Secondary macular hole formation after vitrectomy

Case of Spontaneous Closure and Recurrence of Macular Hole in Vitrectomized Eye

Rationale

Development and spontaneous closure of a macular hole (MH) in a vitrectomized eye is relatively rare. We report our findings in a case in which vitrectomy was performed successfully to treat a vitreous hemorrhage (VH), but a MH developed eight months later. The MH spontaneously closed 2 weeks later, but then reopened. A second vitrectomy was performed with insertion of the internal limiting membrane flap into the MH which led to the successful closure of the MH. The purpose of this article is to present an explanation of how MH developed in this eye without vitreous traction.

Patient

A 64-year-old woman visited an eye clinic with vision reduction in her right eye of 3 days duration. A VH was detected in the right eye and pars plana vitrectomy (PPV) was performed. A retinal tear was detected which was the origin of the VH. The vision was restored to a decimal visual acuity of 1.2. Eight months later, the patient noticed that her vision was distorted and was referred to our hospital.

Diagnosis

Optical coherence tomographic (OCT) images showed a thin epiretinal membrane on the macula, cystoid changes in the macular area, and a full-thickness MH.

Interventions

The MH closed spontaneously in two weeks, however a lamellar MH with an epiretinal proliferation (EP) developed 11 months later. Two months later, OCT showed cyst-like changes in the retina and a full-thickness MH. A second PPV was performed with the insertion of the ILM flap and EP into the MH to close the MH. Her visual acuity improved, and distorted vision was not present.

Lessons

Clinicians should be aware that a MH can develop in a vitrectomized eye without vitreous traction but can close spontaneously. We conclude that careful follow-up examinations are necessary even in vitrectomized eyes.

Relaxing Retinotomy in Recurrent and Refractory Full-Thickness Macular Holes: The State of the Art

The prevailing standard of care for primary repair of full-thickness macular holes (FTMHs) is pars plana vitrectomy with internal limiting membrane (ILM) peeling and gas tamponade, as it gives a high closure rate of roughly 90%. On the other hand, the surgical management of recurrent and refractory FTMHs represents, so far, a demanding and debated subject in vitreoretinal surgery since various approaches have been proposed, with no consensus concerning both adequate selection criteria and the best surgical approach. In addition, the existence of multiple case series/interventional studies showing comparable results and the lack of studies with a direct comparison of multiple surgical techniques may lead to uncertainty. We present an organized overview of relaxing retinotomy technique, a surgical approach available nowadays for the secondary repair of recurrent and refractory FTMHs. Besides the history and the description of the various techniques to perform relaxing retinotomies, we underline the results and the evidence available to promote the use of this surgical approach.

Post-vitrectomy secondary macular holes: Risk factors, clinical features, and multivariate analysis of outcome predictors

Purpose

We report clinical characteristics, risk factors, treatment outcomes, and prognostic predictors of post-vitrectomy secondary macular holes (MHs).

Methods

This was a retrospective observational case series from November 2014 to December 2020. Eyes that developed secondary MH, two weeks and beyond after primary vitrectomy for non-MH indications, were enrolled. Pre- and intraoperative records were screened to exclude pre-existence of MH. Eyes with multiple vitreoretinal surgeries prior to MH detection and tractional myopic maculopathy were excluded.

Results

A total of 29 eyes of 29 patients with a mean age of 52 years developed secondary MH post-vitrectomy. The most common indications for primary vitrectomy were rhegmatogenous retinal detachment (RRD, 48.2%) and tractional retinal detachment (TRD, 24.1%). Time to MH detection after primary vitrectomy was 91.5 ± 117.6 days. The mean minimum hole diameter was 530 ± 298 microns. Epi-retinal membrane and cystoid degeneration was noted in 6 (20.7%) and 12 (41.3%) eyes, respectively (p = 0.088). The mean time from MH detection to MH repair was 34 ± 42 days. The surgical intervention included internal limiting membrane peeling with tamponade in 25 eyes. Overall, 80% showed anatomic hole closure, 90.9% versus 57.1% in the RRD and TRD (p = 0.092), respectively. The mean best-corrected visual acuity (BCVA) at the final visit was 0.71 logarithm of the minimum angle of resolution. Thirteen eyes (52%) had a BCVA of 20/100 or better. Minimal hole diameter (p = 0.029) only predicted final visual acuity. The interval between MH diagnosis and repair did not affect hole closure significantly (p = 0.064).

Conclusion

Secondary MH post-vitrectomy closed successfully with limited visual improvement and trails behind idiopathic MH.

In-Office Sulfur Hexafluoride (SF6) Injection to Close Recently Operated or Reopened Macular Holes: A Minimal Approach Technique

To describe an in-office minimal approach technique for closing recently operated full thickness macular holes (FTMH), when closure was not fully achieved or there was macular hole re-formation, without performing another pars plana vitrectomy (PPV). Retrospective case series study. Nine patients were included in this case series. All patients were diagnosed with FTMH characterized by a decrease in visual acuity (VA) and metamorphopsias. All patients initially underwent a standard PPV procedure with 20% sulfur hexafluoride (SF6) injection. After 1-16 weeks, no closure or reformation of the macular hole was observed. Fluid-SF6 exchange was performed in the slit lamp, with the aim of injecting a 50% gas bubble of pure SF6 into the vitreous cavity, according to a minimally invasive in-office technique. Postoperatively, all patients achieved successful macular hole closure and VA showed an average improvement of approximately 4 lines on the EDTRS logarithm of the minimum angle of resolution (logMAR) chart. In particular, the mean corrected distance visual acuity improved from 0.99 ± 0.27 logMAR to 0.33 ± 0.23 logMAR (P = 0.03). The minimal surgical in-office technique of SF6 injection for the management of reopened macular holes after a recent PPV procedure shows promising results.

