Spontaneous closure of small full-thickness macular holes: Presumed role of Müller cells

Presence of subfoveal hyperreflective dots as an anatomic and functional prognostic biomarker in macular holes

OBJECTIVE

To evaluate the presence of subfoveal hyperreflective dots (SfHD) using optical coherence tomography (OCT) in macular holes (MH) and establish whether there is a relationship with postoperative anatomical and functional outcomes.

METHODS

An observational cross-sectional study was conducted at the Dr. Elías Santana Hospital. Sixty-eight eyes of 67 patients with a tomographic diagnosis of full-thickness MH who underwent pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peeling were included. Preoperative and postoperative measurements were obtained using radial macular scans and HD raster scans with Optovue and Cirrus 5000 (Zeiss) OCT machines. The main outcome measures were anatomical closure by OCT and functional outcome through best-corrected visual acuity (BCVA).

RESULTS

The anatomical closure rate in our study was 63%. MHs that failed to achieve anatomical closure exhibited a higher number of hyperreflective dots and worse postoperative BCVA. A statistically significant association was found between exposed retinal pigment epithelium (RPE) in microns and the number of SfHD (P = .001).

CONCLUSION

SfHD is a common tomographic finding in MH, and the presence of a higher number of these points is associated with poorer anatomical and functional outcomes. This imaging finding is a potential prognostic biomarker in this pathology.

[Lamellar macular holes-In the center of vitreomacular interface diseases : Pathophysiology, spontaneous courses and treatment concepts]

BACKGROUND

A lamellar macular hole (LMH) is characterized by a distinct morphologic configuration and can be distinguished from related entities such as macular pseudohole (MPH) and epiretinal membrane with foveoschisis (ERM-FS) by clear morphologic features.

PURPOSE

Based on current knowledge, the pathophysiologic function of LMH in the spectrum of vitreomacular interface diseases will be described and therapeutic concepts will be presented.

METHODS

Current studies are supplemented by case reports to provide a schematic overview of the natural history and therapeutic concepts at the vitreomacular interface.

RESULTS

The LMH is as a retrospective marker for pathologic posterior vitreous detachment in adult patients and may be interpreted as the pathophysiologic center of tractional maculopathies. Various vitreomacular pathologies can result in LMH: a detached vitreomacular traction, a spontaneously closed penetrating macular hole, or an epiretinal membrane with foveoschisis. Pathophysiologically, a degenerative, progressive loss of the architecture of the foveal muller cell cone may be the underlaying mechanism, resulting in the typical undermining of the hole edges and occasionally in a full thickness macular hole. The optimal timing and the appropriate surgical method are the focus of current clinical studies.

CONCLUSION

The pathophysiology of LMH indicates a smooth transition of tractive maculopathies. These should be prospectively evaluated in order to develop evidence-based treatment strategies for LMH.

The time course of spontaneous closure of idiopathic full-thickness macular holes

PURPOSE

Spontaneous closure of idiopathic full-thickness macular holes (iFTMH) has been reported regularly. However, little is known about its probability and timeline.

METHODS

In this retrospective study all consecutive patients who presented between August 2008 and August 2019 were screened for the presence of a macular hole and only iFTMHs were included. The primary outcome measure was the spontaneous closure of the iFTMH.

RESULTS

Of 1256 eyes with macular holes, 338 fulfilled the inclusion criteria. Spontaneous closure of the iFTMH was detected in 31 eyes (9.2%) with a median time of 44 days after diagnosis. Eyes exhibiting spontaneous closure demonstrated a higher baseline best-corrected visual-acuity (BCVA) and smaller iFTMH diameter (p < 0.0001 and p < 0.0001, respectively). The mean BCVA improved from 0.4 logMAR (SD ± 0.21) to 0.29 logMAR (SD ± 0.20) after spontaneous closure (p = 0.031). The iFTMH diameter was positively correlated with the time to spontaneous closure (Pearson-r = 0.37, p = 0.0377). Spontaneously closed iFTMHs reopened in 16% (n = 5) of cases, with a median of 136 days after closure. A logistic regression model showed the hole diameter was associated with spontaneous closure (odds-Ratio 0.97, 95%CI [0.96, 0.98]). The Kaplan-Meier-Curve revealed that approximately 25% of small-iFTMH (n = 124) and 55% of iFTMH with a diameter < 150µm (n = 48) closed spontaneously within two months.

CONCLUSION

The established gold-standard for the treatment of iFTMHs is macular surgery. However, the potential for spontaneous closure of small iFTMHs must be acknowledged. Therefore, if surgical treatment is delayed in individual cases, close observation is recommended.

Analysis of Macular Pigment Optical Density in Macular Holes with Different Border Phenotypes

INTRODUCTION

We conducted a cross-sectional study to compare macular pigment optical density (MPOD) in eyes with idiopathic macular holes with bumpy (bbMH) and smooth borders (sbMH) and to assess the relation between MPOD and optical coherence tomography findings. Thirty eyes from thirty patients affected by idiopathic macular hole were studied.

METHODS

All patients underwent SD-OCT and macular pigment optical density (MPOD) analysis. Comparison between the two border phenotypes were estimated at baseline, as well as  the differences in MPOD, minimum and basal hole diameter, tractional hole index (THI), macular hole index (MHI), diameter hole index (DHI), and ELM integrity metrics between the two groups.

RESULTS

The mean MPOD was 0.09 ± 0.08 in bbMHs and 0.16 ± 0.11 in sbMHs (p = 0.010). Correlation analysis between MPOD and minimum hole  diameter revealed a negative association (rho = - 0.707, p = 0.008) in bbMH and a positive association (rho = 0.702, p = 0.019) in sbMH. MPOD and basal diameter were negatively correlated in bbMH (rho = - 0.77, p = 0.001) and positively correlated in sbMH (rho = 0.675, p = 0.019). Indeed, MPOD is negatively correlated with THI and MHI in sbMH (rho = - 0.684 p = 0.019; rho = - 0.665 p = 0.019, respectively) and positively correlated in bbMH (rho = 0.593 p = 0.037; rho = 0.658 p = 0.018, respectively).

CONCLUSIONS

MPOD is significantly reduced in bbMHs compared to sbMHs. The two border phenotypes also differ for tractional and tangential indexes, possibly reflecting a different pathogenesis. Further studies are needed to understand the prognostic role of MPOD.

CORRELATIONS BETWEEN SUSPENDED HYPERREFLECTIVE MATERIAL WITH THE MACULAR MICROSTRUCTURE AND SPONTANEOUS CLOSURE OF FULL-THICKNESS MACULAR HOLES

PURPOSE

To investigate the characteristics of spontaneously closed full-thickness macular holes (FTMHs) and to seek potential predictors for the spontaneous closure of FTMHs.

