Vitrectomy and gas tamponade without internal limiting membrane peeling for myopic foveoschisis

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

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

Retinal and Vitreous Changes Associated with Spontaneous Improvement in Myopic Macular Schisis

PURPOSE

To describe the retinal and vitreous changes in eyes showing myopic macular schisis (MMS) improvement when vitrectomy was not performed and identify triggering factors.

DESIGN

Retrospective observational study.

SUBJECTS

Patients with nonoperated MMS.

METHODS

The records of patients with MMS who were followed without performing surgery for >6 months were retrospectively reviewed, and the eyes showing an anatomic improvement were included. Myopic macular schisis evolution was analyzed quantitatively (central foveal thickness [CFT], parafoveal thickness, maximum height) and qualitatively (presence/absence of foveal detachment, lamellar hole, epiretinal membrane, choroidal neovascularization, inner and outer retinoschisis, vitreous status) at baseline and at the final visit. An anatomic improvement was defined as a decrease in CFT by ≥50 μm.

MAIN OUTCOME MEASURES

The rate of anatomic improvement of MMS without performing vitrectomy and the morphological changes observed in these cases.

RESULTS

In a cohort of 74 nonoperated eyes with MMS, MMS improved in 14 eyes (19%) after a mean follow-up of 55 ± 38 months (range, 8-138). In these improved cases, the mean decrease in CFT was 153 ± 166 μm (range, 24-635; P = 0.005) and a complete resolution of MMS was observed in 9 eyes (64%). In 9 eyes (64%), the improvement was associated with visible vitreous changes in the macular area on the OCT scans. The mean visual acuity, which was already good at baseline (20/50, 0.4 ± 0.2 logarithm of the minimum angle of resolution), increased at the last visit (20/40, 0.3 ± 0.3 logarithm of the minimum angle of resolution) but without reaching significance.

CONCLUSIONS

This long-term follow-up analysis showed that almost 20% of MMS in eyes without indication for surgery could improve over time. In most cases, the improvement was associated with an apparent resolution of vitreous tensions.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

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.

Guided Trocar Insertion in Highly Myopic Eyes

PURPOSE

To demonstrate through a diagnostic test used as a new preoperative assessment that trocar insertion for pars plana vitrectomy could be safely placed at a distance >4.0 mm in highly myopic eyes to facilitate the surgical maneuvers.

METHODS

Thirty eyes of 30 patients were tested with a biometer for the axial length measurement and with ultrasound biomicroscopy to measure the pars plana length. Pars plana lengths of highly myopic eyes were then compared with those of emmetropic eyes. The surgeon also measured the pars plana of highly myopic eyes intraoperatively and compared it with ultrasound measurements to assess ultrasound biomicroscopy reliability.

RESULTS

The mean axial length was 23.81 mm (SD ± 0.30) in the control group and 31.11 mm (SD ± 0.56) in the myopic group. The mean pars plana length was 4.96 mm (SD ± 0.19) in control eyes and 6.65 (SD ± 0.36) in myopic eyes. An extremely significant statistical difference ( P < 0.001) was obtained by comparing the length of pars plana between control eyes and myopic eyes. The results of pars plana measurements were 6.65 mm (SD ± 0.36, ultrasound biomicroscopy) and 6.66 mm (SD ± 0.34, intraoperative measurements) in myopic eyes. The statistical comparison of the measurements in these two groups did not give a statistically significant result ( P = 0.950).

CONCLUSION

Ultrasound biomicroscopy is a reliable technique to calculate the length of pars plana in highly myopic eyes, where this parameter is significantly greater than that of emmetropic eyes. Trocars insertion for pars plana vitrectomy may be performed, in eyes with axial length >30 mm, in relative safety at a distance to limbus higher than 4 mm.

Risk Factors and Outcomes of Postoperative Macular Hole Formation after Vitrectomy for Myopic Traction Maculopathy: SCHISIS Report No. 2

PURPOSE

To evaluate the incidence, pathogenesis, risk factors, and treatment outcomes of postoperative macular hole (MH) after pars plana vitrectomy (PPV) for myopic traction maculopathy (MTM).

DESIGN

Multicenter, interventional, retrospective case series.

SUBJECTS

Consecutive eyes that underwent PPV for MTM with a minimum 6-month follow-up.

METHODS

We investigated the characteristics and treatment outcomes of postoperative MH after MTM surgery.

