RESTORATION PROCESS OF THE OUTER RETINAL LAYERS AFTER SURGICAL MACULAR HOLE CLOSURE

Development and preliminary evaluation of a novel preoperative index for quantitative analysis of photoreceptor loss in full-thickness macular holes

PURPOSE

To identify novel quantitative parameters for evaluating photoreceptor loss in full-thickness macular holes (FTMH), exploring their potential clinical impact on postoperative functional and anatomical recovery.

METHODS

This pilot study enrolled 38 eyes from 38 patients diagnosed with FTMH. Preoperatively, eyes underwent analysis and were subsequently followed for six months post-surgery. Best-corrected visual acuity (BCVA) was recorded, and cross-sectional images of FTMH were obtained using B-scan optical coherence tomography (OCT) and en-face OCT. Quantitative assessment of ellipsoid zone (EZ) and external limiting membrane (ELM) integrity changes was conducted and correlated with postoperative anatomical and functional recovery. The photoreceptor Integrity Index (PIIN), calculated as the ratio of photoreceptor area to lumen hole area measured at customized segmentation, was correlated with the minimum and base diameters of the hole, positive change in BCVA, preoperative EZ defect (EZd), preoperative ELM defect (ELMd), and changes in EZ and ELM over the six-month follow-up period (∆-EZ and ∆-ELM). The main outcome measures focused on evaluating the effectiveness of PIIN in predicting postoperative anatomical and functional changes.

RESULTS

A higher PIIN correlated with a greater BCVA change over six months (p < 0.001). Univariate regression analysis using the PIIN as a predictor for positive change in BCVA (|∆-BCVA| [logMAR]) over time yielded significant results (p < 0.001). Additionally, the PIIN significantly correlated with EZd at baseline, ELM at baseline, and ELMd change over the six-month follow-up period.

CONCLUSION

The PIIN shows promise as a tool for evaluating photoreceptor loss in macular holes and estimating postoperative functional and anatomical recovery.

KEY MESSAGES

What is known Previous studies have extensively used optical coherence tomography (OCT) to investigate various biomarkers for assessing patients with full-thickness macular hole (FTMH), without considering detailed MH ultrastructural features Existing indexes used to predict surgical outcomes for FTMH primarily depend on geometrical parameters and do not integrate detailed ultrastructural characteristics, such as cellular components.  What is new A novel concept introduces the quantitative measurement of residual photoreceptors located at the edge of FTMH. The Photoreceptor Integrity Index (PIIN) integrates different ultrastructural components of macular holes, aiming to become a valuable clinical tool to predict both anatomical and functional recovery outcomes following surgical intervention for FTMH.

Prediction of long-term visual outcome of idiopathic full-thickness macular hole surgery using optical coherence tomography parameters that estimate potential preoperative photoreceptor damage

PURPOSE

To identify optical coherence tomography (OCT) parameters that predict postoperative best corrected visual acuity (BCVA) and are based on recent understanding of the pathomechanism of idiopathic full thickness macular hole (iFTMH) formation and closure.

METHODS

A retrospective consecutive case series of patients who had macular hole (MH) surgery at our institution between 2016 and 2022 was performed. 32 eyes of 30 patients were selected with at least 12 months of follow-up, closed MH and good quality OCT at each visit. Univariate correlation analysis, multiple logistic regression with forward stepwise selection, and Akaike's Information Criterion (AIC) were used to identify the best predictors for postoperative BCVA at 6 and 12 months (M), and final (≥ 12 M) visits, and a new OCT index was created. Abilities of best models/indices to predict < 0.30 logMAR (> 20/40) BCVA were compared to macular hole index (MHI) using the area under the receiver operating curve (AU-ROC) analysis.

RESULTS

Statistical analysis revealed base diameter (B) (6 M), preoperative BCVA and B (12 M) and smaller ELM-GCL distance (A), and B (final visit) as predictors for postoperative BCVA. AU-ROC analysis indicated greatest AUC at 6 M for MHI and B (0.797, p = 0.004 and 0.836 p = 0.001, respectively) and for the new A/B index at 12 M and final visit (0.844, p = 0.002 and 0.913, p = 0.003, respectively).

CONCLUSION

Our study suggests that MHI and B can be useful predictors of short term BCVA while the new A/B index that incorporates OCT parameters indicating potential preoperative photoreceptor damage may be a good predictor for long term postoperative BCVA. Our findings support the theory that initial hole formation mechanisms and photoreceptor damage define visual prognosis.

