Double peel using triamcinolone acetonide and trypan blue in the management of myopic macular hole with retinal detachment: a case-control study

The Importance of Posterior Hyaloid Removal in a Case of Vitrectomy for Floaters in High Myopia

A 61-year-old Malaysian Chinese man who has high myopia complained of both eye floaters. Spectral-domain optical coherence tomography (SD-OCT) of the macula showed bilateral posterior staphyloma with right eye (RE) foveoschisis without macula detachment, which had been stable for a seven-year follow-up. When bilateral YAG laser vitreolysis could not alleviate his symptoms, he underwent pars plana vitrectomy with the inducement of posterior vitreous detachment, first in the left eye, followed by the RE one month later. The best-corrected visual acuity for both eyes was 6/6, N5 two months postoperatively, and he was asymptomatic for floaters. However, six months postoperatively, he complained of metamorphopsia and worsening RE vision. Repeat OCT showed worsening of the foveoschisis bilaterally with left foveal detachment. The patient had to undergo a repeat vitrectomy with peeling of the internal limiting membrane (ILM) in bilateral eyes, which successfully restored his foveal architecture and alleviated his symptoms. This article highlights theimportance of preoperative OCT assessment of the fovea in patients undergoing vitrectomy for floaters, as staining and complete removal of posterior hyaloid with ILM peeling during vitrectomy may mitigate the progression of foveoschisis after core vitrectomy for floaters in myopic patients.

Are we facing an increasing surgical demand for high myopic traction maculopathies? A 12-year study from Hong Kong

PURPOSE

We aimed to investigate the longitudinal change in the number of surgically operated myopic traction maculopathies (MTM) cases at a tertiary eye centre.

METHODS

A retrospective study of all consecutive cases of surgically operated MTM over 12 years (2009-2020) was conducted in a myopia prevalent region. We compared outcomes among three groups: (1) myopic macular hole (MH), (2) myopic macular hole with retinal detachment (MHRD), and (3) myopic foveoschisis with retinal detachment (MFRD).

RESULTS

Fifty-one cases were included in the study (8 cases of MH, 33 cases of MHRD and 10 cases of MFRD). The overall mean age was 63.8 +/- 8.7 with a female preponderance (2:1). The mean age of the MH group (58.6) was significantly younger than the MHRD group (64.2) and MFRD group (66.6) (p = 0.02). Subgroup analysis using ATN classification did not show its correlation with both visual improvement and anatomical success. When comparing the first 6-year period (2009-2014) with the second 6-year period (2015-2020), there was a significant increase in the number of cases (p = 0.01).

CONCLUSION

We observe an increase in the number of surgically operated MTM. This follows the trend of the global rise in the prevalence of myopia and baby boomers entering retirement.

[Long-term outcomes of treating rhegmatogenous retinal detachment with macular hole using platelet-rich blood plasma]

Currently there is no specific algorithm for treating rhegmatogenous retinal detachment complicated by macular hole.

PURPOSE

The study analyzed the long-term outcomes of surgical treatment of rhegmatogenous retinal detachment (RRD) complicated by macular hole (MH) using platelet-rich plasma (PRP) and local staining of the internal limiting membrane (ILM).

MATERIAL AND METHODS

This prospective open-label study included 27 patients (15 females and 12 males) aged 57 to 65 (59.2±7.2) years. In all studied cases, RRD complicated by MH was determined. The best corrected visual acuity (BCVA) before surgery was 0.05±0.01 (from 0.02 to 0.08). The average MH diameter measured with OCT was 576.3±150.4 μm (409 μm to 944 μm). After vitrectomy, a perfluororganic compound (PFOC) was injected into the MH area in amount of 2-3 optic nerve head diameters to prevent the ingress of dye under the retina, then the internal limiting membrane (ILM) was stained and removed. After sequential PFOC/air replacement, PRP was injected into the macular hole site.

RESULTS AND DISCUSSION

An increase in BCVA from 0.05±0.01 to 0.09±0.03 was observed in the preoperative period one month after surgery, with a further increase to 0.35±0.11 at the maximum follow-up time (two years). The MH was blocked and a glial scar was present in all cases according to OCT data. 1-2 years after the operation, all patients showed a favorable anatomical effect according to OCT data. According to computer microperimetry data, mean macular photosensitivity was 23.8±1.3 dB two years after the surgery.

CONCLUSIONS

This study shows a favorable anatomical and functional effect in patients with RRD and MH within a 2-year follow-up. A comparative study involving a larger cohort of patients is required to clarify the indications and contraindications for the use of the studied technique.

