SUPRA CHOROIDAL BUCKLING IN MANAGING MYOPIC VITREORETINAL INTERFACE DISORDERS: 1-Year Data

A Novel Technique Using Lyophilized Amniotic Membrane Patch (LAMPatch) as Primary Procedure in Patients with Myopic Traction Maculopathy with Macular Detachment

Introduction

Maculopathy secondary to pathologic myopia (PM) is increasingly causing visual impairment and blindness worldwide. PM is associated with tractional maculopathy that ranges from macular foveoschisis to macular hole. These disorders are treated with different options that offer variable results, reflecting the need for new techniques that address myopic maculopathy with consistent outcomes.

Methods

Since human amniotic membrane (HAM) has been reported to be safe for intraocular use and to promote retinal healing, it was incorporated as an adjuvant in pars plana vitrectomy in patients with different tractional disorders related to myopia. This work presents a prospective, consecutive case series of seven patients with high myopia who underwent a 25-gauge vitrectomy with ILM peeling and HAM transplantation.

Results and Discussion

Our six-month results show that this novel technique delivers functional success related to tissue permanence without recurrence of traction that translates into visual acuity gain and maintenance that are superior to other techniques.

Lamellar macular hole in highly myopic eyes and insights into its development, evolution, and treatment: a mini-review

Lamellar macular holes (LMHs) are a manifestation of myopic tractional maculopathy (MTM). Owing to the complex and multidirectional traction force in the elongated eyeball, the clinical features, development, evolution, and treatment algorithms of LMH in highly myopic eyes may differ from those of idiopathic LMH or MTM in general. This review aimed to specifically explore the LMHs in highly myopic eyes. Several developmental processes of LMH and their association with macular retinoschisis have been demonstrated, with the tractional component identified in all processes. Epiretinal proliferation was more prevalent and more extensive in LMHs in highly myopic eyes than in idiopathic LMHs. LMHs in highly myopic eyes may remain stable or progress to foveal detachment and full-thickness macular hole with or without retinal detachment. The predictive factors associated with disease progression were summarized to facilitate monitoring and guide surgical intervention. The treatment of LMHs in highly myopic eyes was based on an algorithm for treating myopic tractional maculopathy, including gas tamponade, pars plana vitrectomy, macular buckling, and a combination of vitrectomy and macular buckling. New internal limiting membrane (ILM) manipulation techniques such as fovea-sparing ILM peeling or fovea-sparing ILM peeling combined with ILM flap insertion could reduce the risk of developing iatrogenic full-thickness macular holes postoperatively. Further research should focus on the treatment of LMH in highly myopic eyes.

DIFFERENCES IN THE PROGRESSION BETWEEN MYOPIC MACULOSCHISIS EYES WITH AND WITHOUT MACULAR DETACHMENT IN THE NATURAL COURSE OF THE DISEASE: A Retrospective Longitudinal Study Based on the New Myopic Traction Maculopathy Staging System

PURPOSE

To investigate the pace of visual acuity loss in myopic maculoschisis eyes with or without macular detachment and identify associated risk factors.

METHODS

One thousand three hundred and thirty-four eyes of 991 patients with high myopia were reviewed. A new myopic traction maculopathy staging system classified four retinal stages and three foveal stages. To the myopic traction maculopathy eyes with normal fovea, maculoschisis with and without macular detachment was defined as Stage 3a and Stages 1a, 2a respectively.

RESULTS

One hundred and ten (8.25%) eyes with maculoschisis were included, with a follow-up of 24.00 ± 17.47 months. Of them, 84 (76.36%) were Stages 1a, 2a, and 26 (23.64%) were Stage 3a. The visual acuity loss per year during the follow-up period was similar between eyes with Stages 1a, 2a and Stage 3a (3.13 ± 12.21 vs. 3.41 ± 18.42 letters, P = 0.930). Multivariate analyses revealed that vitreomacular interface factors were significantly associated with visual acuity loss during the follow-up, no matter in Stages 1a, 2a or Stage 3a ( P = 0.039 and P = 0.038, respectively). In the Stages 1a, 2a group, the percentage of eyes that lost at least 10 letters at the final visit compared with the baseline visual acuity was higher in eyes with vitreomacular interface factors than in those without vitreomacular interface factors (13 eyes, 50.00% vs. 14 eyes, 24.14%, P = 0.019).