METHODS

In this retrospective cohort study, the clinical data and optical coherence tomography images were reviewed from 19 eyes with spontaneously closed FTMHs (spontaneous closure group) and 37 control eyes with FTMHs that were delayed for nonmedical reasons, but ultimately required surgery (control group). The term, suspended hyperreflective material, was defined as hyperreflective material suspended within the FTMHs observed via optical coherence tomography; the presence of suspended hyperreflective material was evaluated in these eyes.

RESULTS

The median time from diagnosis to spontaneous closure of the FTMHs was 13.7 (range, 2.4-32.4) weeks in the spontaneous closure group. The mean diameter of FTMHs in the spontaneous closure group was significantly smaller than that in the control group (191.68 ± 70.57 vs. 401.68 ± 162.19 µ m, P < 0.0001). The incidence of vitreomacular traction was higher in the spontaneous closure group compared with the control group (9/19 vs. 5/37, P = 0.009, odds ratio [95% confidence interval], 5.76 [1.56-21.21]); in seven of the nine eyes with vitreomacular traction from the spontaneous closure group, spontaneous vitreomacular traction separation and subsequent FTMH closure was observed. Suspended hyperreflective material was observed in nine eyes (47%) from the spontaneous closure group and three eyes (8%) from the control group ( P = 0.001, odds ratio [95% confidence interval], 10.20 [2.31‒45.02]).

CONCLUSION

Smaller diameters, vitreomacular traction, and presence of suspended hyperreflective material may be suggestive of the potential for spontaneous closure of FTMHs.

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.

MicroRNA-152-3p and MicroRNA-196a-5p Are Downregulated When Müller Cells Are Promoted by Components of the Internal Limiting Membrane: Implications for Macular Hole Healing

Müller cells play a critical role in the closure of macular holes, and their proliferation and migration are facilitated by the internal limiting membrane (ILM). Despite the importance of this process, the underlying molecular mechanism remains underexplored. This study investigated the effects of ILM components on the microRNA (miRNA) profile of Müller cells. Rat Müller cells (rMC-1) were cultured with a culture insert and varying concentrations of ILM component coatings, namely, collagen IV, laminin, and fibronectin, and cell migration was assessed by measuring cell-free areas in successive photographs following insert removal. MiRNAs were then extracted from these cells and analyzed. Mimics and inhibitors of miRNA candidates were transfected into Müller cells, and a cell migration assay and additional cell viability assays were performed. The results revealed that the ILM components promoted Müller cell migration (p < 0.01). Among the miRNA candidates, miR-194-3p was upregulated, whereas miR-125b-1-3p, miR-132-3p, miR-146b-5p, miR-152-3p, miR-196a-5p, miR-542-5p, miR-871-3p, miR-1839-5p, and miR-3573-3p were significantly downregulated (p < 0.05; fold change > 1.5). Moreover, miR-152-3p and miR-196a-5p reduced cell migration (p < 0.05) and proliferation (p < 0.001), and their suppressive effects were reversed by their respective inhibitors. In conclusion, miRNAs were regulated in ILM component-activated Müller cells, with miR-152-3p and miR-196a-5p regulating Müller cell migration and proliferation. These results serve as a basis for understanding the molecular healing process of macular holes and identifying potential new target genes in future research.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Internal limiting membrane peeling combined with mouse nerve growth factor injection for idiopathic macular hole

BACKGROUND

The study was intended to confirm whether Pars Plana Vitrectomy (PPV) with Internal Limiting Membrane (ILM) peeling and intravitreal injection mouse Nerve Growth Factor(mNGF) was effective for the treatment of Idiopathic Macular Hole(IMH) by Optical Coherence Tomography Angiography(OCTA) and microperimetry.

METHODS

A retrospective study was performed in adults' patients. A total of 44 eyes (March 2021-October 2021) with IMH who received surgical treatment in the Affiliated Eye Hospital of Nanchang University in Nanchang City, Jiangxi Province were selected. The subjects were treated using PPV combined with ILM peeling and intravitreal mNGF (combined group) or PPV combined with ILM peeling (placebo group). The Best Corrected Visual Acuity (BCVA), Optical Coherence Tomography Angiography (OCTA) and MP-3 microperimetry were carried out and observed at baseline, 1 week(1W), 1,3 and 6 months (1 M,3 M,6 M) postoperatively.

RESULTS

The minimum diameter of MH were (568.650 ± 215.862)μm and (533.348 ± 228.836)μm in the Placebo and Combine group pre-operative. During the observation, the macular hole closure rate in the placebo group and combined group were 90% and 95.8% respectively and the difference was not statistically significant(p = 0.583). Compared to pre-surgery, the perimeter and circularity of Foveal Avascular Zone (FAZ) in the placebo group decreased at 1,3,6 M (p = 0.001, < 0.001, < 0.001) and 1W,1,6 M (p = 0.045,0.010, < 0.001) post-surgery respectively. And the perimeter and circularity of FAZ showed significant reduction in the combined group at 1,3,6 M (p = 0.005,0.004, < 0.001) and at each follow-up time point (all values of p < 0.001). The vascular density of SCP increased at 1W(p = 0.031) and 6 M(p = 0.007), the perfusion density of SCP was significantly improved at each follow-up time point (p = 0.028, 0.011, 0.046, 0.004) in the combined group. The BCVA in the combined group was more obvious than that in the placebo group at 1 M, 3 M and 6 M after operation (t₁ = 2.248, p₁ = 0.030; t₃ = 3.546, p₃ = 0.001; t₆ = 3.054, p₆ = 0.004). The changes of BCVA in the combined group was more conspicuous than that in the placebo group at each follow-up time point, and the difference was statistically significant (t₁ = 2.206,p₁ = 0.033;t₂ = 2.54,p₂ = 0.015;t₃ = 3.546,p₃ = 0.001;t₆ = 3.124,p₆ = 0.003).At 1 M, 3 M and 6 M, the MRS of 2° and 4° in the combined group was better than that in the placebo group(t = -2.429,-2.650,-3.510,-2.134,-2.820,-3.099 p = 0.020,0.011,0.001,0.039,0.007,0.004). During various time points, the MRS of 12°in the combined group was better than that in the placebo group, the difference was statistically significant (t = -3.151, -3.912, -4.521, -4.948, p₁ = 0.003, < 0.001, < 0.001 < 0.001). The integrity of External Limiting Membrane (ELM) in combination group was better than that in placebo group at 6 M postoperative(p = 0.022) and that of Ellipsoid Zone(EZ) was preferable in the combined group at 3 M and 6 M after surgery(p = 0.012,0.004). Correlation analysis showed that the integrity of EZ was correlated with 12°MRS at 1 M, 3 M and 6 M after surgery(r = -0.318, -0.343,-0.322;p = 0.023,0.033, < 0.001). There was no correlation between postoperative ELM integrity and postoperative BCVA and 12°MRS(p > 0.05).

