Intravitreal gas injection for macular hole with localized retinal detachment in highly myopic patients

Vitrectomy for retinal detachment associated with macular hole: Prognostic factor analysis under different axial length conditions

PURPOSE

To identify prognostic factors for complete anatomical success (CAS) under different axial length (AL) conditions after vitrectomy plus internal limiting membrane (ILM) peeling for retinal detachment associated with macular hole (MHRD).

METHODS

This retrospective study included 243 patients (251 eyes) with MHRD who underwent primary vitrectomy plus ILM peeling. Multivariate logistic regression explored prognostic factors for CAS in AL <30 mm and ≥ 30 mm groups.

RESULTS

Overall, 113 eyes (45.0% of 251) exhibited complete CAS after initial surgery. Eyes with CAS had greater best-corrected visual acuity improvement than eyes without CAS (p < 0.001). CAS was more common in eyes with AL < 30 mm (50.3% of 155) than in eyes with AL ≥ 30 mm (36.5%, 35/96; p = 0.032). In the AL < 30 mm group, CAS was associated with ILM insertion (odds ratio [OR], 2.824, 95% confidence interval [CI], 1.189-6.710; p = 0.019), silicone oil (SO)/perfluoropropane (C3F8) tamponade (SO: OR, 0.408, 95% CI, 0.191-0.873; C3F8: OR, 2.448, 95% CI, 1.145-5.234; p = 0.021) and staphyloma (OR, 0.318, 95% CI, 0.143-0.707; p = 0.005). In the AL ≥30 mm group, CAS was associated with ILM insertion (OR, 11.621, 95% CI, 2.557-52.813; p = 0.001), SO /C3F8 tamponade (SO: OR, 5.305, 95% CI, 1.206-23.334; C3F8: OR, 0.188, 95% CI, 0.043-0.829; p = 0.027) and age (OR, 0.928, 95% CI, 0.876-0.983; p = 0.011).

CONCLUSION

Vitrectomy plus ILM peeling can effectively treat MHRD but has limited efficacy in eyes with AL ≥ 30 mm. ILM insertion was associated with more frequent CAS at any AL. C3F8 tamponade yielded better outcomes with AL < 30 mm; SO tamponade yielded better outcomes with AL ≥ 30 mm.

Vitreoretinal Interface Changes After Anti-vascular Endothelial Growth Factor Treatment in Highly Myopic Eyes: A Real-World Study

INTRODUCTION

To investigate changes in the vitreoretinal interface after anti-vascular endothelial growth factor (anti-VEGF) treatment in highly myopic eyes.

METHODS

Eyes with myopic choroidal neovascularization (mCNV) treated with intravitreal injection of anti-VEGF in a single-center were retrospectively reviewed. Fundus abnormalities and features of optical computed tomography were studied.

RESULTS

A total of 295 eyes from 254 patients were recruited to the study. Prevalence of myopic macular retinoschisis (MRS) was 25.4%, and the rates of progression and onset of MRS were 75.9% and 16.2%, respectively. Outer retinal schisis (β = 8.586, p = 0.003) and lamellar macular hole (LMH) (β = 5.015, p = 0.043) at baseline were identified risk factors for progression and onset of MRS, whereas male sex (β = 9.000, p = 0.039) and outer retinal schisis at baseline (β = 5.250, p = 0.010) were risk factors for MRS progression. Progression of MRS was first detected in outer retinal layers in 48.3% of eyes. Thirteen eyes required surgical intervention. Spontaneous improvements of MRS were observed in five eyes (6.3%).

CONCLUSION

Changes in the vitreoretinal interface, such as progression, onset, and improvement of MRS, were observed after anti-VEGF treatment. Outer retinal schisis and LMH were risk factors of progression and onset of MRS after anti-VEGF treatment. Intravitreal injection of ranibizumab and retinal hemorrhage were protective factors for surgical intervention for vision-threatening MRS.

INTRAVITREAL GAS INJECTION WITH LASER PHOTOCOAGULATION FOR HIGHLY MYOPIC FOVEOSCHISIS: Technique and Outcome

This article documented the effects of intravitreal perfluoropropane (C₃F₈) injection combined with macular laser photocoagulation 1 week later for patients with highly myopic foveoschisis. This modified combined therapy can yield an acceptable success rate.

