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

Platelet-rich Fibrin Membrane Transplantation for the Treatment of Highly Myopic Macular Hole Retinal Detachment

INTRODUCTION

Highly myopic macular hole retinal detachment (MHRD) is often associated with a poor prognosis, and there is currently no optimal treatment. Platelet-rich fibrin (PRF), an autologous blood product, has been shown to promote tissue regeneration. This prospective, randomized, controlled study investigated the efficacy of conventional internal limiting membrane (ILM) peeling versus PRF membrane transplantation in highly myopic MHRD.

METHODS

Eyes with highly myopic MHRD were randomly assigned to either a conventional ILM peeling group (IP group, n = 19) or a PRF membrane transplantation group (PMT group, n = 21). The study followed participants for a period of 6 months. The primary outcome measure was macular hole (MH) closure assessed using optical coherence tomography. Secondary outcomes included best-corrected visual acuity (BCVA), central retinal thickness (CRT), superficial vascular density (SVD), deep vascular density (DVD), rate of retinal reattachment, and any complications encountered.

RESULTS

MH closure was achieved in a significantly greater proportion of eyes in the PMT group (21/21, 100.00%) compared to the IP group (15/19, 78.95%) (P = 0.042). Retinal reattachment was accomplished in all patients (100.00%) within both groups. Except for an insignificant difference in BCVA observed at 1 week post-surgery in the IP group, significant improvements in BCVA and CRT were documented in both groups across all other post-operative time points. Final BCVA (P = 0.040), CRT (P = 0.002), SVD (P = 0.002), and DVD (P = 0.013) were all significantly higher in the PMT group compared to the IP group. No serious complications were identified in either group.

CONCLUSIONS

This study demonstrated the superiority of PRF membrane transplantation compared to conventional ILM peeling in promoting MH closure and enhancing retinal vascular density in patients with highly myopic MHRD. Additionally, PRF membrane transplantation effectively restores retinal reattachment, improves visual function, and increases retinal thickness without introducing additional complications.

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Temporal inverted internal limiting membrane flap technique for myopic macular hole retinal detachment reconstruction

OBJECTIVE

To examine the effects of the temporal inverted internal limiting membrane (ILM) flap technique for foveal reconstruction in patients with highly myopic macular hole-associated retinal detachment (MHRD).

METHODS

A retrospective case series analysis of four patients (four eyes) with MHRD was conducted. The foveal optical coherence tomography changes following treatment using the temporal inverted ILM flap technique were evaluated.

RESULTS

In Patient 1, the ILM bridged the macular hole and residual subretinal fluid on postoperative day 6, and complete retinal reattachment was achieved at 19 months. Patient 2 exhibited reduced retinal detachment, with visible ILM inversion and macular hole closure after 14 days. In Patient 3, macular hole closure and fovea formation had occurred by day 25, and the ILM flap was visible. At 2 months, the outer collagenous layer connection in the central fovea and recovery of the external limiting membrane and ellipsoid zone were observed. Patient 4 had a "white hole" MHRD, with macular hole closure achieved on postoperative day 20, albeit with a suboptimal foveal shape.

CONCLUSION

The temporal inverted ILM flap technique in conjunction with vitrectomy facilitates foveal reconstruction in patients with successful treatment of MHRD, and this reconstruction process can be observed by optical coherence tomography.

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.

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.

Impact of the Inverted Internal Limiting Membrane Flap Diameter on Large Idiopathic Macular Hole Closure: Comparative Randomized Study

BACKGROUND AND OBJECTIVE

To study the impact of the size of internal limiting membrane inverted flap on the rate and timing of large idiopathic macular hole (MH) closure.

PATIENTS AND METHODS

A prospective randomized comparative study included patients with large idiopathic MH. Eligible eyes underwent pars plana vitrectomy with either inverted small flap (SF < 2 disc diameters) or inverted large flap (LF from 2 to 4 disc diameters). The primary outcome measure included the rate of MH closure at the sixth month. Secondary outcome measures included the timing of MH closure and best-corrected visual acuity.

RESULTS

Twenty-five eyes were included: 13 in the SF group and 12 in the LF group. At 6 months, the rate of closure was 84.6% in the SF group and 91.6% in the LF group, with no significant difference. Timing of closure was significantly shorter with LF, with better postoperative best-corrected visual acuity.