CONCLUSIONS

Our results manifested that PPV combined with ILM peeling and intravitreal injection mNGF might be more effective for initial IMH. This method increased the blood flow, MRS and promoted the recovery of ELM and EZ in the macular and might improve the visual function of patients postoperatively.

Iatrogenic macular hole during liquid perfluorocarbon injection in retinal detachment surgery

To describe a macular hole development during intravitreal injection of perfluorocarbon liquid used to repair a regmatogenous retinal detachment. CLINICAL CASE: A 73-year-old man presented with superotemporal regmatogenous retinal detachment. During surgery, along the perflorocarbon liquid injection, a full thickness macular developed and perfluorocarbon was accumulated in subretinal space. Perfluorocarbon liquid was then extracted through the macular hole. Postoperatively, ocular coherence tomography confirmed the existence of a full-thickness macular hole. One month later, this macular hole was successfully treated with the use of an Inverted internal limiting membrane flap. Intravitreous liquid PFC injection is a resource to aid in subretineal fluid exit. A number of complications, both intra and postoperative, have been associated with the use of PFC. This is the first reported case of a complete macular hole secondary to PFC injection.

Long-term assessment of internal limiting membrane peeling for full-thickness macular hole using en face adaptive optics and conventional optical coherence tomography

OBJECTIVE

To evaluate the long-term structural and microvascular retinal effects of internal limiting membrane peeling for full-thickness macular hole (FTMH) using en face adaptive optics optical coherence tomography (AO-OCT), conventional OCT, and OCT angiography (OCTA).

DESIGN

Interventional case series.

PARTICIPANTS

Patients with FTMH treated with vitrectomy, internal limiting membrane peeling, and gas tamponade.

METHODS

Eleven eyes with FTMH that had at least 12 months of postoperative follow-up were enrolled in the study. En face AO-OCT was used to image the superficial retina in the peeled and nonpeeled areas. En face structural OCT was performed to image the inner retinal dimples (IRDs), macular thickness, and retinal nerve fibre layer (RNFL). En face OCTA was used to examine the integrity of the peripapillary nerve fibre layer (NFL) plexus.

RESULTS

AO-OCT showed RFNL wrapping around the IRDs, and no obvious peripapillary NFL plexus dropout was seen with OCTA. Scattered hyper-reflective dots were observed on the surface of the peeled retina in all patients imaged with AO-OCT. No significant differences were found in IRD number (91.5 ± 24.4 versus 77.2 ± 14.7; P = 2.07), IRD proportionate area (8.36 ± 3.34 versus 7.53 ± 2.60; P = 0.159), or macular thickness between the 6- and 12-month (or greater) postoperative visits.

CONCLUSION

IRDs do not to progress beyond 6 months postoperatively, and no obvious damage to RFNL and peripapillary NFL plexus was detected. Hyper-reflective dots on the surface of the retina suggestive of possible Müller cell reactive gliosis were identified with AO-OCT.

Comparison of long-term visual and anatomical outcomes between internal limiting membrane flap and peeling techniques for macular holes with a propensity score analysis

OBJECTIVES

To compare visual and anatomical outcomes between internal limiting membrane (ILM) flap (IF) and peeling (IP) techniques for full-thickness macular holes (FTMHs).

METHODS

A retrospective case series with propensity-score matching (PSM). Patients with a minimum 12 months follow-up were divided into IF and IP groups and matched based on FTMH size and preoperative best-corrected visual acuity (BCVA). BCVA and optical coherence tomography (OCT) findings were obtained to assess outer retinal layer integrity, foveal thickness, and foveal displacement.

RESULTS

Twenty-six eyes were included in each group after PSM. The IF group showed significantly greater BCVA after 1 month, its corresponding change from preoperative BCVA, proportions of eyes with ellipsoid zone defects <250 μm after 1 month, and interdigitation zone restoration after 6 and 12 months (P = 0.007, 0.038, 0.048, 0.025, and 0.023, respectively), as well as less foveal gliosis after 1, 3, 6, and 12 months (P = 0.020, 0.017, 0.050, and 0.024, respectively). In the IP group, the mean outer nuclear layer thickness significantly decreased at 3 (P = 0.019) and 12 months (P = 0.016) compared to 1 month, and the foveal displacement toward the optic disc was significant after 1, 3, 6, and 12 months (P = 0.049, 0.006, 0.001, and <0.001, respectively).

CONCLUSIONS

Compared to IP, IF promoted faster recovery of BCVA and outer retinal layers and was more protective against postoperative foveal thinning and displacement; hence, it should be considered for small and large FTMHs.

FULL-THICKNESS MACULAR HOLE WITH PERSISTENT BROAD VITREOMACULAR ATTACHMENT: Clinical Characteristics and Surgical Outcomes

PURPOSE

To describe the characteristics and surgical outcomes of full-thickness macular holes (FTMHs) with persistent broad vitreomacular attachment.

METHODS

This was a retrospective, observational case series. Consecutive patients undergoing pars plana vitrectomy for FTMHs with persistent broad vitreomacular attachment (study group) were reviewed. Clinical charts, optical coherence tomography (OCT) features of macular holes, and surgical outcomes were reviewed and compared with those with typical FTMH with focal vitreomacular traction (control group).

RESULTS

A total of 15 eyes of 14 consecutive patients (eight males and six females with a mean age of 60.6 years) were included in the study group. OCT showed a zone of at least 1,500 µm all around the circumference of the fovea where the vitreous was attached. On OCT, epiretinal membrane and epiretinal proliferation were observed in 73% and 87% of cases, respectively. Compared with the control group, the study group was younger (P = 0.027) and had better preoperative visual acuity (P = 0.007). All FTMHs closed after one surgery in both groups, and the postoperative visual acuity of the study group was better than that of the control group (P = 0.002).

CONCLUSION

Full-thickness macular holes may have developed under the condition that the vitreous cortex was broadly attached around the hole. These FTMHs were associated with younger age, better baseline visual acuity, and a higher incidence of epiretinal membranes and epiretinal proliferations compared with macular hole with focal vitreomacular traction. The surgical outcome was favorable, but the pathogenesis of FTMH development remains unclear.