MAIN OUTCOME MEASURES

Incidence, risk factors, and anatomic and visual outcomes of postoperative MH.

RESULTS

We included 207 eyes (207 patients) with a mean follow-up of 25.9 months. During follow-up, 24 (11.6%) eyes developed MH (10 with concurrent MH retinal detachment); 15 eyes within 30 days (early), 4 eyes between 31 and 180 days (intermediate), and 5 eyes after 180 days (late). Logistic regression analysis revealed male gender (odds ratio [OR], 2.917; 95% confidence interval [CI], 1.198-7.100; P = 0.018), thinner preoperative choroidal thickness (OR, 0.988; 95% CI, 0.976-1.000; P = 0.048), and use of indocyanine green for internal limiting membrane peeling (OR, 2.960; 95% CI, 1.172-7.476; P = 0.022) as significant risk factors for postoperative MH. Internal limiting membrane peeling with a fovea-sparing technique tended to protect against postoperative MH, but it was not statistically significant (P = 0.096), because 1 eye still developed MH. Postoperative MHs were treated by observation (6 eyes), in-office octafluoropropane (C3F8) gas injection (7 eyes), or PPV (11 eyes). Macular hole closure was achieved in 20 eyes (83%). The hole closure rate was 67% (4/6 eyes) after observation, 71% (5/7 eyes) after C3F8 gas injection, and 91% (10/11 eyes) after PPV. However, visual outcomes were significantly worse for eyes with postoperative MH than those without (0.38 ± 0.43 vs. 0.68 ± 0.46; P = 0.002).

CONCLUSIONS

Postoperative MH may occur in 11.6% of patients with MTM at any time after surgery. Retreatment resulted in relatively favorable anatomic closure but unfavorable visual outcomes.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Anatomical and visual outcomes of fovea-sparing internal limiting membrane peeling with or without inverted flap technique for myopic foveoschisis

BACKGROUND

Vitrectomy and peeling of the internal limiting membrane (ILM) was an effective therapeutic approach for myopic foveoschisis with progressive visual loss. This study investigated the anatomical and visual outcomes of fovea-sparing ILM peeling with or without the inverted flap technique for patients with symptomatic myopic foveoschisis (MF).

METHODS

We retrospectively reviewed the clinical data of patients with MF. Vitrectomy with fovea-sparing ILM peeling and air tamponade was performed in all patients. The primary outcome measures included best-corrected visual acuity (BCVA), mean macular thickness (MMT), and central foveal thickness (CFT). Depending on whether an inverted ILM flap technique was utilized, further subgroup comparisons between the inverted flap group and the non-inverted flap group were conducted.

RESULTS

Twenty-six eyes of 22 patients were included. Fifteen eyes were underwent fovea-sparing ILM peeling without inverted ILM flap and 11 of the 26 eyes were treated with fovea-sparing ILM peeling and an inverted ILM flap technique. In the mean follow-up period of 10.74 ± 4.58 months, a significant improvement in BCVA was observed from 0.97 ± 0.45 logMAR to 0.58 ± 0.51 logMAR (P < 0.01), during which the BCVA of 20 eyes (76.92%) improved and remained stable in 5 eyes (19.23%). Moreover, a positive correlation was also found between the preoperative BCVA and the postoperative BCVA (r = 0.50, P = 0.01). At the last visit, the final MMT decreased from 492.69 ± 209.62 μm to 234.73 ± 86.09 μm, and the CFT reduced from 296.08 ± 209.22 μm to 138.31 ± 73.92 μm (all P < 0.01). A subgroup analysis found no significant differences in BCVA, MMT, or CFT between the inverted and non-inverted flap groups (all P > 0.05).

CONCLUSION

Fovea-sparing ILM peeling with or without inverted flap technique resulted in favorable visual and anatomical outcomes for the treatment of MF. An important factor affecting the postoperative visual outcome was the preoperative visual acuity. Our study found no significant difference between the presence and absence of the inverted ILM flap.

Factors Affecting Visual Prognosis of Myopic Foveoschisis after Macular Buckling

Purpose

To analyze the visual prognosis of macular buckling in patients with high myopia foveoschisis (FS) and to identify factors that predict the final visual outcome.

Methods

We retrospectively included 155 eyes of 155 patients who underwent foveoschisis-related macular buckling. Best-corrected visual acuity (BCVA) and coexisting macular pathologies were assessed as a measure of surgical outcome, and multivariate linear regression was performed to identify factors affecting final visual prognosis.