CONCLUSION

No differences were found in visual acuity loss pace between Stages 1a, 2a and Stage 3a. Surgical intervention or at least more intensive follow-up should be considered for Stages 1a, 2a eyes with vitreomacular interface factors, to promote a more favorable visual outcome.

CHANGES IN THE CHOROIDAL THICKNESS AFTER MACULAR BUCKLING IN HIGHLY MYOPIC EYES

PURPOSE

To assess changes in the choroidal thickness (CT) after macular buckling in eyes with high myopia.

METHODS

Highly myopic eyes that underwent macular buckling surgery were retrospectively analyzed. Data of swept-source optical coherence tomography scanning at baseline and at 1, 3, 6, 12, and 18 months after macular buckling were collected. Subfoveal CT and CT at 750 µm superior, inferior, nasal, and temporal to the fovea were measured. The total choroidal area, vascular area, and stromal area were measured by the binarization method. The choroidal vascularity index was calculated by dividing the vascular area by the total choroidal area.

RESULTS

Forty-one eyes were included in the final analysis. The subfoveal CT increased from 49.85 ± 31.23 µm preoperatively to 75.74 ± 37.89 µm 1 month after macular buckling (P < 0.001), then decreased over time, coinciding with the trends of parafoveal CT, total choroidal area, vascular area, and stromal area. The subfoveal CT was restored to the preoperative level six months postoperatively (P = 0.202) and remained stable until the end of follow-up. The choroidal vascularity index increased at 1 and 3 months postoperatively (P = 0.001 and 0.005, respectively).

CONCLUSION

The choroid thickened in the early postoperative period. The compression force of the buckle implant might disturb microcirculatory drainage and contribute to the thickening. The choroid spontaneously recovered to the preoperative level over time.

Hemorrhagic complications associated with suprachoroidal buckling

Background

Multiple surgical techniques exist for the repair of rhegmatogenous retinal detachments (RRD). Suprachoroidal buckling (SCB), consisting of injecting viscoelastic material in the suprachoroidal space to allow chorioretinal apposition, has been recently described in the repair of RRD. The aim of this study is to report the complications of SCB and to propose measures to decrease their incidence during the learning curve.

Methods

A total of 26 eyes of 26 patients who underwent a SCB procedure for the management of RRD secondary to a single or multiple retinal breaks were enrolled. Patients were operated between January 2014 and March 2017 at two academic institutions. Patient and retinal detachment characteristics were obtained from the charts. Surgical videos were reviewed for every case and intraoperative complications were recorded. Complications observed postoperatively were obtained from the charts.

Results

Sixteen eyes (62%) underwent SCB alone, 5 eyes (19%) underwent additional gas tamponade and 5 eyes (19%) had combined pars plana vitrectomy. The most common complication was hemorrhage (6 cases, 23%). There were no cases of ischemic choroidal changes or hyperpigmentation at the edge of the dome. All six complications occurred in phakic patients who had inferior RRD with retinal breaks in the inferior quadrants. Isolated subretinal hemorrhage occurred in 4 patients and isolated suprachoroidal hemorrhage in 1 patient, and those did not affect final visual outcome. Extensive combined subretinal and suprachoroidal hemorrhage occurred in one case, and was complicated by phthisis bulbi. Re-detachment occurred in 4/6 (67%) of patients, and 5/6 (83%) of patients required a secondary procedure. Three out of 6 patients (50%) had at least 2 lines of visual acuity improvement.

Conclusion

SCB performed for RRD can be associated with hemorrhagic complications. The hemorrhages are usually self-limited but may occasionally result in severe visual compromise when involving the suprachoroidal space. Specific surgical measures need to be undertaken in order to decrease the likelihood of complications and further studies are needed to assess the safety and efficacy of this technique.

Inverted internal limiting membrane (ILM) flap technique for macular hole closure: patient selection and special considerations

This paper reviews the current status of the newer inverted internal limiting membrane flap technique for macular hole surgery. It gives an overview of the importance of patient selection and special considerations along with variations in technique. It discusses the pathophysiology and how the technique has been an important addition in the armamentarium of vitreoretinal surgeons to attain better anatomical as well as functional results in challenging situations.