ILM Flap Repositioning for Persistent Macular Hole

We present a case of a persistent macular hole which was initially treated by pars plana vitrectomy with the inverted ILM flap technique. In a second procedure, the internal limiting membrane (ILM) flap was mobilized from its perifoveal adherence to the retina and peeled back to its adherence at the foveal ring. The eye was filled with 25% C2F6 gas. Three weeks after the second procedure, closure of the hole was observed. Best corrected visual acuity increased from 20/400 to 20/50. We assume that contractile elements within the ILM may cause perifoveal adhesion and centrifugal effects preventing macular hole closure. If macular hole closure does not occur after surgery with an inverted ILM flap, it is worth to peel back the existing flap again towards the foveal edge in order to induce hole closure and preserve the benefits of flap surgery. If the flap is only attached to the foveal ring, centripetal contraction could lead to annular closure of the macular hole. If the flap is lost, alternative surgical methods for refractory MHs should be considered.

Progression rate analysis of idiopathic macular hole using optical coherence tomography before vitrectomy: short-term results

PURPOSE

While the postoperative closure rate of idiopathic macular holes (IMH) is quite high, its success rate and visual prognosis differ depending on macular hole (MH) characteristics. This study investigated the IMH progression rate before vitrectomy.

METHODS

This retrospective study compared optical coherence tomography (OCT) taken at baseline and on operation day for patients with stage 2, 3 and 4 IMH to determine the changes in minimum linear diameter (MLD), base diameter (BD), height and MH index (MHI). The IMH progression rate was calculated by dividing each difference in OCT parameters by the time interval.

RESULTS

A total of 224 eyes of 216 patients were included. The average time interval from baseline to operation was 35.59 ± 23.43 (7-137) days. Final visual acuity was related to preoperative MLD, BD, best-corrected visual acuity and time interval between baseline and operation (p = 0.005, p = 0.003, p <0.001 and p = 0.005 respectively). Between baseline and operation, the average MLD and BD increased significantly (all p <0.001). The average progression rates of MLD and BD assessed by simple regression analysis were 0.698 μm/day (R²  = 0.066, p <0.001) and 1.368 μm/day (R²  = 0.097, p <0.001) respectively. When patients were classified according to the MH stage, the progression rates of MLD and BD in those with stage 2 MH were significantly faster than those with stage 3 or 4 MH.

CONCLUSION

The relatively smaller MHs in stage 2 progress faster than those in stages 3 and 4. Therefore, it would ultimately be beneficial to perform vitrectomy without delay in patients with stage 2 MH.

Spontaneous closure of a chronic full-thickness idiopathic macular hole after Irvine-Gass syndrome resolution

Background

Full-thickness idiopathic macular hole (IMH) usually causes serious visual deformities and visual acuity loss. Pseudophakic cystic macular edema, also known as Irvine-Gass syndrome, is another entity that causes visual disturbances, and occurs mainly after cataract extraction. We present a case report of a patient that was diagnosed with a full-thickness macular hole that spontaneously closed after the resolution of an Irvine-Gass syndrome, which occurred after an uneventful cataract extraction.

Case presentation

A 75 years-old female presented with the complaints of decreased visual acuity and color contrast sensitivity on both eyes (OU) and central visual field deformations on her left eye (LE). She was diagnosed with a full-thickness IMH on her LE, and cataract on OU. After an uneventful cataract extraction via phacoemulsification, she developed an Irvine-Gass syndrome at her LE, which was treated topically. The IMH closed spontaneously after the resolution of the Irvine-Gass syndrome, and the patient is being followed with no further complaints.

Conclusion

The exact mechanism for spontaneous closure of full-thickness idiopathic macular holes is still not completely understood. In this case, we hypothesize that the coalesced intraretinal cysts caused by the Irvine-Gass syndrome formed a bridge-like structure connecting the inner walls of the macular hole, thus connecting the remnants of the Muller cells which enabled the full recovery of the normal foveal structure.

Single-Layer Inverted Internal Limiting Membrane Flap Versus Conventional Peel for Small- or Medium-Sized Full-Thickness Macular Holes

PURPOSE

To analyze the outcomes of using an internal limiting membrane (ILM) flap and the conventional ILM peel technique for small- or medium-sized full-thickness macular hole (FTMH) repair.

DESIGN

Retrospective, interventional case series.

METHODS

Eyes with an FTMH ≤400 µm that underwent vitrectomy with a single-layer inverted ILM flap (flap group, 55 eyes) or an ILM peel (peel group, 62 eyes) were enrolled. Best-corrected visual acuity (BCVA) and optical coherence tomography (OCT) measurements were obtained preoperatively and at 1, 3, 6, and 12 months postoperatively.

RESULTS

Primary hole closure was achieved in 54 (98%) and 60 (97%) eyes in the flap and peel groups, respectively. The preoperative and postoperative 12-month BCVA values were comparable between the groups but were significantly better in the flap than in the peel group at 1 month (mean ± SD logMAR: 0.83 ± 0.43 vs 1.14 ± 0.50; P = .001), 3 months (0.58 ± 0.33 vs 0.82 ± 0.43; P = .002), and 6 months (0.56 ± 0.32 vs. 0.72 ± 0.48; P = .028). In the flap group, foveal gliosis was less common than in the peel group at 1 month (P = .030), and restored external limiting membrane and interdigitation zone was more common at 3 months (P = .046 and P < .001, respectively).

CONCLUSIONS

The single-layer ILM flap and conventional ILM peel techniques both closed FTMHs and improved vision. ILM flaps were associated with better visual outcomes up to 6 months postoperatively and should be considered in FTMHs ≤400 µm.

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

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

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

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

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

AN ASSOCIATION BETWEEN STELLATE NONHEREDITARY IDIOPATHIC FOVEOMACULAR RETINOSCHISIS, PERIPHERAL RETINOSCHISIS, AND POSTERIOR HYALOID ATTACHMENT

PURPOSE

Stellate nonhereditary idiopathic foveomacular retinoschisis is a disorder characterized by splitting of the retina at the macula, without a known underlying mechanical or inherited cause. This study investigates demographic, anatomical, and functional characteristics of subjects with stellate nonhereditary idiopathic foveomacular retinoschisis, to explore potential underlying mechanisms.

METHODS

In this single-site, retrospective, and cross-sectional, observational study, data were collected from 28 eyes from 24 subjects with stellate nonhereditary idiopathic foveomacular retinoschisis. Descriptive statistics were reported, based on the observed anatomico-functional features.

RESULTS

The visual acuity remained stable (median 20/20) in all subjects over a median follow-up of 17 months. All cases demonstrated foveomacular retinoschisis within Henle's fiber layer, at the junction of the outer plexiform and outer nuclear layers. This schisis cavity extended beyond the limits of the macular OCT temporally in all eyes. In most affected eyes, there were documented features of peripheral retinoschisis and broad attachment of the posterior hyaloid at the macula. Functional testing in a cross-sectional subset demonstrated normal retinal sensitivity centrally but an absolute scotoma peripherally.