Purpose:

To evaluate the effects of gas tamponade combined with laser photocoagulation without vitrectomy in patients with highly myopic foveoschisis.

Methods:

This retrospective noncomparative case series included 30 eyes of 23 patients with highly myopic foveoschisis who were treated by intravitreal injection of 0.5 to 0.7 mL C₃F₈ combined with laser photocoagulation 1 week later, and remained in the face-down position for 3 weeks. The patients were followed up for at least 6 months after the treatment. The refractive status, best-corrected visual acuity, and anatomical parameters of retina observed with the optical coherence tomography before and after the treatment were recorded.

Results:

The mean age of the 23 patients (6 men and 17 women) was 50.4 ± 15.1 years. The average follow-up duration was 20.8 ± 20.6 months. At the final follow-up, 23 eyes (76.7%) completely (17 eyes) or partially (6 eyes) resolved. Seventeen eyes had complete data of optical coherence tomography parameters, the mean central foveal thickness decreased significantly from 505.24 ± 466.22 μm to 186.41 ± 95.36 μm (P = 0.01), and the mean maximal macular thickness from 687.88 ± 397.00 μm to 313.65 ± 83.07 μm (P = 0.001). The mean final logarithm of the minimum angle of resolution best-corrected visual acuity (Snellen equivalent) of the 30 eyes ranged from 1.6 (20/800) to 0.2 (20/32), showing a slight improvement from 0.91 ± 0.44 (20/163) preoperatively to 0.90 ± 0.39 (20/160) postoperatively (P = 0.87).

Conclusion:

C₃F₈ tamponade combined with laser photocoagulation could be an alternative treatment for highly myopic foveoschisis.

Office-based intravitreal injection of expansile gas for management of macular hole in previously vitrectomized eyes

Purpose

To report the successful closure of full-thickness macular hole (MH), using an office-based intravitreal gas injection, in two eyes having undergone prior pars plana vitrectomy (PPV).

Observations

Patient 1 presented with acute loss of visual acuity to 20/300 in the left eye 5 months following PPV for fovea-off rhegmatogenous retinal detachment; MH was confirmed by examination and optical coherence tomography (OCT). 0.6 cc of 100% C3F8 gas was injected, with subsequent MH closure following one week of face-down positioning. Patient 2 presented with right eye visual acuity of 20/60 one month following PPV for optic nerve pit-associated maculopathy; MH was confirmed by examination and OCT. 0.85 cc of 100% C3F8 gas was injected in the office, with subsequent MH closure following one week of face-down positioning.

Conclusions and importance

MH management in previously vitrectomized eyes has traditionally been repeat PPV with internal limiting membrane peeling, fluid-air exchange, and expansile gas exchange. Intravitreal gas injection, in an office-based setting, is a viable clinical approach to close MH in some previously vitrectomized eyes.

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

PURPOSE

We investigated the surgical results of macular hole retinal detachment (MHRD) with a modified C-shaped temporal inverted internal limiting membrane (ILM) flap to reconstruct the foveolar architecture in highly myopic eyes.

METHODS

Eighteen highly myopic eyes with MHRD in 17 patients who underwent a vitrectomy with a modified C-shaped temporal inverted ILM flap were followed for 12 months. Anatomic outcomes were evaluated by fundus examinations and optical coherence tomography. The preoperative and postoperative best-corrected visual acuities (BCVAs) were compared as functional outcomes.

RESULTS

Women accounted for 88% of the MHRD patients. The mean age was 60.2 ± 8.2 years. The mean axial length was 29.25 ± 2.10 mm. Type 1 and type 2 MHRD was present in four eyes and 14 eyes, respectively. After a single surgery, the hole was closed in 18 eyes (100%). Retinal attachment was achieved in 95%. Persistent shallow subretinal fluid (SRF) was noted in one case, which was resolved at follow-up. The surgery significantly improved BCVAs (from 1.7 ± 0.6 to 0.72 ± 0.4 logarithm of the minimum angle of resolution units [p < 0.001]) at the last visit. In total, 94.4% of the eyes had restored foveolar architecture. Ellipsoid zone recovery within the foveola was found in 77.8% of the eyes.