Results

The mean preoperative BCVA was 1.19 ± 0.55 logMAR (20/308), while the mean postoperative BCVA was 0.82 ± 0.51 logMAR (20/133) (P < 0.001). Anatomical success was achieved in 151/155 eyes (97.42%) after the first surgery and in 155/155 eyes (100%) at the 2-year follow-up visit. Both preoperative and postoperative BCVA were better in eyes without macular hole (MH) than in eyes with MH. In patients with MH, the postoperative BCVA was significantly better than that before surgery when the MH was closed. However, the difference was not significant in patients with unclosed MH. Univariate analysis identified that baseline BCVA, age, MH, atrophic myopic maculopathy category, and postoperative intraretinal cyst were significantly related to BCVA at the postoperative 2-year follow-up. Multivariate analysis revealed that preoperative BCVA and age were significant factors.

Conclusion

Better preoperative BCVA and younger age are predictors of better prognosis. Prompt surgery is advised for patients with myopic foveoschisis to improve their visual prognosis.

POSTERIOR SCLERAL CONTRACTION TO TREAT MYOPIC FOVEOSCHISIS IN HIGHLY MYOPIC EYES

PURPOSE

To evaluate the efficacy of posterior scleral contraction to treat myopic foveoschisis (MF).

METHODS

The records of MF patients treated with posterior scleral contraction were reviewed. During posterior scleral contraction, a cross-linked fusiform strip from allogeneic sclera was used and designed axial length (AL) shortening amount was around 2.0∼3.0 mm based on preoperative AL. The middle part of the strip was placed at the posterior pole of the eye. After few aqueous humors were released, the strip was tightened to contract posterior sclera and shorten AL. Clinical data were collected at pre-operation (op) and post-op follow-ups for 12 months.

RESULTS

Twenty-four eyes were collected. The AL at pre-op, post-op 1-week, 3-month, 6-month, and 12-month were 29.84 ± 1.24, 27.39 ± 1.32, 27.73 ± 1.23, 27.86 ± 1.26, and 27.91 ± 1.29 mm. There was no AL difference between post-op 6-month and 12-month (P = 0.242). The accumulated MF reattachment rate at post-op 1-week, 3-month, 6-month, and 12-month were 8.3%, 16.7%, 50.5%, and 95.8%. The best-corrected visual acuity at post-op 6-month and 12-month were 0.71 ± 0.39 (Snellen acuity 20/80) and 0.64 ± 0.37 (Snellen acuity 20/63), improving significantly compared with pre-op (P = 0.006 and <0.001).

CONCLUSION

The posterior scleral contraction was effective to treat MF. The AL stabilized after post-op 6-month and MF reattached gradually with improved visual acuity up to post-op 12-month.

Fovea-Sparing as Opposed to Total Peeling of Internal Limiting Membrane for Myopic Foveoschisis: A Systematic Review and Meta-analysis

TOPIC

The effectiveness of fovea-sparing (FS) peeling of internal limiting membrane (ILM) to treat myopic foveoschisis (MF) has not been understood fully. The present meta-analysis aimed to compare postoperative visual and anatomic outcomes between FS peeling and total peeling (TP) of ILM in pars plana vitrectomy for the treatment of MF.

CLINICAL RELEVANCE

Postoperative macular hole (MH) development is not uncommon and is a serious complication after surgery for MF, with poor visual prognosis. Fovea-sparing peeling of ILM is expected to reduce the risk of postoperative MH; however, no statistically significant evidence exists to prove this hypothesis. In addition, its effect on postoperative visual acuity has not been clear.

METHODS

MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE were reviewed systematically, and studies that compared FS with total ILM peeling in MF surgery were retrieved. The protocol was registered in International Prospective Register of Systematic Reviews (identifier, CRD42020201675). Primary outcome measures were the postoperative best-corrected visual acuity (BCVA) and frequency of postoperative MH development. Certainty of evidence was evaluated by the Grading of Recommendations Assessment, Development and Evaluation system.