Macular Hole in Myopic Eyes: A Narrative Review of the Current Surgical Techniques

Macular hole (MH) in myopic eyes is a disease arising from complex tractional forces exerted by vitreomacular interface, epiretinal tissue, and progressive scleral ectasia of the posterior ocular globe wall. This retinal disease requires vitreoretinal treatment for its repair, and the surgical intervention remains a challenge also for experienced surgeons. The aim of this review is to describe the current knowledge regarding the pathogenesis of MH in myopic eyes and to detail novel surgical techniques and technological advancements in its surgical management.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ocular drug delivery targeted by iontophoresis in the suprachoroidal space using a microneedle

Treatment of many posterior-segment ocular indications would benefit from improved targeting of drug delivery to the back of the eye. Here, we propose the use of iontophoresis to direct delivery of negatively charged nanoparticles through the suprachoroidal space (SCS) toward the posterior pole of the eye. Injection of nanoparticles into the SCS of the rabbit eye ex vivo without iontophoresis led to a nanoparticle distribution mostly localized at the site of injection near the limbus and <15% of nanoparticles delivered to the most posterior region of SCS (>9 mm from the limbus). Iontophoresis using a novel microneedle-based device increased posterior targeting with >30% of nanoparticles in the most posterior region of SCS. Posterior targeting increased with increasing iontophoresis current and increasing application time up to 3 min, but further increasing to 5 min was not better, probably due to the observed collapse of the SCS within 5 min after injection ex vivo. Reversing the direction of iontophoretic flow inhibited posterior targeting, with just ~5% of nanoparticles reaching the most posterior region of SCS. In the rabbit eye in vivo, iontophoresis at 0.14 mA for 3 min after injection of a 100 μL suspension of nanoparticles resulted in ~30% of nanoparticles delivered to the most posterior region of the SCS, which was consistent with ex vivo findings. The procedure was well tolerated, with only mild, transient tissue effects at the site of injection. We conclude that iontophoresis in the SCS using a microneedle has promise as a method to target ocular drug delivery within the eye, especially toward the posterior pole.

SUPRACHOROIDAL BUCKLING FOR THE MANAGEMENT OF RHEGMATOGENOUS RETINAL DETACHMENTS SECONDARY TO PERIPHERAL RETINAL BREAKS

PURPOSE

To evaluate functional and anatomical outcomes of eyes undergoing suprachoroidal buckling for the management of peripheral retinal breaks in rhegmatogenous retinal detachment.

METHODS

Retrospective cohort study of 41 eyes of 41 patients undergoing suprachoroidal buckling for the management of rhegmatogenous retinal detachment secondary to single or multiple retinal breaks. Suprachoroidal indentation was achieved through the introduction of filler material using a 23-gauge (23-G) olive-tipped, suprachoroidal cannula. This allowed for the creation of a suprachoroidal dome and chorio-retinal apposition. Healon5 (Abbott Medical Optics) was used as filler material in all eyes. Combined 25-G vitrectomy was performed in 5 eyes. Cryopexy and laserpexy were used in 37 and 4 eyes, respectively.

RESULTS

Mean visual acuity gain was the primary outcome measure. Final retinal reattachment rate, single-surgery reattachment rate, and complications were secondary outcome measures. Mean best-corrected distance visual acuity improved from 20/1,100 to 20/42. Single surgery reattachment rate was 92.7% (38/41 eyes). Final retinal reattachment was achieved in all 41 eyes (100%). There was no statistically significant difference in visual acuity gain or anatomical reattachment in terms of retinal break quadrant or extent. No major complications were observed. Two localized suprachoroidal hemorrhages occurred at the entry site for the cannula. These resolved without further intervention.

CONCLUSION

Suprachoroidal buckling using a specially designed cannula is a safe and effective procedure for the management of rhegmatogenous retinal detachment secondary to peripheral retinal breaks.

Long-term follow-up of vitrectomy in patients with pathologic myopic foveoschisis

AIM

To report the long-term surgical outcomes of pathologic myopic foveoschisis (MF) following vitrectomy.

METHODS

We performed a retrospective case series analysis of 50 consecutive patients diagnosed with MF who experienced vision loss due to progression of foveoschisis. The 50 patients (67 eyes) were treated in our hospital with vitrectomy with internal limiting membrane (ILM) peeling from December 2004 to September 2010. Best corrected visual acuity (BCVA), refractive error, optical coherence tomography (OCT), and routine examination results were analysed. The changes of BCVA, foveal anatomical features on OCT scan, and complications were the main outcome measures.