CONCLUSION

A vitrectomy and modified C-shaped inverted temporal ILM flap is effective for closing MHs, reattaching the retina, restoring the foveolar architecture and significantly improving the postoperative BCVA in MHRD patients. This technique is feasible, and we propose 'presumed' Müller cell cone repair in MHRD surgery.

Internal limiting membrane peeling and gas tamponade for myopic foveoschisis: a systematic review and meta-analysis

Background

Myopic foveoschisis (MF) is among the leading causes of visual loss in high myopia. However, it remains controversial whether internal limiting membrane (ILM) peeling or gas tamponade is necessary treatment option for MF.

Methods

PubMed, EMBASE, CBM, CNKI, WANFANG DATA and VIP databases were systematically reviewed. Outcome indicators were myopic foveoschisis resolution rate, visual acuity improvement and postoperative complications.

Results

Nine studies that included 239 eyes were selected. The proportion of resolution of foveoschisis was higher in ILM peeling group than non-ILM peeling group (OR = 2.15, 95% CI: 1.06–4.35; P = 0.03). The proportion of postoperative complications was higher in Tamponade group than non-Tamponade group (OR = 10.81, 95% CI: 1.26–93.02; P = 0.03). However, the proportion of visual acuity improvement (OR = 1.63, 95% CI: 0.56–4.80; P = 0.37) between ILM peeling group and non-ILM peeling group and the proportion of resolution of foveoschisis (OR = 1.80, 95% CI: 0.76–4.28; P = 0.18) between Tamponade group and non-Tamponade group were similar.

Conclusions

Vitrectomy with internal limiting membrane peeling could contribute to better resolution of myopic foveoschisis than non-peeling, however it does not significantly influence the proportion of visual acuity improvement and postoperative complications. Vitrectomy with gas tamponade is associated with more complications than non-tamponade and does not significantly influence the proportion of visual acuity improvement and resolution of myopic foveoschisis.

Electronic supplementary material

The online version of this article (10.1186/s12886-017-0562-8) contains supplementary material, which is available to authorized users.

Utility of microscope-integrated optical coherence tomography (MIOCT) in the treatment of myopic macular hole retinal detachment

Macular hole-associated retinal detachment in high myopia is described as a final stage in progression of myopic traction maculopathy (MTM).^1â€"3 Shimada et al⁴ described the progressive stages of MTM from macular retinoschisis to serous retinal detachment in high myopia. Stage 4 MTM is characterised as disappearance of retinoschisis with progression to retinal detachment due to macular hole formation. It is hypothesised that vitreoschisis and abnormal vitreo-retinal interface create the premacular tangential traction.^{5 6} Intraoperative triamcinolone acetonide is used to visualise the residual posterior vitreous cortex (PVC). We hereby describe the utility of microscope-integrated optical coherence tomography (MIOCT) in assisting complete removal of PVC and internal limiting membrane (ILM) peeling with multilayered inverted ILM flap in the treatment of myopic macular hole retinal detachment. MIOCT helped identify vitreoschisis and confirm the position of ILM flaps over the macular hole intraoperatively.

Inverted Internal Limiting Membrane Insertion for Macular Hole-Associated Retinal Detachment in High Myopia

PURPOSE

To investigate the surgical outcomes of inverted internal limiting membrane (ILM) insertion in macular hole (MH)-associated retinal detachment (RD) in high myopia.

DESIGN

Retrospective, interventional, consecutive case series.

METHODS

This study was conducted at 2 medical centers. Consecutive cases of highly myopic eyes with MH-associated RD were included. Forty eyes were divided into 2 groups: Group 1 (20 eyes) received vitrectomy, ILM peeling within the arcade area, and air-fluid exchange, and Group 2 (20 eyes) received vitrectomy, inverted ILM inserted into the macular hole, and air-fluid exchange. Optical coherence tomography was used to observe the closure of the macular hole. Corrected visual acuity (VA) was also recorded. Two-sample t test and Mann-Whitney U test were used for statistical analysis to compare differences between the 2 groups.

RESULTS

MH was closed in 35% of the eyes in Group 1 and in all eyes in Group 2 (P < .001). Significant improvement in VA in logarithm of minimal angle of resolution (logMAR) was achieved in both groups. There was no difference in the initial, final, or improvement of logMAR VA in the 2 groups.