RESULTS

Eight studies with 300 eyes from 289 patients were included. All studies were nonrandomized and observational. The postoperative BCVA was significantly better in eyes treated with FS (mean difference [MD], -0.15 logarithm of the minimum angle of resolution [logMAR]; 95% confidence interval [CI], -0.24 to -0.05 logMAR; P = 0.002). The risk of postoperative MH was significantly lower in the FS group (odds ratio, 0.19; 95% CI, 0.06-0.56; P = 0.003). No significant difference was found in postoperative central foveal thickness (MD, 12.59 μm; 95% CI, -2.8 to 28.0 μm; P = 0.11). The certainty of evidence regarding lower frequency of postoperative MH after FS peeling was considered moderate, whereas the certainty regarding better postoperative BCVA after FS peeling was judged to be low.

DISCUSSION

Fovea-sparing peeling may contribute to better visual acuity outcome and lower risk of postoperative MH development in eyes with MF.

VITRECTOMY WITH INTERNAL LIMITING MEMBRANE PEELING AND AIR TAMPONADE FOR MYOPIC FOVEOSCHISIS

PURPOSE

To evaluate the functional and anatomical outcomes of 23-gauge or 25-gauge pars plana vitrectomy with internal limiting membrane peeling and air tamponade for the treatment of myopic foveoschisis.

METHODS

Retrospective, noncomparative, interventional case series. The records of 29 patients (32 eyes), with myopic foveoschisis who were treated by 23-gauge or 25-gauge 3-port pars plana vitrectomy with internal limiting membrane peeling and air tamponade, were reviewed. At each visit, a complete ophthalmic examination, intraocular pressure, best-corrected visual acuity, and central foveal thickness measured using optical coherence tomography were assessed.

RESULTS

Twenty-five eyes of 23 patients (M:F = 4:19) matched the inclusion criteria, whereas 7 eyes of 6 patients were excluded. The mean logarithm of the minimum angle of resolution best-corrected visual acuity (Snellen equivalent) was 0.62 (20/80) (SE: 0.061), and the mean preoperative central foveal thickness was 619.5 µm (SE: 16.38) at baseline. Visual acuity significantly improved of 5 Early Treatment Diabetic Retinopathy Study letters (45 letters) at the 1-month follow-up (P < 0.001), 2 lines (50 Early Treatment Diabetic Retinopathy Study letters) at the 6-month follow-up (P < 0.001), and it reached 55 Early Treatment Diabetic Retinopathy Study letters at the 1-year follow-up visit (P < 0.001). Central foveal thickness decreased to 292.4 µm (SE: 15.93), to 227.3 µm (SE: 14.05), and to 208.8 µm (SE: 12.86), respectively, at the 1-, 6-, and 12-month follow-ups (for each P < 0.001). There were no differences in best-corrected visual acuity or central foveal thickness changes between the foveal detachment group and the nonfoveal detachment group (P > 0.05).

CONCLUSION

Small-gauge vitrectomy with internal limiting membrane peeling and air tamponade results in favorable anatomical and functional outcomes for patients affected by myopic macular foveoschisis.

Comparison of fovea-sparing and non-internal limiting membrane peeling for retinoschisis with foveal detachment in highly myopic eyes

PURPOSE

To compare the visual and anatomical outcomes of two different treatment strategies (non-internal limiting membrane (ILM) peeling and fovea-sparing ILM peeling) for retinoschisis with foveal detachment (FD) in highly myopic eyes.

DESIGN

A retrospective cohort study.

METHODS

Ninety-five eyes from 92 highly myopic patients with retinoschisis with FD were divided into two groups, including 44 eyes from 43 patients who received 23-gauge, 3-port vitrectomy without ILM peeling (group A) and 51 eyes from 49 patients who received vitrectomy with fovea-sparing ILM peeling (group B). All eyes also underwent cataract surgery.

RESULTS

There were no significant differences between the two groups in terms of sex, age, diopters, axial length (AL), or central foveal thickness (CFT) before surgery (P > 0.05). One month after surgery, foveoschisis and FD were resolved in 74.47% of the eyes in group B and in only 12.50% of those in group A. Six months after surgery, foveoschisis and FD were resolved in 96.08% of the eyes in group B and in only 72.73% of those in group A (P < 0.05). There were no significant differences between the two groups in terms of BCVA 6 months after surgery. The postoperative complication was macular holes, which were found in seven eyes (15.90%) in group A and in one eye (1.96%) in group B (P < 0.05).

CONCLUSION

Highly myopic eyes with FD that underwent fovea-sparing ILM peeling appeared to obtain a better anatomical outcome than those that did not undergo non-ILM peeling. The two procedures obtained similar results in terms of visual function.