RESULTS

The mean follow-up duration was 42±17mo (range 24 to 93mo). BCVA improved significantly postoperatively (0.76±0.65 logMAR) compared with preoperative baselines (1.31±0.78 logMAR, P<0.0001), and in 53 eyes (79%) including 3 lines gain in 44 eyes (66%) at the last follow-up visit. OCT scans showed that central retinal thickness decreased from 580.0±270.0 µm preoperatively (n=67) to 179.7±84.7 µm postoperatively (n=58, P<0.0001). Total resolution of foveoschisis occurred in 41 eyes (61%). Preoperative BCVA correlated well with postoperative BCVA, whereas other factors such as age, axial length, and refractive error were not correlated. The most common complications were cataract and full-thickness macular hole formation in 14 and 9 cases, respectively.

CONCLUSION

Patients with progressive vision loss due to MF who were treated with vitrectomy with ILM peeling show favourable outcomes. In most eyes, visual acuity and foveal structure remain stable during long-term observation.

Catheter-guided suprachoroidal buckling of rhegmatogenous retinal detachments secondary to peripheral retinal breaks

PURPOSE

To evaluate functional and anatomic outcomes of eyes undergoing suprachoroidal buckling (SCB) using a specially designed catheter for the management of rhegmatogenous retinal detachment (RRD) secondary to peripheral retinal breaks.

METHODS

Retrospective cohort study of 62 eyes of 62 patients. Subjects underwent SCB for the management of RRD secondary to single or multiple retinal breaks. Suprachoroidal indentation was achieved through the introduction of viscoelastic material in the suprachoroidal space overlying the break using an illuminated, 450 μm-wide, flex-tip catheter. This allowed for the creation of a suprachoroidal dome and chorio-retinal apposition. Forty-seven eyes (80 %) underwent SCB alone, while 15 eyes (20 %) were combined with 25-G pars-plana vitrectomy. Cryopexy and laserpexy were used in 38 (61 %) and 24 of eyes (39 %) respectively.

RESULTS

Mean pre-operative best-corrected visual acuity (BCVA) improved from logMAR 0.82 (20/132) to 0.22 (20/33) (p < 0.0001). The single surgery reattachment rate was 92 % (57/62.) Final retinal reattachment was achieved in all eyes (100 %). No significant difference was observed in single-surgery anatomic success rates when stratified by lens status, macular involvement, or break location. There were no major intra- or post-operative complications.

CONCLUSION

Suprachoroidal buckling using a special-design, flexible catheter is a safe and effective procedure for the management of RRD secondary to peripheral retinal breaks.

T-shaped macular buckling combined with 25G pars plana vitrectomy for macular hole, macular schisis, and macular detachment in highly myopic eyes

OBJECTIVE

To report our experience using the T-shaped macular buckle (MB) with or without pars plana vitrectomy (PPV) as primary surgery or with a previous failed surgical approach in patients affected by high myopia and macular hole (MH) with or without macular detachment and with or without macular schisis. The primary goal was to evaluate complete closure of the MH and reattachment of the retina.

DESIGN

Retrospective case series of 21 consecutive patients who underwent T-shaped MB implant alone or combined with PPV at the Academic Medical Center in Amsterdam, The Netherlands, between January 2013 and November 2014. The mean axial length was 31.22 mm. The mean follow-up period was 7 months.

RESULTS

Retinal reattachment was achieved in 100% of cases while MH closure was achieved in 90.5%. No major perioperative complications were observed. Best corrected visual acuity improved in 71.4% of patients.

CONCLUSIONS

MB combined with PPV should be considered as the preferred surgical approach both in primary and recurrent retinal detachment secondary to MH in high myopic eyes.

Short-Term Results of Platelet-Rich Plasma as Adjuvant to 23-G Vitrectomy in the Treatment of High Myopic Macular Holes

Purpose

To investigate the short-term safety and efficacy of autologous platelet-rich plasma (a-PRP) as adjuvant to pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling in the treatment of highly myopic macular holes (MH).

Methods

This was a prospective, nonrandomized interventional case series. Patients with MH associated with high myopia, with or without previous PPV, were included. All patients underwent 23-G PPV with the use of a-PRP. Anatomical and functional results of surgery were recorded.