Macular holes with minimal diameter greater than 650 µm close in 85% of cases after vitrectomy and ILM peeling with visual benefit

PURPOSE

To describe the postoperative outcomes of eyes with primary full-thickness macular holes (MH) greater than 650 μm.

DESIGN

Retrospective, monocentric, consecutive case series.

PARTICIPANTS

Patients with primary MH operated at Lariboisière Hospital, Paris, France.

METHODS

Records of patients with MH with a minimum horizontal diameter greater than 650 μm that underwent primary surgery with internal limiting membrane (ILM) peeling (complete or with inverted ILM flap) between January 2010 and January 2022 were reviewed.

MAIN OUTCOME MEASURES

Postoperative MH closure rate and visual acuity.

RESULTS

74 eyes of 73 patients met the inclusion criteria. The mean minimum horizontal diameter was 777 ± 108 µm (650-1114). It ranged between 650 and 800 µm in 40 eyes (54%) and was ≧ 800 µm in 34 eyes (46%). The closure rate was 77% (57/74) after primary surgery and was significantly higher in MH between 650 and 800 µm, than in MH ≧ 800 µm (87.5% versus 64.7%, p = 0.02). In the 58/74 eyes in which conventional ILM peeling was performed, closure rate was 74.1% (43/58), significantly higher in MH ranging between 650 and 800 µm than in MH ≧ 800 µm (84.8% versus 60.0%, p = 0.03). In closed MH, 50/64 (78%) eyes achieved a VA gain ≥0.2 logMAR (3 lines), and 14 (21.9%) eyes a final BCVA ≥ 0.3 logMAR.

CONCLUSION

MH surgery with conventional ILM peeling allowed closed MH ≧ 650 μm and < 800 μm with a success rate close to 85% that decreased in larger MH. A significant visual improvement was achieved after MH closure, even in MH ≧ 800 μm.

Choroidal hypertransmission width on optical coherence tomography: a prognostic biomarker in idiopathic macular hole surgery

PURPOSE

To test the hypothesis that optical coherence tomography (OCT) choroidal hypertransmission width (CHW) is a prognostic biomarker in idiopathic macular hole (MH) surgery METHODS: Retrospective cohort study of consecutive patients undergoing successful pars plana vitrectomy for idiopathic MH. We collected demographic, clinical, and OCT variables at the preoperative and last available visits. Two investigators assessed the following OCT parameters: MH minimum diameter, base diameter, CHW, ellipsoid zone, and external limiting membrane status (absent vs. present). Delta CHW was calculated as the difference between CHW and MH minimum diameter. Linear models were used to investigate factors associated with postoperative best-corrected visual acuity (BCVA) and BCVA change.

RESULTS

Thirty-six eyes (36 patients) with a median (interquartile range (IQR)) follow-up of 9 (8-11) months were included. The median BCVA (IQR) improved from 0.75 (1-0.6) logMAR preoperatively to 0.2 (0.6-0.1) logMAR at the last visit (p < 0.001). Preoperative MH minimum diameter (for a 10-μm increase, estimate (standard error (SE)): 0.009 (0.003) logMAR, p = 0.003), base diameter (for a 10-μm increase, 0.003 (0.001) logMAR, p = 0.032), CHW (for a 10-μm increase, 0.008 (0.002) logMAR, p < 0.001), and delta CHW (for a 10-μm increase, 0.013 (0.005) logMAR, p = 0.009) were significantly associated with postoperative BCVA. The proportion of variance explained was the highest for MH CHW (R2 0.35), followed by minimum MH diameter (R2 0.24), delta CHW (R2 0.19), and MH base diameter (R2 0.14). None of the study variables was associated with delta BCVA.

CONCLUSION

Preoperative CHW is associated with postoperative visual acuity in patients undergoing successful idiopathic MH surgery and may be a useful OCT prognostic biomarker.

Single Layered Free ILM Graft Technique in Large Macular Holes with Associated ERM

PURPOSE

We aimed to describe single layered free ILM graft technique (FIGT) and present results of this technique in the primary surgery of large macular holes (MHs).

METHODS

In this retrospective study, we identified MHs with a minimum hole diameter >400 μm that underwent FIGT by a single surgeon. Nineteen eyes were found to have an associated epiretinal membrane (ERM) and four eyes demonstrated a patchy ILM staining intraoperatively. A single layered FIGT was performed first by peeling the ILM around the hole and then creating a free ILM flap and transplanting it to cover the hole. All cases were evaluated for anatomical closure and visual improvement.

