of MH and achieved high MH closure rate. The ILM flap technique has many variations, including the difference of the size, shape, number, and manner in which the flaps put on the MHs. The ILM flap technique also has some auxiliary means including perfluoro-n-octane (PFO), dye, autologous blood and adhesive viscoelastics. There is controversy about the effects between several technique variations of ILM flap, and it needs to be explored in the future.

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

PURPOSE

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Effects of perfluorocarbon liquids in macular hole retinal detachment treatment

OBJECTIVE

This study aims to evaluate the clinical efficacy and visual function prognosis of macular hole retinal detachment treatment for high myopia by inverting the internal limiting membrane to overlay the macular hole with the assistance of perfluorocarbon liquids.

METHODS

A total of 55 high myopia patients, who received macular hole retinal detachment treatment from 2013 to 2016, were included in this study. Among these patients, 38 patients were assigned to the first group and 17 patients (perfluorocarbon liquids) were assigned to the second group. The second group was further divided into two subgroups, according to the overlaying layer number of the internal limiting membrane valve: A group (multiple layers) and B group (single layer).

RESULTS

The success rate of the internal limiting membrane inversion and overlaying on the macular hole was 23.68% and 100% in the first and second group, respectively. The differences in macular hole closing rate and postoperative best-corrected visual acuity between these two groups were statistically significant (p < 0.05). Furthermore, the differences in macular morphology recovery between the A and B groups were also statistically significant (p = 0.004 < 0.05).

CONCLUSION

Perfluorocarbon liquids play a positive role in the operation process of the internal limiting membrane.

A human Amniotic Membrane plug to manage high myopic macular hole associated with retinal detachment

OBJECTIVE

To assess the efficacy of the human amniotic membrane (hAM) to treat (HMMH) associated with retinal detachment (RD).

MATERIAL AND METHODS

Ten eyes of 10 patients with recurrent HMMH and RD, who had already undergone one or more pars plana vitrectomy (PPV), underwent a PPV with an hAM plug implanted in the macular hole. The initial five patients enrolled were tamponaded with (SO) while the subsequent five patients with 10% octafluoropropane (C₃ F₈ ). Silicon oil was removed in all five patients 2 months later. No statistical differences were reported between the two groups.

RESULTS

Final retinal reattachment was achieved in all the patients. BCVA improved from 1.73 logMAR to 0.94 logMAR after 6 months. No adverse events were registered during follow-up.

CONCLUSION

An hAM plug is an efficient substrate to manage HMMH associated with RD resulting in encouraging visual acuity recovery.

ANATOMICAL AND VISUAL OUTCOMES OF INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE VERSUS INTERNAL LIMITING MEMBRANE PEELING IN MYOPIC MACULAR HOLE WITHOUT RETINAL DETACHMENT: A Preliminary Retrospective Study

PURPOSE

To compare the results of vitrectomy with internal limiting membrane (ILM) peeling and inverted ILM flap for treating myopic macular hole without retinal detachment.

METHODS

Twenty-eight eyes of 28 patients undergoing vitrectomy with either ILM peeling (n = 16) or inverted ILM flap technique (n = 12) were included. Outcomes were myopic macular hole closure by optical coherence tomography and visual acuity at 6 months and at the end of follow-up.

RESULTS

Closure of myopic macular hole was achieved in 13 eyes (81.2%) of the ILM peeling group and in 11 eyes (91.7%) of the inverted ILM flap group. The median length of follow-up was 18 months in the peeling group and 10.3 in the inverted group. There were not statistically significant differences between restoration of the external limiting membrane, external limiting membrane and ellipsoid zone, and none of both layers between the two groups. The median best-corrected visual acuity (logarithm of minimal angle of resolution) at the end of follow-up was 0.25 (20/35 Snellen) in the peeling group and 0.4 (20/50) in the inverted group (P = 0.027).

CONCLUSION

Both techniques were associated with high closure rates of myopic macular hole but the small sample size and the retrospective design prevents any claims of superiority of one technique over the other.

Vitrectomy with internal limiting membrane peeling versus its flap insertion for macular hole in high myopia: a Meta-analysis

AIM

To compare the anatomic and functional outcomes between vitrectomy with internal limiting membrane (ILM) peeling and internal ILM flap insertion technique for high myopia macular hole (MH).

METHODS

PubMed, Cochrane Library, EMBASE, and CNKI were systematically searched, and all studies involved MH were included. The closure rate of MH and the postoperative best-corrected visual acuity (BCVA) at 6mo after the initial surgery were the primary measures. All statistical tests were performed in Review Manager 5.3.

RESULTS

Five studies that included 151 eyes of 151 patients were finally included, all of which were retrospectively comparative studies. Between the pars plana vitrectomy (PPV) with ILM peeling surgery and the ILM insertion technique, the latter had significantly better efficacy with respect to the closure rate of MH (OR=21.32, 95%CI=7.25-62.67, P<0.001); However, regarding BCVA at 6mo after the initial surgery in MH, there was no statistical significance between the groups (OR=-0.04, 95%CI=-0.22-0.14, P=0.66). In addition, regarding the rate of retinal reattachment after the initial surgery, the two different methods were not significantly different (OR=2.22, 95%CI=0.34-14.32, P=0.4).