Long-term results and risk factors influencing outcome of gas tamponade for myopic foveoschisis with foveal detachment

OBJECTIVE

To evaluate the long-term results of gas tamponade without vitrectomy in patients with myopic foveoschisis (FS) and foveal detachment (FD).

METHODS

Twenty eyes of 20 patients with myopic foveoschisis and foveal detachment were analysed retrospectively. All patients received an intravitreal injection of 0.2-0.3 mL C3F8 as an initial treatment. The patients were followed up for at least 18 months after the procedure. The refractive status, best-corrected visual acuity (BCVA), and anatomical abnormalities in macular area before and after the treatment were assessed and recorded.

RESULTS

After initial gas tamponade, FD resolved completely (defined as responders) in 14 eyes, resolved partially in 2 eyes (defined as partial responders), and worsened in 4 eyes (non-responders) at the 3-month follow-up visit. Vitrectomy was performed in four eyes that showed increased detachment (two cases) or developed macular hole (two cases). Repeated gas injection was performed in two recurrent cases after initial success at the 3-month follow-up, and the foveal detachment once again resolved. Overall, 70% of our cases demonstrated resolution of FD at the 3-month follow-up and the long-term responders to gas injection was 65%. The risk factors for treatment failure were: (1) The presence of optical coherence tomography (OCT)-evident premacular membranes (p = 0.03) and (2) the height of FS measured >588 µm (p = 0.009).

CONCLUSION

Our data supported that gas tamponade may be effective as an alternative treatment for selected cases of myopic FS with FD. The procedure may be especially beneficial in patients without OCT-evident premacular membranes and have low height of FS.

Outcomes of 23G vitrectomy and internal limiting membrane peeling with brilliant blue in patients with myopic foveoschisis from a retrospective cohort study

The aim of the present study was to investigate whether internal limiting membrane (ILM) peeling in patients with myopic foveoschisis (MF) treated with 23-gauge (23G) vitrectomy improved the anatomical and visual outcomes. In this retrospective cohort study, from March 2014 to August 2017 at the Department of Ophthalmology, The Second Affiliated Hospital of Nanchang University (Nanchang, China), 60 patients (60 eyes) with MF underwent 23G vitrectomy. The patients were grouped according to whether they underwent brilliant blue-assisted ILM peeling (peeling group) or not (non-peeling group). Best-corrected visual acuity (BCVA) and central macular thickness (CMT) on optical coherence tomography were measured. There were 30 eyes in each group and the baseline characteristics were similar (all P>0.05). BCVA improved in 24 eyes (80%) in the peeling group and 25 eyes (83.3%) in the non-peeling group (P=0.922). Preoperative CMT was not significantly different between the peeling and non-peeling group (458±62.2 vs. 460±61.1 µm, respectively, P=0.229). However, postoperative CMT was significantly different between the peeling and non-peeling group (269.3±67.7 vs. 294.4±60.5 µm, respectively; P=0.015). In the peeling group, MF was completely resolved in all 30 eyes, but only in 26 eyes in the non-peeling group (P=0.038). Postoperative Amsler testing was positive in five eyes in the peeling group and 13 eyes in the non-peeling group (P=0.024). Complications were similar in both groups; postoperatively, there were one and two cases of iatrogenic peripheral retinal break, three and two cases of macular hole, and one and one case of retinal detachment in the peeling and non-peeling groups, respectively.23G vitrectomy combined with brilliant blue-assisted ILM peeling resulted in better visual and anatomical effects compared with 23G vitrectomy alone in patients with MF.

Morphologic and functional outcomes of different optical coherence tomography patterns of myopic foveoschisis after vitrectomy and inner limiting membrane peeling

OBJECTIVE

To evaluate the morphologic and functional outcomes of different optical coherence tomography (OCT) patterns of myopic foveoschisis after vitrectomy with Inner Limiting Membrane (ILM) peeling.

METHODS

In this prospective non-randomised study, 62 consecutive eyes with Myopic Foveoschisis were categorised into three groups according to OCT pattern: retinoschisis type (Rt) Group (23/62), foveal detachment type (FDt) Group (20/62) and macular hole type (MHt) Group (19/62). All patients underwent 25-Gauge vitrectomy and ILM peeling. Air or gas tamponade was used. All patients were observed at month 1, 2, 4 and 6 after surgery.