Incidence and Risk Factors Affecting the Recurrence of Primary Retinal Detachment in a Tertiary Hospital in Spain

(1) Objective: To determine the incidence, visual outcomes and risk factors associated with the recurrence of primary retinal detachment (RD) in a tertiary hospital. (2) Methods: A retrospective observational study was conducted, and data were collected on all eyes diagnosed with primary RD between January 2017 and December 2020. A detailed database was generated with data on anatomic and visual outcomes, and surgical technique information, for all the cases. (3) Results: 570 eyes with primary RD were included. Mean annual incidence of primary RD was 21.8 cases per 100,000 inhabitants. Mean follow-up time was 465 (±410.5) days. Mean time to redetachment was 114.4 (±215.8) days, with the median being 35 days. Statistically significant variables related to a higher risk of recurrence were: male sex (p = 0.04), type of tamponade (p = 0.01), surgeon (p = 0.035), inferonasal (p = 0.002) and inferotemporal (p = 0.032) involvement, complex RD (p < 0.001) and ocular comorbidity (p < 0.001). More satisfactory final visual acuity (VA) in patients not suffering redetachment was associated with shorter duration of central vision loss. (4) Conclusions: Sex, type of tamponade, inferior detachment, RD complexity, surgeon and ocular comorbidity were identified as prognostic factors for recurrence. Worse final postoperative VA was found in patients referring central vision loss for more than 4 days before surgery.

Human Amniotic Membrane Plug for Macular Holes Coexisting with Rhegmatogenous Retinal Detachment

Purpose

To evaluate the efficacy of human amniotic membrane in promoting closure of macular holes coexisting with rhegmatogenous retinal detachment.

Methods

This is a retrospective case series of 14 eyes (14 patients) with macula off retinal detachment. These patients had a macular hole coexistent with peripheral retinal breaks. A human amniotic membrane plug was used to close the macular hole during vitrectomy without ILM peeling.

Results

The mean preoperative BCVA (logMAR value) was 1.87 ± 0.31. At the 6-month follow-up visit, the mean LogMAR best-corrected visual acuity was 0.67 ± 0.17. At the 6-month follow-up, all patients showed complete retinal reattachment with macular hole closure.

Conclusion

The use of human amniotic membrane is a valid option in surgery for macular holes coexisting with rhegmatogenous retinal detachment.

Floating flap of internal limiting membrane in myopic macular hole surgery

PURPOSE

To evaluate the surgical results of macular hole (MH) in patients with high myopia treated with pars plana vitrectomy (PPV) leaving the internal limiting membrane (ILM) flap floating in vitreous fluid at the edge of the MH.

METHODS

Nine highly myopic eyes with MH of nine consecutive patients who underwent PPV were retrospectively evaluated. Three eyes were accompanied by retinal detachment (RD). ILM peeling was performed around the MH and some part of the ILM flap was left attached to the edge of the MH. Further manipulation of the ILM flap to cover the MH was not performed. Fluid-gas exchange was performed to the retinal vessel arcade level. Patients maintained a face down position for 3 to 7 days postoperatively.

RESULTS

Complete MH closure was confirmed using optical coherence tomography in all eyes and three eyes with RD showed reattachment of the retina after the initial surgery. Visual acuity significantly improved (P = 0.02) and no eyes experienced MH reopening or RD occurrence during the follow-up period of 8.33 ± 3.61 months after the surgery.

CONCLUSIONS

MH with or without RD in highly myopic eyes could be successfully treated with PPV leaving ILM flap floating in vitreous fluid at the edge of the MH. After the ILM peeling, further manipulation of the ILM flap to cover the MH would not be necessary for the treatment of MH in high myopia.

A meta-analysis of vitrectomy with or without internal limiting membrane peeling for macular hole retinal detachment in the highly myopic eyes

Background

To evaluate the anatomical and visual outcomes by par plana vitrectomy with or without internal limiting membrane (ILM) peeling in highly myopic eyes with macular hole retinal detachment (MHRD).

Methods

MEDLINE (Ovid, PubMed) and EMBASE were used for data collection up to September 30, 2015. The parameters of anatomical success, macular hole closure and improved best corrected visual acuity (BCVA) at or beyond 6 months after operation were assessed as the primary outcome measurement. The meta-analysis was performed with the fixed-effects model.

Results

Seven comparative analyses involving a total of 373 patients were included in the present meta-analysis. Statistically the pooled data showed significant relative risk (RR) in terms of primary reattachment between ILM peeling and non-peeling groups (RR, 1.19; 95 % CI, 1.04 to 1.36; P = 0.012). An effect favoring ILM peeling with regard to macular hole closure was also detected (RR, 1.71; 95 % CI, 1.20 to 2.43; P = 0.003). However, no statistically significant difference was found in the improved BCVA (logarithm of the minimum angle of resolution) at 6 months or more (95 % CI, −0.31 to 0.44; P = 0.738).