CONCLUSION

Stellate nonhereditary idiopathic foveomacular retinoschisis seems to be associated with peripheral retinoschisis and anomalous or incomplete posterior hyaloid detachment. Despite chronic manifestation, this does not significantly affect central visual function but can manifest with profound loss of peripheral visual function.

Spontaneous closure of degenerative lamellar macular hole with epiretinal membrane proliferation

Background

To describe the spontaneous closure of a degenerative lamellar macular hole with epiretinal proliferation (LHEP) as documented with tracked spectral domain optical coherence tomography (SD-OCT).

Case presentation

A 54-years-old diabetic female patient presented with progressive vision loss in the left eye. SD-OCT illustrated LHEP associated with cystic fluid in the outer nuclear layer. Sequentially tracked SD-OCT showed progressive closure of the degenerative lamellar macular hole and resolution of the CME over almost 4 years, in the absence of any surgical intervention.

Discussion/conclusion

LHEP may represent a specialized form of degenerative epiretinal membrane associated with Muller cell activation. Spontaneous degenerative LMH closure may rarely occur with these lesion types, in the absence of surgical intervention, possibly due to Muller cell proliferation preceded by PVD.

Inverted Internal Limiting Membrane Flap Technique: Is It the Best Option for Macular Holes?

Surgical treatment is generally necessary to repair full-thickness macular holes (FTMH). Although vitrectomy with or without internal limiting membrane (ILM) peeling remains the standard surgical technique, the inverted ILM flap procedure has increasingly assumed a role in the primary surgical repair of FTMHs. Some vitreoretinal surgeons reserve this technique to treat large or myopic holes, whereas others use it routinely in all cases. This paper is a comprehensive review of the current scientific evidence on the anatomical and functional outcomes of the inverted ILM flap technique in the repair of macular holes, following the International Vitreomacular Traction Study (IVTS) group classification.

Foveal reorganization after treatment of acute foveal toxoplasmic retinochoroiditis

Purpose

To report a patient with impaired vision due to foveal involvement of toxoplasmic retinochoroiditis, who was successfully treated with intravitreal clindamycin and dexamethasone and oral therapy with azithromycin, trimethoprim-sulfamethoxazole, and prednisolone and led to successful visual and anatomic recovery.

Case presentation

A 32-year-old man presented with three-day history of gradually decreasing visual acuity, redness, pain and photophobia of the right eye. Anterior chamber cellular reaction, vitritis and a white retinochoroiditis patch with adjacent retinal vasculitis in the fovea was suggestive of the toxoplasmic retinochoroiditis. He was treated with intravitreal clindamycin and dexamethasone injection followed by six-week regimen of azithromycin, trimethoprim-sulfamethoxazole, and prednisolone. In serial optical coherence tomography imaging, retinitis patch changed to cavitary foveal destruction. Fovea reorganized gradually, and visual acuity concurrently improved from counting finger 3 m to 20/25.

Conclusion

In foveal toxoplasmic retinochoroiditis lesions, timely treatment is associated with retinal reorganization and visual improvement.

Full-thickness macular holes after surgical repair of primary rhegmatogenous retinal detachments: incidence, clinical characteristics, and outcomes

PURPOSE

Full-thickness macular hole (FTMH) formation following rhegmatogenous retinal detachment (RRD) repair may limit post-operative visual acuity and often requires a return to the operating room, but little is known about this phenomenon.

METHODS

This study included all patients with a FTMH that developed after RRD repair from January 1, 2015-July 31, 2020. The main outcome was the rate of FTMH formation following RRD repair as well as characteristics of FTMH following RRD repair that spontaneously close.

RESULTS

There were 470 eyes with a diagnosis of both a FTMH and a RRD during the study period. Of these, 27 (0.28%) developed a FTMH following RRD repair. The median time to FTMH diagnosis was 91 days (25th, 75th quartiles 40, 204 days). The mean minimum hole diameter was 514.5 ± 303.6 microns. There were 4 FTMHs (14.8%) that spontaneously closed without surgical intervention. The spontaneous closure was noted from 4 to 12 weeks after the initial diagnosis of the FTMH. These holes were smaller than the holes that did not close spontaneously (mean minimum diameter 161.8 ± 85.2 vs 588.7 ± 279.3 microns, p = 0.0058). Of the 27 post-operative FTMHs, there were 23 eyes (85%) that underwent surgical intervention with pars plana vitrectomy and internal limiting membrane peeling. Nineteen eyes (83%) closed with one surgery, 20 eyes (87%) ultimately closed, while 3 eyes (11.1%) did not close.

CONCLUSIONS

FTMH is relatively uncommon to occur following RRD repair with a prevalence of 0.28% in our series with 87% of these holes achieving closure following surgery or spontaneously. Approximately 15% of FTMHs following RRD repair closed spontaneously and these holes were significantly smaller.

Müller cells and astrocytes in tractional macular disorders

Tractional deformations of the fovea mainly arise from an anomalous posterior vitreous detachment and contraction of epiretinal membranes, and also occur in eyes with cystoid macular edema or high myopia. Traction to the fovea may cause partial- and full-thickness macular defects. Partial-thickness defects are foveal pseudocysts, macular pseudoholes, and tractional, degenerative, and outer lamellar holes. The morphology of the foveal defects can be partly explained by the shape of Müller cells and the location of tissue layer interfaces of low mechanical stability. Because Müller cells and astrocytes provide the structural scaffold of the fovea, they are active players in mediating tractional alterations of the fovea, in protecting the fovea from such alterations, and in the regeneration of the foveal structure. Tractional and degenerative lamellar holes are characterized by a disruption of the Müller cell cone in the foveola. After detachment or disruption of the cone, Müller cells of the foveal walls support the structural stability of the foveal center. After tractional elevation of the inner layers of the foveal walls, possibly resulting in foveoschisis, Müller cells transmit tractional forces from the inner to the outer retina leading to central photoreceptor layer defects and a detachment of the neuroretina from the retinal pigment epithelium. This mechanism plays a role in the widening of outer lameller and full-thickness macular holes, and contributes to visual impairment in eyes with macular disorders caused by conractile epiretinal membranes. Müller cells of the foveal walls may seal holes in the outer fovea and mediate the regeneration of the fovea after closure of full-thickness holes. The latter is mediated by the formation of temporary glial scars whereas persistent glial scars impede regular foveal regeneration. Further research is required to improve our understanding of the roles of glial cells in the pathogenesis and healing of tractional macular disorders.

Clinical characteristics of full thickness macular holes that closed without surgery

PURPOSE

To ascertain the anatomic factors that help achieve non-surgical sealing in full thickness macular hole (FTMH).