CONCLUSION

LF offered a shorter duration for closure with better visual outcomes in large idiopathic MH. [Ophthalmic Surg Lasers Imaging Retina. 2022;53:103-107.].

Macular hole closure at seven years after surgery

Purpose

To report a case of macular hole (MH) closure at seven years after internal limiting membrane (ILM) peeling.

Observations

A 66-year-old woman developed a MH in her left eye. Pars plana vitrectomy with ILM peeling and SF6 gas injection followed by face-down position for a week slightly improved the visual acuity from 20/400 to 20/200 but did not close the MH. During subsequent three years of follow-up without any treatment, the MH did not close. Seven years after the surgery, she visited us for cataract surgery in her right eye, and the optical coherence tomography (OCT) examination coincidentally found closure of the MH in her left eye. The visual acuity of her left eye remained 20/200 despite the MH closure.

Conclusions and Importance

ILM peeling might indirectly contribute to the closure of MH at seven years after the surgery although the mechanism is unclear. Sharing the serial OCT images until the MH closure would help us explore the mechanisms of ILM peeling to close MH and develop rational surgery technique manipulating ILM for MH.

Current management strategies for atypical macular holes

This review evaluates the current surgical management options for refractory and atypical macular holes (MH) and proposes a treatment paradigm for approaching complex cases. A review of literature was performed to deliver a thorough discussion of the epidemiology and pathophysiology of MH as well as the historic evolution of surgical management strategies. With this context established, an update on recent surgical advances for management of large, chronic, and highly myopic MH is provided. New small MH may be adequately treated with pars plana vitrectomy, while those ≥300 μm should undergo internal limiting membrane (ILM) peel. For MH ≥400 μm with risk factors for failure, primary intervention should involve creation of an ILM flap and various methods of flap creation are discussed. For very large MH ≥700 μm or in refractory cases, autologous retinal transplants and other recently proposed procedures should be considered. While typical MHs enjoy high initial surgical success rates, atypical and refractory MH require additional intraoperative and postoperative considerations to maximize surgical success and optimize vision. With many techniques at the surgeon's disposal, patient selection becomes critical to improving outcomes.

Correlation of morphological characteristics of staphyloma with the structural and functional outcomes of myopic traction maculopathy after macular buckle surgery

Purpose:

To compare morphological features of staphyloma (type and grade) with structural and functional outcomes in 11 patients with symptomatic myopic tractional maculopathy (MTM) who underwent macular buckle surgery.

Methods:

A retrospective observational case series, where a chart review was conducted of the type (Curtin classification) and grade of staphyloma (USG B-scan based). Optical coherence tomography (OCT) macula analysis done preoperatively and postoperatively 1 and 6–8 weeks), Visual acuity was recorded in log mar.

Results:

With an average myopia of −10.35 D (−5 to −14.5 D), there were four patients with types II and IX staphyloma and seven with type I staphyloma. The average axial length was 28.6 ± 0.98 mm in type II/IX and 26.2 ± 0.8 mm in type I. Preoperative OCT features were outer retinal layer schisis (11), retinal detachment (foveal: 2, macular: 8), macular hole (lamellar: 3, full thickness: 4), and taut posterior hyaloid (3). Postoperatively, patients with type II/IX staphyloma had significant gain in visual acuity from 1.05 ± 0.3 to 0.74 ± 0.2 Log Mar. The structural features also responded better in patients with types II/IX staphyloma, with all patients having more than 90% reduction in schisis and retinal attachment at 6 weeks. Whereas only two patients with type I staphyloma had similar reduction in schisis at 6 weeks and only one had complete retinal attachment.

Conclusion:

In patients with MTM, the staphyloma characteristics preoperatively can help us prognosticate about structural and functional success after macular buckle surgery. In our small case series, patients with type II/IX staphyloma and larger axial length had better structural and functional outcomes.

Posterior pole retinotomy for treatment of recurrent macular hole retinal detachment in highly myopic eyes: a pilot study

BACKGROUND

To investigate the feasibility and efficacy of posterior pole retinotomy to treat recurrent macular hole retinal detachment (MHRD) in highly myopic patients.