Secondary Full-thickness Macular Holes after Diabetic Vitrectomy: Clinical Manifestations and Rational Approaches to the Treatment

Purpose. The aim of the study is to present the clinical characteristics and surgical treatment of secondary full-thickness macular hole (MH) after diabetic vitrectomy (DV) in patients with proliferative diabetic retinopathy (PDR). Methods. In this retrospective, observational, and longitudinal study, we enrolled consecutive patients with PDR who developed MH after DV. The macular structure was evaluated using optical coherence tomography. The clinical characteristics, surgical techniques, and outcomes were also recorded. Results. Three patients developed MH within 6 weeks, which was associated with foveal thinning, residual fibrovascular proliferation, or anterior proliferative vitreoretinopathy. Six patients developed MH originating from the epiretinal membrane (ERM) with lamellar MH (LMH) after a median interval of 16.5 months. Three of them were complicated with retinal detachment (RD). Various surgical procedures were performed according to the clinical scenarios, including internal limiting membrane (ILM) peeling, inverted ILM flap insertion, temporal inverted ILM flap, lens posterior capsular flap insertion, and neurosensory retinal free flap insertion. All patients achieved MH closure after surgery, and 5 patients exhibited improved visual acuity. Conclusions. MH may develop after successful DV, with a high rate of associated RD. Rapid MH formation was attributed to unreleased tractional force and weakened foveal structure. The development of ERM and LMH also led to MH. Various surgical techniques could be used for MH closure.

Secondary Macular Holes Post Pars Plana Vitrectomy

Purpose

To report incidence, clinical presentation, and treatment outcome of full-thickness macular hole (FTMHs) diagnosed post pars plana vitrectomy.

Methods

We retrospectively reviewed the demographics, best-corrected visual acuity (BCVA), indication for the primary vitrectomy, time to diagnose the secondary FTMH, optical coherence tomographic (OCT) appearance, and treatment outcome of FTMHs, occurring after vitrectomy performed between January 2019 and December 2020.

Results

Six of 523 vitrectomized eyes developed FTMHs, an incidence of 1.1%. There were five females and one male, mean age of 56.5 years (range 37–85). The indication for primary vitrectomy was rhegmatogenous retinal detachment (RRD) in three eyes, one eye each for sub internal limiting membrane hemorrhage from a ruptured macroaneurysm, vitreous hemorrhage from polypoidal choroidal vasculopathy (PCV), and pre-insertion of Ahmed glaucoma drainage device (GDD). FTMHs occurred within one week to three months after vitrectomy (time from primary vitrectomy to the identification of the secondary MH was a mean of 1.03 months). Mean BCVA in all six MH eyes was log MAR 0.9 (Snellen: 6/54). Anatomical closure was achieved after one surgery in three eyes, two surgeries in 1 eye, after photodynamic therapy (PDT) in the PCV eye, and one patient declined surgery. The mean BCVA in the four surgically closed MH eyes improved marginally from log MAR 0.82 (Snellen: 6/38) to log MAR 0.72 (Snellen: 6/30), mean follow-up 7.6 months.

Conclusion

Post-vitrectomy FTMH is rare, and RRD was the commonest indication for initial vitrectomy. We observed that all secondary MHs were closed successfully using the inverted internal limiting membrane (ILM) flap technique with limited improvement in vision. The visual outcome of these secondary MHs trails behind that of idiopathic MHs.

Modified internal limiting membrane flap technique for large chronic macular hole: Two case reports

RATIONALE

Internal limiting membrane (ILM) peeling and gas tamponade are the standardized treatments for macular holes (MHs). However, the close rate is low, and postoperative vision is unsatisfactory in large, chronic MHs. Currently, various modifications of the ILM flap techniques are being gradually applied for large MHs in the hope of obtaining better postoperative effects. This study described 2 successful cases achieved by "Sandwich-type" modified ILM flap covering technique in patients with large, chronic MHs.

PATIENT CONCERNS

A 62-year-old woman presented with decreased vision and visual distortion of the left eye for 18 months. Optical coherence tomography (OCT) showed the absence of full-thickness neuroepithelial tissue in the central fovea, with a minimum MH diameter of 742 μm and a base diameter of 1630 μm. A 57-year-old man experienced decreased visual acuity for 8 months. OCT showed the absence of full-thickness neuroepithelial tissue in the central fovea, with a minimum MH diameter of 713 μm and a basal diameter of 939 μm.

DIAGNOSES

Two patients were diagnosed with large, chronic MH based on the OCT results and duration of the hole.

INTERVENTIONS

The 2 patients were treated with the "sandwich-type" modified ILM flap covering technique.

OUTCOMES

Large, chronic MH closure was observed using SD-OCT, and the BCVA improved. The patients were very satisfied with the postoperative results.

LESSONS

"Sandwich-type" modified ILM flap covering technique may be a safe, effective way for large, chronic MH.

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

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

SURGICAL OUTCOMES OF VITREOMACULAR TRACTION TREATED WITH FOVEAL-SPARING PEELING OF THE INTERNAL LIMITING MEMBRANE

PURPOSE

To compare sensitivity of the retina after complete internal limiting membrane (ILM) peeling versus foveal-sparing ILM peeling in vitrectomy for vitreomacular traction syndrome.