METHODS

Retrospective collaborative study of FTMH that closed without surgical intervention.

RESULTS

A total of 78 patients (mean age 57.9 years) included 18 patients with blunt ocular trauma, 18 patients that received topical or intravitreal therapies and 42 patients with idiopathic FTMH. Mean±SD of the initial corrected visual acuity (VA) in logMAR improved from 0.65±0.54 to 0.34±0.45 (p<0.001) at a mean follow-up of 33.8±37.1 months. FTMH reopened in seven eyes (9.0%) after a mean of 8.6 months. Vitreomacular traction was noted in 12 eyes (15.8%), perifoveal posterior vitreous detachment in 42 (53.8%), foveal epiretinal membrane in 10 (12.8%), cystoid macular oedema (CME) in 49 (62.8%) and subretinal fluid (SRF) in 20 (25.6%). By multivariate analysis, initial VA correlated to the height (p<0.001) and narrowest diameter of the hole (p<0.001) while final VA correlated to the basal diameter (p<0.001). Time for closure of FTMH (median 2.8 months) correlated to the narrowest diameter (p<0.001) and the presence of SRF (p=0.001). Mean time for closure (in months) was 1.6 for eyes with trauma, 4.3 for eyes without trauma but with therapy for CME, 4.4 for eyes without trauma and without therapy in less than 200 µm in size and 24.7 for more than 200 µm.

CONCLUSION

Our data suggest an observation period in new onset FTMH for non-surgical closure, in the setting of trauma, treatment of CME and size <200 µm.

Foveal configurations with disappearance of the foveal pit in eyes with macular pucker: Presumed role of Müller cells in the formation of foveal herniation

Many eyes with macular pucker are characterized by a centripetal displacement of the inner foveal layers which may result in a disappearance of the foveal pit. In this retrospective case series of 90 eyes with macular pucker of 90 patients, we describe using spectral-domain optical coherence tomography different foveal configurations with ectopic inner foveal layers, document the relationship between posterior vitreous detachment (PVD) and idiopathic epiretinal membrane (ERM) formation and spontaneous and postoperative morphological alterations of the fovea, and propose an active role of Müller cells in the development of foveal herniation. We found that ERM were formed during or after partial perifoveal PVD, or after foveal deformations caused by tissue edema. The ERM-mediated centripetal displacement of the inner foveal layers and in various eyes anterior hyaloidal traction caused a disappearance of the foveal pit and an anterior stretching of the foveola with a thickening of the central outer nuclear layer (ONL). After the edges of the thickened inner layers of the foveal walls moved together, continuous centripetal displacement of the inner foveal layers generated a bulge of the fovea towards the vitreous (foveal herniation). Macular pseudoholes with a herniation of the inner foveal layers show that the outer layer of the protruding foveal walls is the outer plexiform layer (OPL). If the ERM covered the foveal walls and parafova, but not the foveola, the inner layers of the foveal walls were not fully centripetally displaced and the foveal pit was present. The visual acuity of eyes with ectopic inner foveal layers was inversely correlated with the thickness of the foveal center. Spontaneous morphological alterations after disappearance of the foveal pit may include the development of cystoid macular edema or additional thickening of the foveal tissue and foveal herniation. The foveal configuration with ectopic inner layers of the foveal walls and a thick central ONL persisted over longer postoperative time periods. The data show that the centripetal displacement of the inner foveal layers in eyes with macular pucker, which results in a disappearance of the foveal pit, may also generate foveal herniation which is suggested to be caused by contraction of Müller cell processes in the OPL. The centripetal displacement of the inner foveal layers and the formation of foveal herniation are suggested to reverse the foveal pit formation during development.

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.

Treatment of Inflammatory Macular Hole: Case Series and Review of Literature

Purpose: To present the success rate of nonsurgical management of full-thickness inflammatory macular hole (IMH)Method: Retrospective case series of five patients with IMH.Result: Five eyes from five patients with IMH enrolled in the current case series. All five eyes had successful closure with corticosteroid in the form of topical, periocular, or intravitreal injections. Systemic immunomodulatory treatment was employed for two patients, in addition to local therapy. For local therapy, one patient received topical eye drops, subtenon injection of corticosteroid, and intravitreal injection of combination of corticosteroid and anti-VEGF was performed in two patients. The closed macular hole reopened in one patient after two years, which required pars plana vitrectomy and anatomical and visual success achieved.Conclusion: Inflammatory macular holes can be closed with non-surgical interventions, although reopening may occur which requires surgery.

Degenerative lamellar macular holes: tractional development and morphological alterations

Purpose

The development of degenerative lamellar macular holes (DLH) is largely unclear. This study was aimed at documenting with spectral-domain optical coherence tomography the tractional development and morphological alterations of DLH.

Methods

A retrospective case series of 44 eyes of 44 patients is described.

Results

The development of DLH is preceded for months or years by tractional deformations of the fovea due to the action of contractile epiretinal membranes (ERM) and/or the partially detached posterior hyaloid, or by cystoid macular edema (CME). DLH may develop after a tractional stretching and thickening of the foveal center, from a foveal pseudocyst, after a detachment of the foveola from the retinal pigment epithelium, a disruption of the foveal structure due to CME, and after surgical treatment of tractional lamellar or full-thickness macular holes (FTMH). The foveal configuration of a DLH can be spontaneously reestablished after short transient episodes of CME and a small FTMH. A DLH can evolve to a FTMH by traction of an ERM. Surgical treatment of a DLH may result in an irregular regeneration of the foveal center without photoreceptors.

Conclusions

Tractional forces play an important role in the development of DLH and in the further evolution to FTMH. It is suggested that a DLH is the result of a retinal wound repair process after a tractional disruption of the Müller cell cone and a degeneration of Henle fibers, to prevent a further increase in the degenerative cavitations.

Spontaneous Conversion of Lamellar Macular Holes to Full-Thickness Macular Holes: Clinical Features and Surgical Outcomes

PURPOSE

To describe the clinical features and surgical outcomes of patients experiencing a spontaneous conversion of a lamellar macular hole (LMH) to a full-thickness macular hole (FTMH).

DESIGN

Retrospective, multicenter, observational case series.

PARTICIPANTS

Patients with LMH who experienced a spontaneous conversion to FTMH and underwent FTMH surgery.

METHODS

Clinical charts and OCT features of 20 eyes of 20 patients were reviewed.

MAIN OUTCOME MEASURES

OCT features and surgical outcomes of FTMH derived from LMH.