CONCLUSION

Inverted ILM insertion into a macular hole effectively helps close the macular hole in MH-associated RD in high myopia. This may prevent the possible re-detachment from the MH. A prospective study with a larger number of cases and longer follow-up may help validate our findings.

The development and evolution of full thickness macular hole in highly myopic eyes

PURPOSE

To evaluate the morphological changes before and after the formation of a full-thickness macular hole (MH) in highly myopic eyes.

PATIENTS AND METHODS

Retrospective observational case series. From 2006 to 2013, clinical records of patients with MH and high myopia who had optical coherence tomography (OCT) before the development of MH were reviewed. All patients had been followed for more than 1 year since MH formation to observe the morphological changes.

RESULTS

Twenty-six eyes of 24 patients were enrolled. The initial OCT images could be classified into four types: (1) normal foveal depression with abnormal vitreo-retinal relationship (eight cases), (2) macular schisis without detachment (six cases), (3) macular schisis with concomitant/subsequent detachment (nine cases), and (4) macular atrophy with underlying/adjacent scar (three cases). After MH formation, one case in type 1 and one case in type 4 group developed retinal detachment (RD). In type 2 group, four cases developed RD at the same time of MH formation. The preexisting detachment in type 3 group extended in eight cases and improved in one case. Among all the cases, 14 eyes received vitrectomy and 7 eyes received gas injection. MH sealed in nine eyes after vitrectomy and four eyes by gas injection.

CONCLUSION

The study revealed four pathways of MH formation in highly myopic eyes. MH from macular schisis tended to be associated with detachment. However, the evolution and the results of surgical intervention were not always predictable.

Tamponade or filling effect: changes of forces in myopic eyes

Myopia is the most common ocular abnormality. Its high and growing prevalence has contributed to a recent surge in surgical interest in the disorder, since retinal detachment in eyes with high myopia differs from that in emmetropic eyes or eyes with low myopia. The myopic eye, because of its specific anatomy, poses special challenges that need to be overcome to ensure the appropriate use of vitreous substitutes. However, intraocular tamponades have shown great potential for revolutionizing retinal detachment surgery and vitreomacular surgery in general in myopic eyes. We provide an updated review of the clinical use of vitreous substitutes in the myopic eye, paying particular attention to analyzing the ideal function of endotamponade agents and comparing the effects of these agents on the physical and biological properties of the eye.

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.

Treatment of retinal detachment secondary to macular hole in high myopia: vitrectomy with dissection of the inner limiting membrane to the edge of the staphyloma and long-term tamponade

PURPOSE

To evaluate the rates of retinal reattachment and the closure of myopic macular hole because of posterior pole retinal detachment after treatment with pars plana vitrectomy and subsequent dissection of the inner limiting membrane.

METHODS

Prospective noncomparative study of 27 eyes from 27 phakic patients diagnosed with posterior pole retinal detachment as a result of myopic macular hole. All underwent pars plana vitrectomy with dissection of the inner limiting membrane and intravitreal silicone oil tamponade performed by the same surgeon. The main variables assessed were visual acuity, retinal reattachment, and macular hole closure determined by optical coherence tomography.

RESULTS

Of the 27 eyes, 16 (59.3%) were right eyes and 11 (40.7%) were left eyes. Mean age was 50.5 years. Myopia ranged from -9 diopters (D) to -27 diopters (mean, -18 diopters), and axial length ranged from 28.5 mm to 35.6 mm (mean, 32.05 mm). After a mean postoperative period of 12 months, retinal reattachment was found in 85.1% of the patients and anatomical closure of the macular hole in 51.9%.

CONCLUSION

This technique offers good rates of retinal reattachment and macular hole closure, although seldom increases the final visual acuity. It showed limited effectiveness in eyes with an axial length >30 mm.

Macular detachment for treatment of persistent macular hole

The authors report a technique for treatment of persistent macular holes in cases refractory to traditional surgical techniques. With a standard pars plana vitrectomy approach, subretinal infusion of balanced salt solution was performed and followed by a fluid-air exchange. This intervention resulted in hole closure despite poor prognosis and may be considered as a treatment option for patients with persistent flat macular holes.