METHODS

This was a randomized, prospective, comparative study. Thirty-four eyes were randomized to undergo peeling with foveal sparing of the ILM (FS group) or complete peeling group. Foveal and perifoveal retinal sensitivity, visual acuity, and central macular thickness were the main outcome measures.

RESULTS

Parafoveal retinal sensitivity exhibited a significant improvement in both the FS and complete peeling groups (+2.43 ± 0.82 dB and +1.79 ± 0.86 dB, respectively; P = 0.037). Significant improvements were observed in both visual acuity and central macular thickness in both groups. No cases of epiretinal membrane recurrence were observed in the FS group.

CONCLUSION

Both the FS and complete peeling surgical techniques are safe and yielded good anatomical and functional results; however, a significant difference in favor of FS was found in relation to the best-corrected visual acuity and perifoveal retinal sensitivity. Preservation of the foveal ILM disc allowed the anatomical restoration of the foveal architecture in most vitreomacular traction syndrome cases without signs of stiffening or ILM fibrosis over a follow-up period of 1 year.

Recurrent Spontaneous Macular Hole Formation and Resolution in a Patient With Previous Vitrectomy

Purpose:

We report a case of recurrent macular hole (MH) formation and spontaneous closure in the absence of any vitreoretinal interface abnormality.

Methods:

A 49-year-old man presented for his annual ocular examination with no specific ocular complaints. He had a history of retinal detachment in the left eye, which was treated years prior with vitrectomy and scleral buckle. During a routine follow-up, the patient was discovered to have a full-thickness MH. Optical coherence tomography revealed the formation of an MH with spontaneous closure after 3 months without intervention. One month later, the MH recurred but once again closed spontaneously over 4 months.

Results:

The patient remained asymptomatic during the entire follow-up without any symptoms, vision changes, or therapeutic intervention.

Conclusions:

To our knowledge, this is the first known case report of recurrent spontaneous opening and closure of an MH in the absence of any vitreoretinal interface abnormality, as revealed by macular optical coherence tomography imaging.

Macular holes following vitrectomy for rhegmatogenous retinal detachment: epiretinal proliferation and spontaneous closure of macular holes

PURPOSE

To describe the characteristics and management of full-thickness macular holes (MHs) that develop after pars plana vitrectomy for rhegmatogenous retinal detachment (RD).

METHODS

Retrospective, interventional, consecutive case series. Patients who developed secondary full-thickness MHs after prior pars plana vitrectomy for RD over a 6-year period were included. The main outcome measures included optical coherence tomography (OCT) findings and the clinical course of full-thickness MHs.

RESULTS

A total of 11 eyes of 11 consecutive patients were included in the study. The mean age of the patients was 58.8 years (range, 47-70 years). The median time between RD repair and MH diagnosis was 36 months (range, 1 month-11 years). The fovea was attached to 10 eyes (91%) at the time of RD repair. OCT demonstrated epiretinal proliferation (EP) at the hole margin in 10 eyes (91%). MH spontaneously closed in 7 eyes (63%) but reopened in 5 eyes. A total of 7 eyes (63%) required a vitrectomy to repair the MHs. All MHs were closed at the last follow-up visit.

CONCLUSION

Full-thickness MHs after pars plana vitrectomy for RD have features that are distinct from that of typical idiopathic MH. The presence of EPs is common, and MHs are prone to spontaneous closure and reopening. These findings suggest that EP may be associated with spontaneous hole closure and that long-term follow-up is necessary even if the MHs close spontaneously.

Foveal Crack Sign: An OCT Sign Preceding Macular Hole After Vitrectomy for Rhegmatogenous Retinal Detachment

PURPOSE

To describe an optical coherence tomography (OCT) sign preceding macular hole (MH) formation after pars plana vitrectomy (PPV) for rhegmatogenous retinal detachment (RRD).

DESIGN

Retrospective observational case series.

METHODS

Patients who underwent PPV for RRD at Osaka Rosai Hospital between January 2014 and December 2017 were examined. First, the medical records of the patients who had secondary MH after RRD repair were examined, and their sequential changes of the OCT images until MH formation were evaluated. Second, the OCT findings and the medical records of all patients who underwent PPV for RRD were evaluated based on the findings of the cases of secondary MH.

RESULTS

Ten eyes of 10 patients who had secondary MH after PPV for RRD were enrolled. Before MH formation, all eyes had parafoveal epiretinal membrane (ERM) and a characteristic OCT sign that was termed a foveal crack sign (FCS), a hyperreflective vertical line in the foveola with a deformation of the fovea. FCS was found 255 ± 217 days after PPV for RRD, and MH developed 232 ± 171 days after FCS appearance. Furthermore, among 518 eyes that underwent PPV for RRD, FCS with parafoveal ERM was found in 3 eyes without succeeding MH after RRD repair. FCS of these 3 eyes were found 363 ± 4 days after PPV for RRD.

CONCLUSIONS

In all cases of secondary MH formation after PPV for RRD, FCS with parafoveal ERM was found before MH formation. This sign may predict secondary MH formation caused by ERM traction.