METHODS

We performed a retrospective study and reviewed the medical records in our hospital between January 1, 2016 and December 31, 2018. Highly myopic patients who received posterior pole retinotomy with silicone oil tamponade for their recurrent MHRD after pars plana vitrectomy were included in the analysis. Postoperative retinal reattachment, best-corrected visual acuity (BCVA), macular hole closure, and complications were evaluated.

RESULTS

There were 11 patients (11 eyes) included in this study. All retinas were reattached. Silicone oil was successfully removed from all eyes 1.5-3 months after the surgery. Macular holes were completely closed in three eyes and remained flat open in eight eyes. The BCVA of all eyes improved significantly at 12 months after surgery (logarithm of the minimal angle of resolution, pre vs. postoperatively, 1.87 ± 0.44 vs. 1.15 ± 0.24, P < 0.05). None of the patients had complications such as endophthalmitis, fundus hemorrhage, retinal redetachment, and proliferative vitreoretinopathy.

CONCLUSION

Posterior pole retinotomy is a safe and effective surgery to treat recurrent MHRD after pars plana vitrectomy in highly myopic patients.

Surgical Outcomes of Vitrectomy for Macular Hole-induced Retinal Detachment According To Various Surgical Methods: A Multicenter Retrospective Study

PURPOSE

To investigate the surgical outcomes of vitrectomy for macular hole-induced retinal detachment(MHRD), with respect to the surgical adjunctive method used.

METHOD

We performed retrospective multicenter study of patients who underwent vitrectomy for MHRD. The visual/anatomical outcomes after vitrectomy were analyzed. We also analyzed these outcomes according to surgical method and the presence of persistent macular hole after the vitrectomy.

RESULT

Thirty-four patients (34 eyes) from 6 hospitals were included in this study. The mean age of the patients was 64.56 ± 12.23 years; 31 patients (91.2%) were female. The mean LogMAR best-corrected visual acuity (BCVA) significantly improved 6 months after vitrectomy (p < .001). Retinal detachment completely improved in 32 eyes (94.1%). The visual prognoses and macular hole closure rates were not different depending on subretinal fluid drainage site. The presence or absence of a persistent macular hole after vitrectomy did not affect the visual outcomes. However, the recurrence of MHRD was significantly higher in eyes with persistent macular holes(p = .015).

CONCLUSION

The surgeries to treat MHRD differed in terms of the procedure depending on the surgeons, but the visual outcomes did not differ depending on the surgical adjunctive method employed. There were no differences in the visual prognoses, regardless of whether there was a persistent macular hole; however, recurrence was significantly higher in eyes with persistent macular holes. Therefore, further surgical treatment might be considered for eyes with persistent macular holes after MHRD surgery.

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.

COMPARISON OF THE INTERNAL LIMITING MEMBRANE INSERTION TECHNIQUE AND THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE WITH VITRECTOMY TO TREAT MACULAR HOLE-ASSOCIATED RETINAL DETACHMENT

PURPOSE

To compare the anatomical and functional outcomes of macular hole (MH)-associated retinal detachment after vitrectomy with the internal limiting membrane (ILM) insertion technique or the inverted ILM flap technique.

METHODS

In this retrospective observational study, we reviewed the medical records of 49 eyes with MH-associated retinal detachment that underwent vitrectomy with the ILM insertion (26 eyes) or ILM flap (23 eyes) technique.

RESULTS

The MH closure rate at 12 months was greater in the ILM flap group versus the ILM insertion group (95% vs. 73%, respectively, P = 0.059). The postoperative best-corrected visual acuity (BCVA) at 12 months was significantly better in the ILM flap group (P = 0.014). All eyes (100%) showed an improvement in the BCVA of ≥0.3 logarithm of the minimum angle of resolution (15 Early Treatment Diabetic Retinopathy Study letters) in the ILM flap group versus 20 eyes (77%) in the ILM insertion group (P = 0.026). The preoperative BCVA and the ILM flap technique were significantly correlated with the postoperative BCVA (P = 0.028 and 0.027, respectively) and BCVA improvement (≥0.3 logarithm of the minimum angle of resolution [15 Early Treatment Diabetic Retinopathy Study letters]; P = 0.003 and 0.026, respectively).