RESULTS

The mean baseline visual acuity (VA) was 0.21 ± 0.19 logarithm of the minimum angle of resolution (logMAR) (20/32 Snellen equivalent [SE]). Epiretinal proliferation was noted in 18 eyes (90%), and 14 eyes (75%) had an epiretinal membrane. At the diagnosis of FTMH, the mean VA decreased to 0.61 ± 0.50 logMAR (20/81 SE) (P = 0.001). The mean FTMH diameter was 224.4 ± 194.8 μm, with 15 (75%) small (≤250 μm), 2 (10%) medium (>250-≤400 μm), and 3 (15%) large (>400 μm) FTMHs. Eighteen (90%) FTMHs were sealed after 1 surgery, and 2 (10%) required an additional procedure. At the last follow-up, the mean VA was increased to 0.29 ± 0.23 logMAR (20/38 SE) (P = 0.003), but did not significantly differ from the baseline VA (P = 0.071).

CONCLUSIONS

Patients with LMH may develop an FTMH with no evidence of vitreomacular traction. A tangential traction from an epiretinal membrane may contribute to its genesis, but a progressive loss of retinal tissue and an inherent weakness of the foveal architecture in LMH eyes could be sufficient. Most FTMHs derived from LMH had a small diameter, showed epiretinal proliferation, showed limited retinal hydration, and were associated with relatively poor surgical outcomes compared with idiopathic FTMH.

Different modes of full-thickness macular hole formation

Full-thickness macular holes (FTMH) are an important cause of visual deterioration. However, different modes of FTMH formation are less investigated. It is also not clear whether the development of edematous cysts contributes to FTMH formation. In this retrospective case series of 30 eyes of 30 patients, we describe using spectral-domain optical coherence tomography different modes of FTMH formation. Morphological alterations of established FTMH are shown in 5 eyes of 5 patients. We found in 2 of 30 eyes investigated that anterior hyaloidal traction induced a hyperreflectivity of the inner Müller cell layer of the foveola prior to FTMH formation. In 3 eyes, FTMH were caused by anterior hyaloidal traction which produced foveal pseudocysts that developed to an outer lamellar hole (OLH) characterized by a disruption of the central outer retina. The OLH developed to a FTMH by the disruption of the inner layer of the foveola. FTMH formation from an OLH by hyaloidal traction was observed also in further 7 eyes. In 2 eyes, the OLH, which preceded FTMH formation, was generated by a serous retinal detachment. In 3 eyes, anterior hyaloidal traction caused a detachment of the fovea from the retinal pigment epithelium (RPE); the subsequent disruption of the foveola resulted in a FTMH. Six eyes showed the development of a FTMH from a degenerative lamellar hole (DLH). In 5 eyes with macular pucker, FTMH were formed by traction of epiretinal membranes (ERM) or hyaloidal traction. Two eyes showed the development of a FTMH by anterior or tangential hyaloidal traction likely without a formation of an OLH. FTMH formation from an OLH proceeded with or without an enlargement of cystic cavities in the foveal walls. The formation of FTMH from a DLH, after a detachment of the fovea, and in macular pucker eyes was associated with a formation of cystic cavities in the foveal walls. The best-corrected visual acuity (BCVA) of eyes with an OLH or FTMH was inversely correlated to the base and minimum diameters of the holes, and with the height of the foveal walls; the highest correlation coefficients were found between the BCVA and the base diameter. The data show that FTMH may be formed via different modes by hyaloidal traction and/or traction of ERM, or after a serous retinal detachment. It is suggested that, after FTMH formation, the impaired fluid clearance through the RPE after detachment of the central outer retina causes the development of edematous cysts in the foveal walls which enlarges the FTMH. The BCVA of eyes with an OLH or FTMH mainly depends on the size of the central photoreceptor-free area.

Spontaneous macular hole closure after posterior vitreous detachment in an eye with hyperreflective OCT stress line

PURPOSE

The aim of this report is to describe a patient who presented with a central hyper-reflective line (HRL) with spectral domain-optical coherence tomography (SD-OCT) after posterior vitreous detachment that evolved to full thickness macular hole (FTMH) with subsequent spontaneous resolution.

OBSERVATIONS

A 59-year-old patient presented with a history of photopsia and floaters followed by the development of a central scotoma in the right eye (OD). The left eye (OS) was normal. On examination, visual acuity (VA) was 20/20- OD and 20/20 OS. Retinal examination OD was remarkable for a retinal tear, and SD-OCT demonstrated a central HRL. The patient underwent laser retinopexy to barricade the retinal tear. Sequential SD-OCT of the macula was performed and the patient eventually developed a small FTMH 8 months after the baseline presentation. VA was correspondingly reduced to 20/80 OD. Upon return after 4 months, the hole was completely resolved with improvement of VA to 20/20 OD.

CONCLUSION

Vitreomacular traction (VMT) may lead to foveal dehiscence. This instability can be detected with SD-OCT as a vertical hyperreflective stress line that is a risk factor for progression to a FTMH. With release of VMT, FTMH can spontaneously close.

Role of growth factors and internal limiting membrane constituents in müller cell migration

This study investigated the effects of growth factors and internal limiting membrane components on Müller cell migration. We studied the effects of epidermal growth factor (EGF), fibroblast growth factor (FGF), somatomedin (IGF-1), platelet derived growth factor (PDGF), and stromal cell-derived factor-1 alpha (SDF-1α) as well as collagen IV, laminin, and fibronectin on the proliferative and migratory activities of rat Müller cells in vitro. A water soluble tetrazolium-1 assay was used to quantify the viability of Müller cells in respective cultures, and analysis was performed using an enzyme-linked immunosorbent assay reader. All the factors examined had significant proliferative effects on cultured Müller cells (p < .05). A two-well Ibidi silicone culture insert was used to assess Müller cell migration. Müller cells cultured in EGF, FGF, IGF-1, collagen IV, and laminin but not in SDF, PDGF, or fibronectin effectively increased the cell migratory activity (p < .001). In addition, combined EGF and collagen IV, combined FGF and collagen IV, and combined IGF-1 and laminin exhibited more significant (p < .001) effects on Müller cell migration compared with culture a single factor. In summary, this study revealed the combinatorial effects of various growth factors and individual internal limiting membrane constituents. This may assist Müller cell migration together with the macular hole healing process.

Macular microhole and foveal red spot syndrome: a critical review of the literature

PURPOSE

The purpose of this article is to review the literature on nomenclature, natural history, clinical features, diagnosis, management, and prognosis of both macular microhole (MMH) and foveal red spot syndrome (FRS).

METHODS

A PubMed primary literature search (February 1, 2020) utilizing the terms macular microhole, foveal red spot syndrome, and outer retinal hole was conducted. All chosen articles were case reports or case series. Articles qualified for inclusion if they documented symptoms, imaging findings, or followed patients longitudinally.