Full thickness macular hole formation and spontaneous closure associated with branch retinal vein occlusion in a vitrectomized eye: A case report

RATIONALE

Macular hole (MH) formation after vitrectomy is rare and it may be due to several mechanisms associated with change of foveolar anatomy by vitrectomy. If a MH develops after vitrectomy, surgical treatments including internal limiting membrane peeling and intravitreal gas injection are usually needed for repair of hole. Spontaneous closure of MH is much rarer.

PATIENT CONCERNS

A 66-year-old patient had a vitrectomy for rhegmatogenous retinal detachment not involving the macula of the right eye. Eight months after the vitrectomy, the visual acuity decreased and full-thickness defect of macula, epiretinal membrane progression, intraretinal cysts, and flame shape hemorrhage along with superior temporal vascular arcade were observed on fundus examination and optical coherence tomography.

DIAGNOSES

MH and branch retinal vein occlusion (BRVO) accompanying cystoid macular edema (CME) were both present on her right eye. Thus, we planned a surgery for MH repair.

INTERVENTIONS

The status of MH was observed while waiting the surgery schedule. At 2 weeks after detection of the MH, optical coherence tomography showed that intraretinal cysts had decreased in extent and the inner wall of the MH had contracted; 4 weeks later, the MH was closed with a subtle subretinal space.

OUTCOMES

The fovea was well-maintained with a complete closure for 9 months.

LESSONS

MH formation and spontaneous closure occurred in association with BRVO accompanying CME in a patient who had a vitrectomy. In vitrectomized eyes, physicians should consider the possibility of MH development in association with BRVO, and possible spontaneous closure of the MH in accordance with CME resolution.

Perfluorocarbon liquid-assisted inverted inner limiting membrane-flap for large macular hole after recurrent rhegmatogenous retinal detachment

A 45-year-old Caucasian myopic woman with a severe vision impairment (20/320) in the left eye due to a macula-off rhegmatogenous retinal detachment (RRD) underwent vitrectomy with silicone oil tamponade followed by an inferior relaxing retinectomy with heavy silicone oil tamponade during the second procedure for recurrence of RRD due to proliferative vitreoretinopathy. Four weeks after the second surgery, visual acuity was 20/200 and the patient complained metamorphopsia in the same eye due to a large full-thickness macular hole. A perfluorocarbon liquid-assisted inverted inner limiting membrane-flap technique was performed. Visual acuity improved to 20/80 after closing of macular hole and partial recovery of outer retinal layers at 3 months from the last surgery.

Full-Thickness Macular Hole with Coats Disease: A Case Report

We report a case of full-thickness macular hole (FTMH) which developed during follow-up for Coats disease. To our knowledge, this is the first report on a case of FTMH which developed during follow-up for Coats disease. A 17-year-old boy was referred to our institution with blurred vision in his left eye. Fundus examination showed yellowish subretinal exudates with overlying telangiectatic retinal vessels in the temporal periphery in the left eye; the right eye was normal. Fluorescein angiography revealed diffusion indicative of temporal peripheral vascular leakage. We made a diagnosis of stage 2A Coats disease and performed argon laser photocoagulation (PC). Moreover, he received intravitreal injection of anti-vascular endothelial growth factor. At 30 months after the first visit, the best-corrected visual acuity (BCVA) of the left eye worsened to 20/50. We observed tensioned internal limiting membrane (ILM), serous macular detachment (SMD) and retinal thinning; the intraretinal exudate remained. We performed PC and at 36 months after the first visit, BCVA further declined to 20/63 in his left eye and FTMH was observed. We then performed a 27-gauge pars plana vitrectomy and ILM peeling following which the FTMH was found to have closed by 4 days after vitrectomy. SMD gradually decreased, and BCVA improved to 20/20. Chronic inflammation by peripheral vascular leakage and PC application might have caused FTMH. In this case, the vitrectomy for FTMH with Coats disease provided good visual and anatomic outcomes.

Macular optical coherence tomography findings after vitreoretinal surgery for rhegmatogenous retinal detachment

The primary aim of this study was to summarize and illustrate the main structural cross-sectional optical coherence tomography findings encountered after vitreoretinal surgery for rhegmatogenous retinal detachment. This was a non-systematic review of literature on structural cross-sectional optical coherence tomography findings after vitreoretinal surgery for rhegmatogenous retinal detachment. Adequate illustrations of the main findings described were found after a retrospective analysis of imaging and charts of patients operated at the department where this study was performed. The main structural cross-sectional optical coherence tomography findings after vitreoretinal surgery for rhegmatogenous retinal detachment included persistent subretinal fluid, subretinal blebs, retinal folds, subretinal perfluorocarbon liquids, macular alterations related to silicone oil, epiretinal membranes, proliferative vitreoretinopathy, cystoid macular edema, macular holes, and recurrent retinal detachment. In conclusion, optical coherence tomography was a useful tool after vitreoretinal surgery for rhegmatogenous retinal detachment. Some optical coherence tomography findings may not be evident on fundus examination, and optical coherence tomography can reveal essential details for the clinical management and the visual prognosis. Other findings, despite being visible on funduscopic examination, may be better assessed with the aid of optical coherence tomography. All these elements contribute to support the importance of tomographic assessment in the follow-up of eyes treated for vitreoretinal conditions.