CONCLUSION

The inverted ILM flap technique was more effective in improving the postoperative BCVA in patients with MH-associated retinal detachment when compared with the ILM insertion technique. The preoperative BCVA and the ILM flap technique were independent prognostic factors for visual outcomes in patients with MH-associated retinal detachment.

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.

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.

Clinical characteristics and long-term evolution of lamellar macular hole in high myopia

Purpose

To evaluate the clinical characteristics and evolution of lamellar macular hole (LMH) in high myopia and the parameters associated with structural worsening, defined as the development of foveal detachment or full-thickness macular hole.

Methods

Patients with high myopia and LMH were retrospectively recruited. The clinical characteristics and various parameters of optical coherence tomography were identified at baseline and during follow-up visits. Cox regression analysis was used to evaluate the hazard ratios for foveal detachment and full-thickness macular hole.

Results

Among 112 eyes (98 patients), 64.3% were female; the mean axial length of all eyes was 29.6 ± 1.9 mm. The ‘LMH without retinoschisis’ group accounted for 39.3% of the eyes. Forty-two percent developed structural worsening within a median follow-up of 67 months. Multivariable regression on all cases showed elevated tissue inside the LMH (P = 0.003) protected against structural worsening while V-shaped LMH (P = 0.006) predicted it. In the “LMH with retinoschisis group”, ellipsoid zone disruption (P = 0.035), and V-shaped LMH (P = 0.014) predicted structural worsening, while elevated tissue inside the LMH (P = 0.028) protected against it. In the “LMH without retinoschisis group”, no associated factor was identified.

Conclusions

LMHs in high myopia are unstable, especially those with V-shaped LMH. Elevated tissue inside LMHs have a protective effect against further structural worsening.

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.

Sub-perfluoro-n-octane injection of ocular viscoelastic device assisted inverted internal limiting membrane flap for macular hole retinal detachment surgery: a novel technique

Background

To evaluate the feasibility of a surgical technique using a sub-perfluoro-n-octane (PFO) injection of ocular viscoelastic device (OVD) to stabilize inverted internal limiting membrane (ILM) flap for the treatment of macular hole retinal detachment (MHRD).

Methods

This study was a retrospective, consecutive, interventional case series. Patients who underwent MHRD surgery with sub-PFO injection of OVD to stabilize inverted ILM flap onto the macular hole (MH) were reviewed. The color fundus and optical coherence tomography (OCT) images were collected and evaluated. The best-corrected visual acuity (BCVA) before and after surgery were compared as the functional outcome.

Results

The study included 8 eyes of 8 consecutive patients (mean age: 61.8 ± 7.1 years; mean follow-up period: 9.0 ± 2.5 months). All eyes (100%) achieved successful MH closure; 7 eyes (87.5%) demonstrated complete retinal reattachment, and 1 eye (12.5%) had minimal residual subretinal fluid parafoveally. Of the 8 patients, 7 patients (87.5%) had achieved improvement in BCVA after the primary surgery, whereas 1 eye remained stable. The average BCVA before and after the surgery at the last visit improved from 20/843 (1.63 ± 0.48 logMAR) to 20/200 (1.00 ± 0.39 logMAR) (P = 0.016). Anatomically, near-normal foveal contour was noted in five (62.5%) eyes at the final follow-up.

Conclusions

The use of sub-PFO injection of OVD in MHRD surgery could stabilize inverted ILM flaps, achieve good anatomical results and improve postoperative BCVA.

The impact of extent of internal limiting membrane peeling on anatomical outcomes of macular hole surgery: results of a 54-week randomized clinical trial

PURPOSE

To compare the anatomical outcomes of different extents of internal limiting membrane (ILM) peeling in idiopathic macular hole surgery.

METHODS

Prospective, parallel-group, randomized clinical trial. A total of 121 eyes of 121 patients with idiopathic macular hole underwent pars plana vitrectomy, and peeling of the ILM with a diameter of two disk diameters (DD) or 4DD based on randomization. The main outcome was the proportion of eyes with complete hole closure at 12 months. The second outcome was the hole closure grading stratified by macular hole closure index (MHCI) at each visit.