Conclusions

There is no proved benefit of postoperative visual improvement. However, the available evidences from this study suggested a superiority of ILM peeling over no peeling for myopic patients with MHRD.

Complications of Macular Peeling

Macular peeling refers to the surgical technique for the removal of preretinal tissue or the internal limiting membrane (ILM) in the macula for several retinal disorders, ranging from epiretinal membranes (primary or secondary to diabetic retinopathy, retinal detachment…) to full-thickness macular holes, macular edema, foveal retinoschisis, and others. The technique has evolved in the last two decades, and the different instrumentations and adjuncts have progressively advanced turning into a safer, easier, and more useful tool for the vitreoretinal surgeon. Here, we describe the main milestones of macular peeling, drawing attention to its associated complications.

Vitrectomy with internal limiting membrane peeling vs no peeling for Macular Hole-induced Retinal Detachment (MHRD): a meta-analysis

BACKGROUND

we conducted our meta-analysis of published studies to assess existing evidence about the efficacy and safety of vitrectomy with ILM peeling vs. that of vitrectomy with no ILM peeling for Macular hole-induced retinal detachment.

METHODS

Databases, including Pubmed, Cochrane Library, Ovid, Web of Science, Wanfang and CNKI, were searched to identify studies comparing outcomes following vitrectomy with ILM peeling and that with no ILM peeling for macular hole-induced retinal detachment. The meta-analysis was performed by RevMan 5.1.

RESULTS

Six comparative studies comprising 180 eyes were identified. It was indicated that the rate of retinal reattachment (Odds ratio (OR) = 3.03, 95 % Confidence interval (CI):1.35 to 6.78; P = 0.007) and macular hole closure (OR = 6.74, 95 % CI:3.26 to 13.93; P < 0.001) after initial surgery was higher and the rate of recurrent retinal detachment (OR = 0.08, 95 % CI:0.02 to 0.30; P = 0.0002) was lower in the group of vitrectomy with ILM peeling than that in the group of vitrectomy with no ILM peeling. However, the improved BCVA (Weighted mean difference (WMD) = 0.14, 95 % CI: -0.20 to 0.47; P = 0.42) and the rate of postoperative complications were similar between the two groups.

CONCLUSION

Vitrectomy with internal limiting membrane peeling is an efficient and safe procedure for macular hole-induced retinal detachment.

Retrospective Comparison of 25- and 23-Gauge Microincision Vitrectomy Surgery and 20-Gauge Vitrectomy for the Repair of Macular Hole Retinal Detachment

PURPOSE

To compare the anatomical and functional outcomes of 25- and 23-gauge microincision vitrectomy surgery (25G and 23G MIVS) instrumentation with the standard 20G pars plana vitrectomy (20G PPV) system in the treatment of primary macular hole retinal detachment (MHRD).

DESIGN

A retrospective comparative study.

METHODS

Forty-six eyes of 45 patients with MHRD underwent pars plana vitrectomy from March 1, 2006 to April 31, 2011. Fourteen, 13, and 19 eyes underwent 20G PPV, 23G MIVS, and 25G MIVS, respectively. The analysis included characteristics of the patients, single operation reattachment rate, final reattachment rate, closure rate of the macular hole, and rate of complications. The median follow-up period was 273 days.

RESULTS

Preoperative characteristics were similar in the 3 groups. The single operation success rate was 11 (79%) of 14 for 20G PPV, 10 (77%) of 13 for 23G MIVS, and 14 (74%) of 19 for 25G MIVS (P = 0.95). The closure rate of the macular hole was 9 (64%) of 14 for 20G PPV, 9 (69%) of 13 for 23G MIVS, and 11 (58%) of 19 for 25G MIVS (P = 0.78). One hundred percent of patients achieved final reattachment after multiple surgeries, excluding 2 patients who dropped out during the follow-up period. Rates of visual recovery and complications, including hypotony, were similar for all 3 procedures.

CONCLUSIONS

The outcomes of 25G and 23G MIVS for the management of MHRD did not differ significantly from 20G PPV. Microincision vitrectomy surgery may be considered an alternative treatment, even for MHRD.

Vitreous tamponades in highly myopic eyes

The use of endotamponade agents has gained a major role in the management of macular complications of high myopia. Myopic foveoschisis and macular hole are the main macular complication of pathologic myopia, this growing condition that is a main cause of visual loss, especially in patients at a younger age. We discuss the physical properties and advantages and disadvantages of the main ocular tamponade agents used in the treatment of these diseases.