Clinical characteristics, risk factors, and surgical outcomes of secondary macular hole after vitrectomy

Secondary macular hole(MH) formation after vitrectomy is rare and its risk factors and pathogenesis are not clearly understood. This retrospective study was conducted to identify the risk factors of this complication and assess outcomes at 2 tertiary centres. The primary outcomes were the clinical characteristics associated with development of secondary MH, which included the primary diagnosis for initial vitrectomy, features on optical coherence tomography, and adjuvant surgical techniques used during the initial surgery. Secondary outcomes included the change in best-corrected visual acuity(BCVA), clinical factors associated with the need for re-operations for MH closure and prognostic factors for the visual outcomes. Thirty-eight eyes out of 6,354 cases (incidence 0.60%) developed secondary MH after undergoing vitrectomy for various vitreoretinal disorders over an 11-year period, most frequently after initial surgery for retinal detachment(RD) (9 eyes) and secondary epiretinal membrane (6 eyes). The mean age was 57.1 years (range: 17.8-76.7), and the mean follow-up was 51.1 months (range: 6.8 to 137.6). Prior to secondary MH formation, development of ERM was the most common OCT feature (19 eyes, 50%), and no cases of cystoid macular oedema (CME) were observed. A greater proportion of eyes with secondary MH had long axial lengths (32% ≥26 mm vs 5% of eyes ≤22 mm). MH closure surgery was performed in 36 eyes and closure was achieved in 34 (success rate 94%, final BCVA 20/86), with ≥3-line visual gain in 18 cases. BCVA at MH onset (OR = 0.056, P = 0.036), BCVA at post-MH surgery month 3 (OR = 52.671, P = 0.011), and axial length ≥28 mm (OR = 28.487, P = 0.030) were associated with ≥3-line visual loss; a history of macula-off RD (OR = 27.158, P = 0.025) was associated with the need for multiple surgeries for MH closure. In conclusion, secondary MH occurs rarely but most commonly after vitrectomy for RD. Patients with axial length ≥28 mm and poor BCVA at 3 months post-operation may have limited visual prognosis; those with a history of macula-off RD may require multiple surgeries for hole closure.

Alterations of Foveal Architecture during Vitrectomy for Myopic Retinoschisis Identified by Intraoperative Optical Coherence Tomography

PURPOSE

To determine the changes in the foveal architecture before and after internal limiting membrane (ILM) peeling with and without fovea-sparing ILM peeling (FSIP) during vitrectomy for high myopic retinoschisis by intraoperative optical coherence tomography (iOCT).

METHODS

Qualitative assessments were made of the alterations of the retinal architecture imaged by iOCT following complete ILM peeling (peeled group) or fovea-sparing ILM peeling (FSIP group). A microscope-integrated real-time iOCT device was used to analyze the retinal architectures. The alterations included a worsening of the retinoschisis, development of a foveal detachment, and development of a full thickness macular hole. The changes in the retinal architecture, clinical characteristics, and outcomes were compared between the 2 groups.

RESULTS

The medical records of 15 eyes of 15 patients were studied. Complete ILM peeling was performed on 9 of 15 eyes, and 8 of the 9 eyes (89%) showed a worsening of the retinal architectures following the ILM peeling. FSIP was performed on 6 of the 15 eyes, and none of these eyes developed any retinal architectural changes in the iOCT images. The mean postoperative best-corrected visual acuity (BCVA) in eyes that underwent FSIP (20/38) was significantly better than that of preoperative BCVA (20/128; p < 0.05), although the differences in the preoperative BCVA (20/87) and postoperative BCVA (20/55) in the cases that underwent complete ILM peeling were not significant.

CONCLUSIONS

The lack of alterations of the foveal architecture and significant improvements in the BCVA after FSIP indicate that FSIP peeling should be considered for eyes with retinoschisis. We recommend that iOCT be used to monitor the retinal architecture during intraocular surgery involving the retina.

A Case of Giant Macular Hole Progression after Rupture of a Giant Retinal Pigment Epithelial Detachment

We report a case of giant macular hole progression after rupture of giant retinal pigment epithelial detachment (PED). The patient was a 91-year-old man who had a giant PED in the left eye. He had bilateral hypermetropia (+2.00 dpt), and he had developed posterior vitreous detachment. The PED was 5,800 μm in diameter and 800 μm in height and ruptured during follow-up. A macular hole was formed, with a diameter of 400 μm, and the height of the PED had reduced to 360 μm. After 5 months, the macular hole expanded up to a diameter of 600 μm. Therefore, some cases of giant PED may lead to macular hole.

DOUBLE ARCUATE RELAXING RETINOTOMY FOR A LARGE MACULAR HOLE

PURPOSE

To describe double arcuate relaxing retinotomy as an alternative surgical technique in a case with a secondary large macular hole.

METHODS

The management of a patient who developed a large macular hole and macular tractional rhegmatogenous retinal detachment after pars plana vitrectomy for proliferative diabetic retinopathy was retrospectively assessed. Despite surgical procedures, such as dissection of a preretinal membrane from the retina and peeling of the retinal internal limiting membrane, the macular hole could not be closed. In the absence of an alternative method, superior and inferior posterior arcuate, 120° relaxing retinotomies were performed.

RESULTS

At the follow-up, the macular hole closure was confirmed by clinical examination and optical coherence tomography imaging, and visual acuity improved. There were no intraoperative or postoperative complications.

CONCLUSION

In cases of large macular holes, double arcuate relaxing retinotomy can reduce traction, leading to hole closure.

Macular Hole Formation After Pars Plana Vitrectomy for Diabetic Tractional Retinal Detachment

BACKGROUND AND OBJECTIVE

To investigate the incidence, clinical features, and outcomes of patients with macular hole (MH) formation after pars plana vitrectomy (PPV) for diabetic tractional retinal detachment (TRD).