MAIN OUTCOMES MEASURES

surgical success as resolution of myopic foveoschisis, central retinal thickness (CRT), IS/OS junction recovery and best-corrected visual acuity (BCVA) measurement. Any complication was reported.

RESULTS

In all eyes OCT showed a resolution of the retinoschisis, foveal detachment and macular hole pattern, respectively. CRT significantly decreased in all Groups (p < .001), mainly in MHt. IS/OS junction recovery was mainly observed in MHt. BCVA significantly increased in all Groups (p < .01). A functional gain ≥2 Snellen lines occurred in 70, 85 and 68% in the Rt, FDt and MHt Group, respectively. Final BCVA was correlated with preoperative BCVA (R 0.74, p < 0.0001), postoperative CRT (R -0.49, p < 0.0001), and the recovery of IS/OS junction at 6 months (R 0.76, p < 0.0001). Few postoperative complications occurred.

CONCLUSIONS

Vitrectomy with ILM peeling results in favourable anatomic and functional outcomes for different patterns of myopic foveoschisis.

A Review of Current Myopic Foveoschisis Management Strategies

Myopic foveoschisis (MF) is common in highly myopic eyes with posterior staphyloma, and optical coherence tomography is essential for establishing the diagnosis and monitoring disease progression. Untreated MF may lead to significant visual loss due to secondary complications. Vitrectomy with or without internal limiting membrane peeling followed by gas tamponade is the standard treatment; however, in recent years, new techniques, including macular buckling, have been introduced. We selected a total of 41 articles with 30 describing various modifications of pars plana vitrectomy, six describing the macular buckling technique, and five reporting combined surgery. The present review describes current MF treatment strategies, including outcomes, and provides a comprehensive understanding of current therapeutic options. Early detection and surgical intervention in eyes with specific risk factors may contribute to both improved visual recovery and more favorable anatomical outcomes.

Comparative Study of 27-Gauge Versus 25-Gauge Vitrectomy With Air Tamponade in the Treatment of Myopic Foveoschisis

BACKGROUND AND OBJECTIVE

To compare the surgical outcome of 27-gauge pars plana vitrectomy (PPV) with 25-gauge PPV and evaluate the efficacy of air tamponade for the treatment of myopic foveoschisis (MF).

PATIENTS AND METHODS

Sixty eyes of 60 consecutive patients were recruited to undergo vitrectomy, internal limiting membrane (ILM) peeling, and air tamponade for treatment of MF. These eyes were divided into two groups: the 27-gauge group (n = 29) and the 25-gauge group (n = 31).

RESULTS

There were no significant differences in the mean operating time (P = .32), the mean time for vitrectomy (P = .20), and the suturing rate(P = .46) between the 27-gauge group and the 25-gauge group. At the final follow-up, anatomical resolution rate did not differ between the two groups (P = .65).

CONCLUSION

The 27-gauge vitrectomy system is as efficient and feasible as the 25-gauge system for the treatment of MF. Air tamponade can provide good postoperative anatomic resolution of MF. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:e135-e142.].

Comparison of effectiveness between complete internal limiting membrane peeling and internal limiting membrane peeling with preservation of the central fovea in combination with 25G vitrectomy for the treatment of high myopic foveoschisis

Vitrectomy combined with internal limiting membrane peeling (ILMP) treats high myopic foveoschisis with good results, but there is a risk of iatrogenic macular holes, which may be reduced by preserving the internal limiting membrane of the central fovea. This study compared complete ILMP with partial ILMP, both combined with 25G vitrectomy, for the treatment of high myopic foveoschisis.Thirty-three cases (33 eyes) of high myopic foveoschisis were retrospectively analyzed. They underwent 25G vitrectomy combined with C3F8 gas filling; Group A (20 patients, 20 eyes) underwent complete ILMP, while Group B (13 patients, 13 eyes) underwent partial ILMP to preserve the internal limiting membrane of the central fovea. Patients were followed up for 6 months and underwent best corrected visual acuity (BCVA), intraocular pressure, diopter, slit lamp microscopy, indirect ophthalmoscope, A-mode and/or B-mode ultrasound, and optical coherence tomography. Surgical complications were recorded.Up to the last follow-up, the BCVA improved and central fovea thickness (CFT) was lower compared with before surgery in both groups (All P < .05). There were no significant differences in BCVA and CFT at each time point between the groups (P > .05). Most of the postoperative retinas of the 2 groups were completely reattached, with disappearance of the macular retinoschisis cavity. Two patients in the Group A and none in the Group B developed a macular hole during follow-up (P = .508).The results did not support the superiority of partial ILMP over complete ILMP in reduced incidence of macular hole. Both methods had a similar curative effect.