Prognostic factor analysis of vitrectomy for retinal detachment associated with myopic macular holes

PURPOSE

To describe the anatomic and functional outcomes in a cohort of subjects undergoing vitrectomy for retinal detachment (RD) resulting from myopic macular hole (MH) and to analyze the prognostic and surgical factors predicting retinal reattachment and MH closure.

DESIGN

Retrospective case series.

PARTICIPANTS

All patients who underwent vitrectomy for RD resulting from myopic MH between 2000 and 2009 at our center.

METHODS

Case records were reviewed at 6 months after surgery. Retinal reattachment and complete anatomic success, defined as retinal reattachment with MH closure, were assessed. Multivariate logistic regression models, including age, gender, duration of symptoms, spherical equivalent refraction (SE), internal limiting membrane peeling, tamponade choice, and concurrent scleral buckling, were constructed to assess associations with covariates.

MAIN OUTCOME MEASURES

Retinal reattachment and complete anatomic success (retinal reattachment with MH closure).

RESULTS

In total, 114 subjects were analyzed. Most were women (n = 79 [69.3%]), and the mean age was 57.5±13.3 years. The mean SE was -9.88±6.37 diopters. At 6 months, 98 subjects (86.0%) demonstrated retinal reattachment, of whom 93 subjects required only 1 operation. Complete anatomic success was achieved in 61 subjects (53.5%), of whom 55 needed only 1 operation. Subjects with retinal reattachment had better best-corrected visual acuity (BCVA; mean BCVA, 1.22±0.81 logarithm of the minimum angle of resolution [logMAR] units) than those without (mean BCVA, 1.98±1.26 logMAR units; P < 0.001), and subjects with complete anatomic success had better BCVA (mean BCVA, 1.05±0.87 logMAR units) than those without (mean BCVA, 1.62±0.87 logMAR units; P < 0.001). In multivariate analyses, increasing age and the use of perfluoropropane (C3F8) tamponade were predictive of anatomic success (per 1-year increase: odds ratio [OR], 1.049; 95% confidence interval [CI], 1.002-1.099; P = 0.04; and for tamponade: OR, 10.71; 95% CI, 1.08-106.29; P = 0.04).

CONCLUSIONS

Vitrectomy is effective in the repair of RD resulting from MH in myopic eyes, with retinal reattachment achieved more frequently than MH closure. Retinal reattachment and MH closure are important for improving visual outcomes. Greater age at presentation and use of C3F8 are associated with a greater likelihood of anatomic success.

Material properties of the internal limiting membrane and their significance in chromovitrectomy

Intraoperative visualization of the internal limiting membrane (ILM), the choice of a point of vantage for lifting an initial flap, the precision with which the ILM is grasped, adhesion between the forceps and the ILM, thickness, stiffness and elasticity of the ILM as well as monitoring of the completeness of ILM removal are all important factors for safety and efficacy of a chromovitrectomy intervention. The understanding of the underlying physical features of the ILM, such as contrast behavior and bioanatomical and biomechanical properties represent, thus, useful prerequisites for successful macular surgery. New analytical tools, such as atomic force microscopy and chromaticity analysis, allow new insights into ILM material characteristics, permitting a systematic approach to refinement of surgical technique. .

Epiretinal membrane surgery outcomes in highly myopic eyes without traction maculopathy: long-term results of a case-control study

PURPOSE

To evaluate the outcomes of epiretinal membrane (ERM) surgery in highly myopic eyes without traction maculopathy, and to compare them with those from non-highly myopic eyes.

DESIGN

Retrospective nested case-control study from a cohort of 509 consecutive patients (509 eyes) who underwent pars plana vitrectomy with ERM removal.

METHODS

Thirty-two highly myopic eyes (with a refractive error of more than -6.00 diopters [D]), which underwent surgery for isolated ERM, were included in the study. For each case studied, we selected from the same cohort 2 age-matched controls who had ERM surgery (n = 64 non-highly myopic eyes). The best-corrected visual acuity (BCVA), the central macular thickness (CMT), and the surgical complications were analyzed.

RESULTS

The mean follow-up duration was 3.2 ± 1.5 years for the study cases and 3.4 ± 1.6 years for the control group (P = .608). At the final follow-up examination, the mean logMAR BCVA had improved significantly, from 0.56 to 0.26 (P < .001) for the case group and from 0.54 to 0.22 (P < .001) for the control group. At the final optical coherence tomography (OCT), the mean CMT had improved significantly, from 433 to 314 μm (P < .001) for the case group and from 428 to 303 μm (P < .001) for the control group. There was no significant difference between the 2 groups as regards visual or CMT improvement (P = .526 and P = .483, respectively). The incidence of surgical complications was not significant between the 2 groups.

CONCLUSIONS

The results of ERM surgery were not different in terms of anatomic and visual outcomes and surgical complication between highly myopic and non-highly myopic eyes.