PATIENTS AND METHODS

We conducted a retrospective review of all cases of PPV for diabetic TRD performed by a surgeon (DS) at a large county hospital between November 2013 and August 2016.

RESULTS

Ninety consecutive eyes of 79 patients were included in this case series, of which four eyes developed MH, yielding an incidence of 4.4% (95% confidence interval [CI], 1.2%-11.0%). The mean interval between PPV for TRD and MH formation was 7.0 ± 5.5 (mean ± 1 standard deviation) months, and mean follow-up time was 29.6 months ± 6.9 months. Three of the four eyes that developed MH underwent intervention, and of the three that underwent intervention, all had successful hole closure.

CONCLUSION

In this case series, the incidence of MH after PPV for TRD is 4.4% (95% CI, 1.2%-11.0%). The mechanism of MH formation after diabetic TRD repair is not certain but may be related to a taut internal limiting membrane, epiretinal membrane formation, macular edema, or residual vitreous contraction. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e256-e262.].

Surgical closure of giant traumatic macular hole with retinal graft

AIM

To present a case with a large traumatic macular hole that we repaired with a retinal graft.

CASE DESCRIPTION

A 24-year-old male patient presented with corneal penetration and an intraocular foreign body caused by a work accident. Vitrectomy and intraocular foreign body removal were performed. One month after the surgery, the patient had macula on retinal detachment in the nasal and superior quadrant. In addition, a giant macular hole was formed. However, the macula was atrophic because of the trauma, and we could not repair the hole with classic macular hole surgery techniques. For this reason, we used a retinal graft to cover the macular hole, and we observed that the hole was closed in follow-up visits.

CONCLUSION

Retinal grafts can be used in patients with giant macular holes. They may be useful especially in patients with atrophic macula in trauma cases.

Full-Thickness Macular Hole Formation in the Postoperative Period After Initial Vitrectomy for Rhegmatogenous Retinal Detachment

Background and Objective

To evaluate full-thickness macular hole (MH) formation in the postoperative period after initial vitrectomy for rhegmatogenous retinal detachment (rRD).

Materials and Methods

We retrospectively reviewed the medical records of 4 consecutive eyes that required additional vitrectomy for full-thickness MH between April 2013 and March 2016 after undergoing an initial vitrectomy for rRD.

Results

Epiretinal membrane (ERM) was identified by preoperative optical coherence tomography or intraoperative dye staining in each case. Photocoagulation of retinal breaks prior to initial vitrectomy was performed in Cases 1, 2, and 3 (4–16 days), with yttrium-aluminum-garnet capsulotomy after cataract extraction also performed prior to the retinal break formation in Case 3. At the initial vitrectomy, there was a superior retinal break which crossed the equator in Case 2, and an intentional hole was created in Cases 1 and 4. The mean interval from the initial vitrectomy until MH formation was 27.5 ± 15.8 months. As with Case 2, the intervals in Cases 1 and 4, in which an intentional hole was created, were clearly shorter than in those in Case 3. Finally, MH closure was achieved after an additional vitrectomy (removal of the internal limiting membrane with ERM and gas tamponade) and best-corrected visual acuity improved in each case.

Conclusion

ERM was identified in the cases examined in our study. The presence of an intentional hole might shorten the interval of MH formation after vitrectomy for rRD.

MACULAR HOLE AFTER PARS PLANA VITRECTOMY FOR RHEGMATOGENOUS RETINAL DETACHMENT

PURPOSE

To report the clinical features, possible associations and treatment outcomes of patients with macular hole after pars plana vitrectomy (PPV) (single or multiple) for rhegmatogenous retinal detachment (RD).

METHODS

Retrospective consecutive case series from July 2009 to July 2014.

RESULTS

In the 15 study patients, the average time from RD surgery to macular hole diagnosis was 119 days (range: 41-398 months). Possible associations include epiretinal membrane (73%, 11/15 patients), macula-off RD (60%, 9/15 patients), recurrent RD (47%, 7/15 patients), and high myopia (56%, 5/9 patients). Single surgery was successful in hole closure in 8/15 patients (Group A) while 7/15 patients underwent multiple surgeries (Group B). Macular hole closure was achieved in 7/8 (87.5%) patients in Group A compared to 4/7 (57.1%) patients in Group B. Improvement of at least two lines of Snellen's visual acuity was achieved in 4/8 (50.0%) and 4/7 (57.1%) patients in Group A and B, respectively.

CONCLUSION

In patients with macular hole formation after pars plana vitrectomy for RD, possible associations were epiretinal membrane, macula-off RD, recurrent RD, and high myopia. Even when macular hole closure was achieved, limited visual improvement occurred.

RECURRENT OPENING AND CLOSURE OF MACULAR HOLE AFTER PARS PLANA VITRECTOMY FOR RHEGMATOGENOUS RETINAL DETACHMENT

PURPOSE

To report a case of full-thickness macular hole formation and closure twice after pars plana vitrectomy for macula-off rhegmatogenous retinal detachment.

METHODS

Case report.

RESULTS

A 45-year-old woman with a macula-off rhegmatogenous retinal detachment underwent uncomplicated pars plana vitrectomy with silicone oil tamponade, which was removed 3 months postoperatively. A full-thickness macular hole developed spontaneously 18 months after silicone oil removal, concurrently with the formation of epiretinal membrane and perifoveal cystoid changes. The hole was noted to close spontaneously within 2 months with normal foveal contour formation and improved vision, but then reopened for the second time after 10 months. A second spontaneous closure was observed within 2 months.