RESULTS

At 12 months, there was no significant difference in anatomical outcomes with complete closure achieved in 52 (82.5%) of 63 eyes in the 2DD group and 53 (91.4%) of 58 eyes in the 4DD group (p = 0.15). For subjects with MHCI ≤0.5 (n = 24), complete closure rate was significantly lower in the 2DD group compared to the 4DD group (p = 0.012; 18.2% versus 75.9%, respectively). Average BCVA was lower in 2DD group than 4DD group (p = 0.014). By contrast, when MHCI was >0.5, the complete closure rate between the two groups showed no significant difference: 96.2% (50 patients) versus 95.6% (43 patients), respectively (p = 0.185).

CONCLUSION

In patients with idiopathic full-thickness macular hole and MHCI ≤0.5, a larger ILM peel of 4DD tends to achieve better anatomical outcomes than a more limited 2DD peel.

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.

Best surgical technique and outcomes for large macular holes: retrospective multicentre study in Japan

The purpose of this study was to compare the surgical outcomes of vitrectomy with conventional internal limiting membrane (C-ILM) peeling to that with the inverted ILM (I-ILM) flap technique for large macular holes (MHs). This was a retrospective chart review of consecutive cases with a large MH at nine hospitals in Japan. Among the 1342 eyes, 165 eyes of 165 cases met the inclusion criteria. The results for medium-large MHs with a diameter 400-550 μm were compared to that of eyes with an extra-large MH with a diameter >550 μm. In addition, the results of C-ILM peeling were compared to that of the I-ILM technique. In medium-large MHs, the closure rate was 95.2% (59/62) by C-ILM peeling and 100% (19/19) by the I-ILM technique. In extra-large MHs, the closure rate was 88.4% (38/43) by C-ILM peeling and 100% (41/41) by I-ILM. Although the difference between the two methods was not significant, the I-ILM technique was successful in 100% of the cases. Multiple logistic regression analysis showed the best-corrected visual acuity (BCVA) at 6 months was significantly associated with the preoperative BCVA, MH size, age and sex of the patient. Analyses of the eyes with extra-large MHs show that the surgical success is high, and the I-ILM technique is more effective for closure in eyes with extra-large MHs.

Foveal microstructure and visual outcomes of myopic macular hole surgery with or without the inverted internal limiting membrane flap technique

Purpose

The aim of this study was to determine the effect of the inverted internal limiting membrane (ILM) flap technique on the macular hole (MH) closure and foveal microstructure recovery of patients with highly myopic MH.

Methods

Pars plana vitrectomy and gas tamponade with the inverted ILM flap technique (19 eyes) or with the ILM peeling technique (21 eyes) were performed in patients with highly myopic MH with or without retinal detachment. The rate of MH closure and retinal reattachment, the reconstructive anatomical change of the foveal microstructure and the best-corrected visual acuities (BCVA) of the two groups were compared.

Results

The anatomic closure rate was statistically significantly higher in the inverted group (100%) than in the peeling group (66.7%; p=0.009). All eyes with MH retinal detachment had successful retinal reattachment in these two groups. However, the rate of the external limiting membrane (ELM) and ellipsoid zone (EZ) (p=0.020), as well as gliosis (p=0.049) in macular area, detected by OCT, was significantly greater in the inverted group than in the peeling group. The postoperative BCVA was significantly better in the eyes with ELM, EZ (p=0.031) and gliosis (p=0.008), but without hyperreflective foci (p=0.001).

Conclusions

These findings demonstrate that the inverted ILM flap technique has better efficacy than the ILM peeling technique for patients with myopic MH in closure rate, foveal microstructure and postoperative BCVA.

Vitrectomy in high myopia: a narrative review

Pathologic myopia is associated with degenerative changes of the globe, especially at the posterior pole. Eyes affected by pathologic myopia have higher odds to undergo posterior segment surgery and, in those eyes, vitreoretinal surgery is challenging. Many practical tips and tricks can make the surgical procedures simpler, significantly preventing sight-threatening intra- and post-operative complications. Moreover, novel surgical techniques and technological advancements (i.e. ad-hoc instrumentation, minimally invasive vitreoretinal surgery, filters, dye staining, intraoperative optical coherence tomography and 3-dimensional surgery) may play role in highly myopic eyes. The aim of the present work is to review practical tips and tricks, novel surgical techniques and technological advancements.