The management of macular hole retinal detachment and macular retinoschisis in pathological myopia; a UK collaborative study

PURPOSE

To study UK practice patterns for the management of retinal detachment secondary to macular hole (MHRD) and macular retinoschisis (MRS) in pathological myopia (PM). To review the anatomical and visual outcomes of the surgically managed cases.

METHODS

A prospective observational case series for the management of MHRD was undertaken in association with the British Ophthalmological Surveillance Unit (BOSU). The results were combined with retrospective data, collected by the COllaboration of British RetinAl Surgeons (COBRA), on the management of both MHRD and MRS in PM in the UK. A total of 20 cases of MHRD and 53 cases of MRS (27 surgical cases and 26 cases managed conservatively) are reported in this combined study.

RESULTS

MHRD: Mean baseline best corrected visual acuity (BCVA) was 1.60 logMAR. All cases underwent pars plana vitrectomy (PPV). Mean post-operative BCVA was 1.49 logMAR (p = 0.674). The macular hole was closed in 5/20 (25%) cases, open/flat in 10/20 (50%) cases and open/elevated in 4/20 cases (20%). MRS: Mean baseline BCVA was 0.87 logMAR in the surgical group and 0.45 logMAR in the conservatively managed group (p = 0.002). All eyes that had surgical intervention underwent PPV. Mean post-operative BCVA was 0.68 logMAR (p = 0.183). Anatomical outcomes demonstrated a persistent MRS in 2/27 (7.4%) cases, partial resolution in 7/27 (25.9%) cases and complete resolution in 16/27 (59.2%) cases.

CONCLUSIONS

PPV is the only surgical procedure performed for the management of MHRD and MRS amongst the study participants. Success rates and visual outcomes are limited for MHRD and consistent with the current literature for MRS.

Paravascular abnormalities observed by spectral domain optical coherence tomography are risk factors for retinoschisis in eyes with high myopia

PURPOSE

To investigate the retinal features and distribution of paravascular abnormalities (PVAs) and their relationship with retinoschisis in eyes with high myopia.

METHODS

One hundred and fifty-two eyes of 88 patients with high myopia [refractive error greater than -6 dioptres (D) or axial length (AL) ≥26.5 mm] who had undergone comprehensive ophthalmic examinations were evaluated in this cross-sectional study. Multiple optical coherence tomography (OCT) scans were performed to study the microstructural alterations adjacent to the retinal vascular arcades and the entire macular area. The presence and distribution patterns of various PVAs, retinoschisis and the association between these parameters were analysed.

RESULTS

Of the 152 highly myopic eyes, PVAs were detected by OCT in 126 eyes (82.9%), including paravascular microfolds in all 126 eyes, paravascular cysts in 109 eyes (71.7%) and paravascular lamellar holes in 44 eyes (28.9%). All three types of PVAs were observed more frequently along the temporal vascular arcades than along the nasal vascular arcades (p < 0.005). Seventy-eight eyes (51.3%) were identified with retinoschisis at retinal vascular arcades, most frequently in the inner plexiform layer (IPL) and along temporal arcades. Eyes with all three types of PVAs (microfolds, cysts and lamellar holes) had the highest incidence of retinoschisis at vascular arcades (p < 0.001). Multivariate analysis indicated that age, the AL, presence of paravascular microfolds and cysts, and simultaneously existence of all three types of PVAs were associated with an increased risk for retinoschisis at vascular arcades. Macular retinoschisis was detected in 25 eyes (19.8%) and presented with splitting of the outer retina in all cases. All seven eyes with entire macular area retinoschisis (S4 grade) were accompanied by retinoschisis at vascular arcades within multiple layers, including outer retinoschisis, IPL schisis and inner limiting membrane (ILM) detachment.

CONCLUSION

Our findings indicated that all three types of PVAs and different types of retinoschisis were most frequently observed along the temporal vascular arcades. Eyes with paravascular microfolds and cysts, and those with all three paravascular lesions may in risk of developing retinoschisis at vascular arcades.