CONCLUSION

Dynamic course of macular hole formation and resolution in a previously vitrectomized eye may justify a more conservative approach with observation for some time before surgical intervention is favored.

MACULAR HOLE FORMATION AFTER PARS PLANA VITRECTOMY FOR PRIMARY VITREORETINAL LYMPHOMA

PURPOSE

To report a case of primary vitreoretinal lymphoma in which a macular hole developed after a diagnostic pars plana vitrectomy.

METHODS

A retrospective interventional case report.

RESULTS

A 65-year-old woman presented with worsening vision in the left eye. Fundus examination showed vitreous haze and multifocal, yellow-white infiltrates in the retina and under the retinal pigment epithelium in the left eye. She underwent a diagnostic pars plana vitrectomy in that eye. Undiluted vitreous specimen showed an increased interleukin-10 level (1,470 pg/mL) with an elevated interleukin-10 to interleukin-6 ratio of 15.1; cytologic analysis of the vitreous showed atypical lymphoid cells with large irregular nuclei and scanty cytoplasm. The retinal and sub-retinal pigment epithelial infiltrates responded well to intravitreal methotrexate injections, but a macular hole developed in the left eye. The second pars plana vitrectomy with internal limiting membrane peeling and 20% sulfur hexafluoride gas tamponade successfully closed the macular hole.

CONCLUSION

Macular hole closure can be accomplished in eyes receiving intravitreal methotrexate injections for treating primary vitreoretinal lymphoma.

Macular Hole Development After Vitrectomy for Floaters: A Case Report

INTRODUCTION

The purpose of this report is to describe a case of macular hole development after vitrectomy for floaters with induction of posterior vitreous detachment.

CASE REPORT

A 44-year-old otherwise healthy man presented with visually debilitating floaters in his right eye; these had been present for more than 2 years. Preoperative examination was unremarkable in both eyes, apart from some degree of vitreous degeneration in the right eye. Preoperative visual acuity was 20/20 bilaterally. A 25-gauge transconjunctival sutureless pars plana complete vitrectomy with induction of posterior vitreous detachment was performed in the right eye. Upon examination 1 month after surgery, a small full-thickness macular hole was detected in the right eye. Visual acuity was diminished to 20/80. The macular hole was closed after a second vitrectomy with internal limiting membrane peeling and gas tamponade.

CONCLUSION

Macular hole development should be listed as a possible complication of vitrectomy for visually debilitating floaters when a posterior vitreous detachment is induced during surgery.

Postvitrectomy macular hole undergoing delayed closure after 28 months

Case report of a 70-year-old male who developed full thickness macular hole (MH) following vitrectomy for vitreomacular traction syndrome. The further intervention was deferred due to the unwillingness of the patient for the second surgery. Periodic follow up of the patient, revealed improvement in visual acuity with the closure of the MH after 28 months.

Macular hole formation and spontaneous closure after vitrectomy for rhegmatogenous retinal detachment documented by spectral-domain optical coherence tomography: Case report and literature review

This case report describes macular hole (MH) formation and spontaneous closure after vitrectomy for rhegmatogenous retinal detachment (RRD) repair. A 58-year-old man referred with a macula-off superior RRD, in whom vitrectomy was performed. MH with vitreomacular traction (VMT) caused by the posterior vitreous cortex remnants developed 2 weeks after vitrectomy. Four weeks postoperatively, optical coherence tomography revealed resolution of the VMT and spontaneous closure of MH without providing any treatment. This is the first report of an MH formation and spontaneous closure after vitrectomy for RRD. This suggests that the VMT mediated by the posterior vitreous cortex remnants has an important role in the development of secondary MH.

Long-term Surgical Outcomes of Epiretinal Membrane in Patients with Retinitis Pigmentosa

Macular complications such as an epiretinal membrane (ERM), a cystoid macular edema and a macular hole lead to unexpected central vision impairment especially for patients with retinitis pigmentosa (RP). To evaluate the long-term surgical outcomes of pars plana vitrectomy (PPV) for ERM in patients with RP, we retrospectively reviewed the charts of a consecutive series of 10 RP patients who underwent PPV for ERM at Kyushu University Hospital. Visual acuity (VA) testing, a fundus examination, and an optical coherence tomography (OCT) analysis were conducted. The standard PPV using three sclerotomies was performed for ERM. PPV was performed in 12 eyes of 10 patients. One eye was excluded from the outcome assessment due to short period observation (18 months). There was no significantly deleterious change from the baseline to final VA between the operation eyes and the fellow eyes (P = 0.19). Moreover, morphological improvement was obtained in 9 of 11 eyes based on OCT. Our present data suggest that PPV may be tolerable in the management for ERM in RP patients over the long-term. Furthermore, the appearance of the ellipsoid zone was an important factor in the prediction of visual outcome and determination of surgical indication.

Novel microarchitectural dynamics in rhegmatogenous retinal detachments identified with intraoperative optical coherence tomography

PURPOSE

To evaluate ultrastructural macular changes during rhegmatogenous retinal detachment repair using intraoperative optical coherence tomography (iOCT).

METHODS

A multisurgeon, single-center consecutive case series of 9 eyes undergoing surgical repair for macula-involving rhegmatogenous retinal detachment with iOCT imaging using a custom microscope-mounted spectral domain OCT system. All patients underwent combined vitrectomy/scleral buckle repair. Imaging characteristics were analyzed, including persistence of subclinical intraoperative subretinal fluid and architectural changes associated with intraoperative maneuvers. Clinical characteristics were analyzed.