Results

We included 7 eyes of 6 patients with highly myopic MH. Primary anatomical success was achieved in 7 out of 7 eyes. Mean best-corrected visual acuity improved by more than 1 line from baseline (0.66 ± 0.36 LogMAR) to final visit (0.52 ± 0.25 logMAR), but with no statistically significant difference (p = 0.246, Wilcoxon test). No surgical-related complications were noticed.

Conclusions

The use of a-PRP as adjuvant to PPV with ILM peeling is effective in the treatment of highly myopic MH. This approach may represent a valid alternative to the inverted ILM flap technique, with comparable visual and anatomical results and the advantage of a simpler procedure. Further studies are necessary to confirm its usefulness in the management of high myopic MH.

Radius of curvature changes in spontaneous improvement of foveoschisis in highly myopic eyes

BACKGROUND

Myopic foveoschisis is the splitting of retinal layers overlying staphyloma in highly myopic patients that can lead to vision loss. We assess possible contributing mechanisms to the formation of foveoschisis by examining two cases of spontaneous improvement of myopic foveoschisis and employ a radius of curvature (ROC) measure to track posterior scleral curvature over time.

METHODS

A retrospective, non-comparative case series was performed and optical coherence tomography images were analysed. Retinal pigment epithelial layer ROC was calculated from manually segmented images through the posterior scleral curvature apex.

RESULTS

Two cases of myopic foveoschisis with foveal detachments in the left eye (OS) were studied. Both patients had high myopia (either <-10 D or >30 mm in axial length). One case occurred in a treatment-naive patient who improved after 4 months of observation. On initial presentation, OS posterior scleral ROC was 12.35 mm and decreased to 12.15 mm at the time of resolution. The other case occurred in a patient who was followed for 7 years, had previously underwent pars plana vitrectomy and removal of epiretinal membrane, experienced recurrence of foveoschisis and then spontaneously improved without further posterior segment surgery. There was an uncomplicated cataract extraction in the interim. Posterior scleral ROC was 4.05 mm on presentation, 4.10 during recurrence, 3.55 mm after cataract extraction and 3.75 mm at resolution.

CONCLUSIONS

Spontaneous improvement of myopic foveoschisis may be due to changes in tractional forces from the internal limiting membrane, cortical vitreous or staphyloma or, alternatively, from a delayed or fluctuant recovery course after intervention.

Macular buckling for previously untreated and recurrent retinal detachment due to high myopic macular hole: a 12-month comparative study

PURPOSE

To evaluate postoperative outcomes after macular buckling together with pars plana vitrectomy (PPV) in previously untreated and recurrent retinal detachment secondary to macular hole (MH) in highly myopic eyes.

METHODS

In a retrospective cohort study, 42 eyes of 42 high myopic patients with retinal detachment due to MH were evaluated. Patients were divided into previously untreated retinal detachment (group 1, 21 eyes) and recurrent retinal detachment (group 2, 21 eyes). Macular buckling and PPV were performed in all patients. Main outcomes included retinal reattachment rate, macular hole closure rate and best-corrected visual acuity (BCVA) at 3, 6, and 12 months. Optical coherence tomography (OCT) was performed both pre- and postoperatively in all patients to assess the anatomical status of the macula.

RESULTS

Primary retinal reattachment rate in group 1 was 95% (20/21), which increased to 100% (21/21) after a second surgery. MH closure was achieved in 81% of patients (17/21) after one surgery. The mean preoperative BCVA (logarithm of the minimum angle of resolution, LogMAR) improved from 1.32 (95% CI 1.19;1.44) to 0.76 (95% CI 0.56;0.96) 12 months postoperatively. In all except one case, gas tamponade was preferred. Primary reattachment and MH closure rate in group 2 were 90.5% (19/21) and 57% (12/21) respectively, and did not improve after a second surgery. Preoperative BCVA (LogMAR) was 1.39 (95% CI 1.29;1.49) and improved to 0.95 (95% CI 0.75;1.15) at 12 months. Silicone oil tamponade was used in seven of 21 patients, and finally was removed in five of them.

CONCLUSIONS

Macular buckling combined with PPV should be considered a preferred surgical approach both in primary and recurrent retinal detachment secondary to MH in high myopic eyes. Nevertheless, visual outcomes seem to be better when macular buckling is chosen as first-line treatment.