RESULTS

A total of 14 studies from 1988 to 2019 that evaluated either MMH, FRS, or both were included in the review. No comparative study between the two defects was found. Studies often used the terms FRS and MMH interchangeably to reference both partial- and full-thickness lesions of the macula. Spectral-domain optical coherence tomography (SD-OCT) was most frequently able to identify these lesions and revealed an absence of all neural retinal layers from the inner limiting membrane (ILM) to the retinal pigment epithelium (RPE) in the full-thickness lesions while the partial-thickness lesions most often involved the photoreceptor layer (PRL) and less frequently the external limiting membrane (ELM). OCT revealed that vitreomacular traction (VMT) was involved in the natural history of both FRS and MMH for a significant subset of patients.

CONCLUSION

The terms MMH and FRS have been used interchangeably in the literature. Advances in OCT have revealed that MMHs and FRSs are distinct but sometimes overlapping entities. We suggest that MMH and FRS are similar entities defined as one or more sharply defined lesions in the fovea of the eye < 150 μm in size. MMHs are a full-thickness defect of the entire neuroretina at the center of the foveola while FRSs are partial-thickness lesions. Current literature suggests that there may be subtle differences in the pathogenesis, clinical features, and diagnosis between MMH and FRS; however, prognosis and management for both are favorable. Lastly, we suggest that the terms outer lamellar macular microholes and full-thickness macular microholes may be the more appropriate terminologies to refer to FRS and MMH, respectively.

Visual Acuity Recovery After Macular Hole Closure Associated With Foveal Avascular Zone Change

Purpose

To evaluate changes in the foveal avascular zone (FAZ) area during the postoperative period of macular hole (MH) surgery using the optical coherence tomography angiography (OCTA) and to investigate its relationship to visual acuity (VA).

Methods

Consecutive unilateral MH patients who underwent successful MH closure with at least a six-month observation period were studied retrospectively. To evaluate the FAZ area, OCTA images were obtained at the preoperative visit, the first postoperative visit, and the six-month visit. Main outcome measures were postoperative FAZ change and its relationship to VA change after MH closure.

Results

Fifty-one cases were studied. The FAZ area was 0.42 ± 0.11 mm² at the preoperative visit, 0.25 ± 0.091 mm² at the first postoperative visit and 0.31 ± 0.11 mm² at the six-month visit. FAZ area at the first postoperative visit was significantly smaller (P < 0.0001) than at the preoperative visit. FAZ area at the six-month visit was significantly greater (P < 0.0001) than at the first postoperative visit, but still significantly smaller (P = 0.0002) compared to the normal fellow eye. The postoperative FAZ area enlargement from the first postoperative visit to the six-month visit was significantly correlated with the postoperative VA recovery (P = 0.0322) and the postoperative photoreceptor reconstruction (P = 0.0213).

Conclusions

The FAZ area once decreases along with MH closure; it thereafter increases toward the normal value over time. The postoperative FAZ change was correlated with the VA recovery.

Translational Relevance

This study suggests that the postoperative FAZ area enlargement might be a potential biomarker indicating foveal reconstruction after MH closure.

Two different populations of Müller cells stabilize the structure of the fovea: an optical coherence tomography study

PURPOSE

To document with spectral-domain optical coherence tomography the structural stabilization of the fovea and the sealing of outer macular defects by Müller cells.

METHODS

A retrospective case series of 45 eyes of 34 patients is described.

RESULTS

In cases of a cystic disruption of the foveola as in macular telangiectasia type 2 and vitreomacular traction, the Müller cell cone provides the structural stability of the fovea. In cases of a detachment or disruption of the Müller cell cone, e.g., in foveal pseudocysts, outer lamellar holes, and degenerative and tractional lamellar holes, Müller cells of the foveal walls may provide the structural stability of the fovea by the formation of a hyperreflective external limiting membrane (ELM) which bridges the holes in the central outer nuclear layer (ONL). Müller cells of the foveal walls and parafovea mediate the regeneration of the foveal architecture in cases of outer lamellar and full-thickness macular holes. The regeneration proceeds by a centripetal displacement of photoreceptor cell somata which closes the holes in the central ONL. The closure may be supported by the formation of a glial tissue band at the ELM which seals the hole.

CONCLUSIONS

The Müller cell cone provides the foveal stability in cases of a cystic disruption of the foveola. The structural stability of the outer foveal layers is mainly provided by the Müller cells of the foveal walls and parafovea; these cells also mediate the regeneration of the outer fovea in cases of a defect of the central ONL.

Different modes of foveal regeneration after closure of full-thickness macular holes by (re)vitrectomy and autologous platelet concentrate

AIM

To describe using spectral-domain optical coherence tomography the regeneration of the foveal morphology after pars plana (re)vitrectomy surgery and gas tamponade combined with injection of autologous platelet concentrate to treat full-thickness macular holes, and to describe different anatomical outcome.

METHODS

A retrospective case series of 8 eyes of 8 patients was described.

RESULTS

In all cases investigated, the platelet-assisted closure of macular holes was associated with a rapid resolution of cystic cavities in the foveal walls. In two patients, there was a regular regeneration of the foveal morphology after hole closure; the regenerated central fovea had a regular structure with a foveola and photoreceptors. In three other patients, there was an irregular regeneration of the fovea; a foveola was not formed, photoreceptor cells were absent from the foveal center, and the center was composed of Müller and retinal pigment epithelial (RPE) cells. The foveal regeneration after hole closure may proceed with or without a temporary detachment of the foveal center from the RPE, and with or without a direct contact between the central outer nuclear layer (ONL) and the RPE. Contacts between the ONL and RPE were observed only in patients with an irregular foveal regeneration after hole closure.

CONCLUSION

The data show that there are different modes of foveal regeneration after closure of macular holes with (re)vitrectomy and platelet concentrate. It is suggested that the regular regeneration of the foveal morphology proceeds by Müller cell-mediated tissue movements without cell proliferation, whereas the irregular foveal regeneration proceeds in part by proliferation of Müller and RPE cells.

Glia of the human retina

The human retina contains three types of glial cells: microglia and two types of macroglia, astrocytes and Müller cells. Macroglia provide homeostatic and metabolic support to photoreceptors and neurons required for neuronal activity. The fovea, the site of the sharpest vision which is astrocyte- and microglia-free, contains two populations of Müller glia: cells which form the Müller cell cone in the foveola and z-shaped Müller cells of the foveal walls. Both populations are characterized by morphological and functional differences. Müller cells of the foveola do not support the activity of photoreceptors and neurons, but provide the structural stability of the foveal tissue and improve the light transmission through the tissue to the photoreceptors. This article gives overviews of the glia of the human retina and the structure and function of both Müller cell types in the fovea, and describes the contributions of astrocytes and Müller cells to the ontogenetic development of the fovea.