RESULTS

Twenty-three eyes of 22 patients (mean age 68.7 ± 7.4 years) were included in the study. The mean follow-up was 9.6 ± 4.9 months. Flap closure was observed in two eyes (8.6%) at week 1, while all eyes (100%) showed a complete closure at month 1. Mean preoperative visual acuity of 1.42 ± 0.66 LogMAR increased to 1.11 ± 0.51, 0.99 ± 0.34, 0.92 ± 0.38, 0.74 ± 0.37, 0.52 ± 0.28, 0.64 ± 0.39 respectively at week 1, month 1, month 3, month 6, year 1 and final follow-up postoperatively (p < .05 for all). In none of the eyes ERM recurred, nor flap contraction developed.

CONCLUSION

The study showed encouraging results using free ILM graft in the primary surgery of large MHs. This technique might be considered in large MHs that are associated with ERM or demonstrate patchy ILM staining. Further studies are needed to prove the effectiveness also in the long-term.

Indistinct retinal outer layers in the walls of the idiopathic full-thickness macular hole - A potential predictive biomarker for surgical outcomes

Purpose

To evaluate the absence of external limiting membrane (ELM) and ellipsoid zone (indistinct retinal outer layers, I-ROL) in the walls of idiopathic full-thickness macular holes (FTMHs) circumferentially on optical coherence tomography (OCT) and its correlation with surgical outcome.

Methods

In this retrospective observational study, OCT images of patients undergoing vitrectomy for FTMHs with at least 3-months of postoperative follow-up were analyzed for preoperative circumferential extent of I-ROL. Derived macular hole indices such as hole form factor (HFF), macular hole index (MHI), tractional hole index (THI), and hole diameter ratio (HDR) were also calculated. The circumferential extent of I-ROL was correlated with derived hole indices as well as anatomical closure, foveal architecture, and restoration of ELM following surgery.

Results

All nine eyes (eight patients) with FTMH (mean size: 610.11 ± 122.95 microns) in the study showed I-ROL in ≥1 quadrant. The mean HFF, MHI, THI, and HDR values were 0.72 ± 0.09, 0.35 ± 0.05, 0.71 ± 0.24, and 0.53 ± 0.14, respectively. All eyes achieved type-1 hole closure with improvement in best-corrected visual acuity to 0.58 ± 0.32 LogMAR from 0.81 ± 0.26 LogMAR. Regular foveal architecture was achieved in six eyes. Out of these, five eyes had I-ROL in ≥2 quadrants, and one eye had I-ROL in <2 quadrants (P = 0.0476). Restoration of ELM was seen in aforementioned six eyes (complete = 5, partial = 1). Out of the five eyes with complete ELM restoration, four had a circumferential extent of I-ROL in ≥2 quadrants (P = 0.0476). Complete restoration of ELM was associated with the complete restoration of the ellipsoid zone in three eyes.

Conclusion

Preoperative circumferential extent of I-ROL in FTMH walls can be a potential predictive OCT marker for the type of closure, postoperative foveal architecture, and ELM restoration.

Visual improvement and regeneration of retinal layers in eyes with small, medium, and large idiopathic full-thickness macular holes treated with the inverted internal limiting membrane flap technique over a period of 12 months

PURPOSE

This study aims to compare the improvement of best-corrected visual acuity (BCVA) and the reduction in defect length of external limiting membrane (ELM) and ellipsoid zone (EZ) in small ([Formula: see text] 250 μm), medium ([Formula: see text] 250 μm), and large ([Formula: see text] 400 μm) full-thickness macular holes (FTMH) treated with inverted internal limiting membrane (I-ILM) flap technique over a follow-up period of 12 months.

METHODS

Ninety-one eyes of 87 patients were enrolled in this retrospective study. BCVA and spectral-domain optical coherence tomography (SD-OCT) were conducted preoperatively as well as after 1, 3, 6, 9, and 12 months postoperatively. The defect length of the ELM and the EZ was measured using the caliper tool at each follow-up time point.

RESULTS

BCVA improved significantly in the group of small, medium, and large FTMH over the time of 12 months, whereby the improvement did not depend on FTMH size over 9 months. Only after 12 months, large FTMH showed significantly higher BCVA improvement compared to small and medium FTMH. The closure rate was 100% (91/91). The defect length of ELM and EZ reduced continuously over the period of 12 months. There was a significant correlation between defect length of ELM and EZ with postoperative BCVA.

CONCLUSION

The I-ILM flap technique has very good morphological and functional outcomes in small, medium, and large FTMH over a long-time period, indicating that it can be considered as a treatment option in small and medium FTMH. The defect length of ELM and EZ is directly connected to postoperative BCVA.