CONCLUSION

Both ILM peeling and ILM insertion technique could significantly improve anatomic outcomes of MH in high myopia with or without retinal detachment (RD), and anatomic outcomes are more effective. However, there is no statistical significance in BCVA at 6mo after the initial surgery in MH, or in the rate of retinal reattachment after the first surgery, between the two methods.

Tailored internal limiting membrane flap technique for primary macular hole

PURPOSE

To investigate the outcomes of primary full-thickness macular hole (MH) after surgical intervention with tailored internal limiting membrane (ILM) flap technique.

METHODS

Patients were reviewed for their clinical characteristics and surgical outcomes. The technique included incomplete circular peeling of the perifoveal ILM which was then trimmed according to the size of the MH. Fluid-gas exchange was done without further manipulation.

RESULTS

Nineteen eyes of 19 patients were included. The patients were in average 61 years old (range 41-83) and had an average follow-up period of 11.0 months. At baseline visit, minimal linear diameter of the MH was 311.6 μm (range 80-768). After a single surgery, the MH closed in all cases with improvement of mean visual acuity (from 0.9 to 0.4 logarithm of the minimum angle of resolution units, p < 0.0001, Wilcoxon signed-rank test). At the final visit, 15 (78.9%) eyes achieved a visual acuity ≥ 20/40. Outer retinal gliosis was found to be associated with less favorable postoperative visual acuity. Factors related to the formation of outer retinal gliosis were worse preoperative visual acuity and a large MH with a diameter > 400 μm.

CONCLUSION

Tailored ILM flap technique is an effective method for favorable anatomical and visual outcomes for treatment of primary MH.

Long-term Outcomes of Macular Hole Retinal Detachment in Highly Myopic Eyes after Surgical Reattachment

PURPOSE

To evaluate visual acuity changes over 3 years following surgical reattachment of macular hole retinal detachment (MHRD) developed in high myopia.

METHODS

A retrospective analysis was performed using the medical records of patients with highly myopic eyes who underwent pars plana vitrectomy with internal limiting membrane peeling or the internal limiting membrane flap technique for MHRD. Changes in best-corrected visual acuity (BCVA) were measured at baseline, 6 months, 1 year, 2 years, and 3 years.

RESULTS

Of the 22 eyes analyzed, macular hole was closed in 13 and unclosed in nine. BCVA significantly improved from 1.61 ± 0.39 logarithm of the minimum angle of resolution (logMAR) at baseline to 1.17 ± 0.43 logMAR at 6 months and 1.33 ± 0.48 logMAR at 2 years after MHRD surgery. At 3 years, BCVA significantly decreased compared with that at 6 months, and visual improvement from baseline was not significant. BCVA and proportion of vision loss ≥0.3 logMAR were not different between the closed and unclosed macular hole groups.

CONCLUSIONS

Visual improvement after surgical reattachment of MHRD in high myopia was not maintained, and favorable macular hole closure effects were not observed at 3-year follow-up.

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.

MECHANISM OF "FLAP CLOSURE" AFTER THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE

PURPOSE

Recent studies described that in approximately 14% to 16% of cases of macular holes treated with the inverted internal limiting membrane flap technique, the hole was closed only by a thin layer of inverted internal limiting membrane-"flap closure." The aim of this article was to describe the functional and anatomical results in flap closure macular holes and also the mechanism of flap closure.

METHODS

A retrospective observational study of 149 eyes of 139 patients treated with vitrectomy using the inverted internal limiting membrane flap technique was reviewed to aggregate eyes with flap closure. Complete ophthalmic examination was performed preoperatively and at 7 days, 1, 3, 6, and 12 months after surgery.

RESULTS

Flap closure (Group 1) was noted in 24 eyes and other closure types in 125 eyes (Group 2). The mean minimal and base diameters of the macular holes in the flap closure group were greater than those in Group 2 (P < 0.001). The mean postoperative best-corrected visual acuity in the flap closure group (20/100) was lower than that in Group 2 (20/50) (P < 0.001).

CONCLUSION

Flap closure probably enables closure of large macular holes with a higher probability of remaining open without the use of the inverted internal limiting membrane flap technique. Foveal architecture continuously improved.

Efficacy of inverted internal limiting membrane flap for large idiopathic macular holes

Objective:

To evaluate the effectiveness of inverted internal limiting membrane flap in large idiopathic macular holes.

Methods:

Twelve patients diagnosed with idiopathic macular holes larger than 400um underwent 23 gauge Pars Plana Vitrectomy (PPV) with inverted internal limiting flap and gas tamponade at Al-Ehsan Eye Welfare Eye Hospital, Lahore from February 2017 to February 2018. All cases were diagnosed on Spectral Domain Optical Coherence Tomography (SD-OCT) and were followed up for 6 months. At every follow-up, best corrected visual acuity and SD-OCT was done.

Results:

We achieved macular hole closure in 91.6% (11/12) patients with idiopathic macular holes larger than 400um. Five out of 12 patients underwent combined phacoemulsification and PPV. One patient has flat hole closure which was considered failure. One patient was excluded from the study due to per-operative flap loss. This patient was not included in final data analysis of 12 patients. There was statistically significant gain in best corrected visual acuity after successful macular hole closure. We did not report any untoward events during or in the post-operative period.

Conclusion:

Inverted internal limiting flap is an effective method for repairing large macular holes.

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.