RESULTS

Nine eyes of nine patients were identified that underwent iOCT imaging during macula-involving rhegmatogenous retinal detachment repair. Persistent subclinical subretinal fluid was identified in 100% of eyes after perfluoro-n-octane instillation. Significant alterations to the foveal architecture were detected with iOCT in 100% of cases. Three foveal configurations were noted based on iOCT findings. Stage 1 was characterized by a small area of subfoveal hyporeflectivity (3/9 eyes), Stage 2 had prominent subretinal hyporeflectivity and foveal thinning with indeterminate macular hole (MH) formation (3/9 eyes), and Stage 3 demonstrated definitive full-thickness MH (3/9 eyes). No eyes were noted to have a MH preoperatively or in the immediate postoperative period. One Stage 3 eye developed a full-thickness MH 7 months postoperatively. Stage 3 configuration was associated with poorer final postoperative visual acuity (P = 0.009).

CONCLUSION

Microarchitectural changes occur during intraoperative repair of retinal detachments, including significant alterations in foveal configuration and persistent subretinal fluid. These features may help to prognosticate outcomes. These findings also suggest a possible novel mechanism for postrhegmatogenous retinal detachment MH formation.

Posterior uveal melanoma coexistent with macular hole

PURPOSE

Three rare cases of macular holes coexistent with posterior uveal melanoma are presented. The possible pathogenesis of a macular hole secondary to uveal melanoma growth is discussed, as well as strategies to treat uveal melanoma before attempting macular hole repair.

CASE REPORT

Each patient from all three cases had a macular hole and uveal melanoma at the initial presentation. The macular holes were present before uveal melanoma treatment in cases 1 and 2. The patient in case 3 had already been treated elsewhere with iodine-125 plaque brachytherapy for her melanoma. It was not known if macular hole formation occurred before or after that treatment. Macular hole repair was performed in case 1, and the hole was successfully closed.

CONCLUSIONS

To the best of the authors' knowledge, there are now only nine documented cases of macular holes accompanying posterior uveal melanoma. Successful macular hole repair may prove difficult because the melanoma must first be properly treated and then monitored carefully to establish tumor inactivity.

Understanding macular holes that develop after repair of retinal detachment

OBJECTIVE

To present the characteristics and outcomes of macular holes (MHs) that arise in eyes that have been treated for retinal detachment (RD).

DESIGN

Retrospective, interventional, consecutive case series.

PARTICIPANTS

We studied 18 eyes that developed a MH following RD repair.

METHODS

We report the demographic and clinical characteristics, MH closure rates, and best corrected visual acuity (BCVA) following MH repair.

RESULTS

We detected 18 full-thickness MHs in 985 eyes. In 14 of 18, the original RD involved the macula, and in 16 of 18, the BCVA was 20/200 or worse. Of the RDs, 8 of 18 required multiple procedures to achieve reattachment. Post-RD BCVA was 20/200 or worse in 15 of 18 patients. The median time to MH diagnosis after RD repair was 1 month (range, 2 days to 53 months), and from MH diagnosis to MH repair, the median time was 1.75 months (range, 3 weeks to 8 months). Of 16 eyes (89%) that underwent surgical repair of the MH, 14 achieved MH closure, 1 requiring multiple pars plana vitrectomy, and 11 saw at least 1 Snellen line of improvement (median, 1; range, 1 to 6); 2 lost vision (1 and 2 Snellen lines, respectively); and 3 remained unchanged at a median follow-up of 3 months (range, 1 month to 25 months). Of the 18 patients, 6 had at least 20/80 BCVA at last follow-up.

CONCLUSIONS

MHs following RDs (incidence 1.9%) are likely to be macula-off RDs requiring multiple interventions for RD repair. Post-MH-repair closure rates are similar to the rates for idiopathic MHs. BCVA outcomes are moderate and are dependent on impairment post-RD repair. The findings suggest other pathogenic mechanisms besides vitreofoveal traction may be leading to these MHs.

Lamellar macular hole formation following vitrectomy for rhegmatogenous retinal detachment repair

BACKGROUND

The purpose of this study was to investigate lamellar macular hole formation in six patients after rhegmatogenous retinal detachment repair.

METHODS

A retrospective review of medical records of patients who underwent primary pars plana vitrectomy for rhegmatogenous retinal detachment repair was performed. Optical coherence tomography characteristics and best-corrected visual acuity were evaluated. Patients who developed lamellar macular hole after pars plana vitrectomy for rhegmatogenous retinal detachment repair were identified.

RESULTS

A total of 1185 eyes underwent pars plana vitrectomy for retinal detachment between 2004 and 2009. Optical coherence tomography evaluation was available in 450 cases. Six of these cases demonstrated lamellar macular hole formation, which was diagnosed by OCT-3. The mean time from retinal detachment surgery to lamellar hole diagnosis was 4.1 months. The presence of an epiretinal membrane on the surface of the juxtafoveal retina was a common finding in all six patients. Visual acuity was improved after successful retinal reattachment and remained unchanged after lamellar hole formation.

CONCLUSION

Lamellar macular holes developing after pars plana vitrectomy is a rare complication. Stability of optical coherence tomography findings and best-corrected visual acuity after lamellar macular hole formation may be observed for at least two years.