Efficacy of non-fovea-sparing ILM peeling for symptomatic myopic foveoschisis with and without macular hole

AIM

To study anatomical and visual outcomes of pars plana vitrectomy (PPV) with non-fovea-sparing (entire) internal limiting membrane (ILM) peeling in eyes with myopic foveoschisis (MF).

METHODS

Prospective interventional case series of eyes undergoing PPV with entire ILM peeling for symptomatic MF.

MAIN OUTCOME MEASURES

Preoperative spectral domain optical coherence tomography (SD-OCT) epiretinal membrane, anomalous posterior vitreous detachment, vitreoschisis and postoperative changes in SD-OCT central foveal thickness (CFT), ellipsoid zone defect, foveal detachment (FD), macular hole (MH) diameter (if present) and best-corrected visual acuity (BCVA) in logarithm of the minimum angle of resolution (logMAR).

RESULTS

This study included 21 eyes (21 patients) with mean age 60.4±13.1, 15 females (71.4%). All patients achieved complete postoperative reattachment by SD-OCT (no FD) 6 months post vitrectomy, with no iatrogenic intraoperative or postoperative MH, and with significant improvement in final BCVA from 1.6±0.30 to1.0±0.2 logMAR, and in CFT from 918.2±311.4 to182.3±33.1 µm. Patients were subdivided into subgroup A: 11 eyes without MH; and subgroup B: 10 eyes with MH, the latter had significant improvement in MH diameter (p=0.005). Preoperative BCVA was a significant risk factor for visual gain, while preoperative FD and CFT were significant for CFT change.

CONCLUSION

Vitrectomy with non-fovea-sparing (entire) ILM peeling resulted in a significant functional and anatomical improvement in eyes with MF with/without MH with no reported complications. Results are comparable to fovea-sparing ILM peeling.

Long-term outcome of internal limiting membrane peeling with and without foveal sparing in myopic foveoschisis

PURPOSE:

To compare between vitrectomy with internal limiting membrane peeling over the whole macula and preservation of the epi-foveal internal limiting membrane in myopic foveoschisis.

PATIENTS AND METHODS:

A prospective controlled non- randomized comparative study included patients with myopic foveoschisis recruited between 2013 and 2017. Patients were allocated into two groups: group A included patients who underwent vitrectomy with complete macular internal limiting membrane peeling and group B included those who underwent preservation of the epi-foveal membrane. Pre- and postoperative best corrected visual acuity and macular optical coherence tomography were obtained and compared.

RESULTS:

There was no statistically significant difference between the two groups regarding the preoperative baseline data. The difference between the two groups was insignificant as regard postoperative best corrected visual acuity (p = 0.18) and central foveal thickness (p =0.504). There was statistically significant improvement in final best corrected visual acuity within each group (p < 0.0001). Central foveal thickness significantly decreased postoperatively within each group (p < 0.001). No macular holes or other visual-threatening complications were recorded in either group.

CONCLUSION:

Vitrectomy with complete internal limiting membrane peeling resulted in comparable outcomes to those achieved with preservation of the epi-foveal membrane in treating cases with myopic foveoschisis. There was no statistically significant difference in final visual acuity between the two groups. No macular holes were recorded in either group.

Ultrastructural analyses of internal limiting membrane excised from highly myopic eyes with myopic traction maculopathy

PURPOSE

To evaluate the ultrastructure of the internal limiting membranes (ILMs) excised during vitrectomy from highly myopic eyes with myopic traction maculopathy (MTM). The clinical findings before and after the vitrectomy were compared.

METHODS

Seven eyes of 7 patients with macular retinoschisis were studied. Four of these eyes also had a foveal detachment but without a retinal break. All the eyes underwent vitrectomy with the creation of a posterior vitreous detachment and ILM peeling. The excised ILMs were examined by transmission electron microscopy (TEM).

RESULTS

The retinas were reattached in all eyes after the vitrectomy. No retinal breaks including macular holes were identified intraoperatively. Transmission electron microscopy showed glial cells in 4 eyes, retinal pigment epithelium-like cells in 4 eyes, and myofibroblast-like cells in 4 eyes on the excised ILMs. A newly produced basement membrane appeared to merge with the ILM in 5 eyes. Thick collagen was seen in 2 eyes, and fibrous long-spacing collagen in the newly synthesized collagen fibers was seen in 3 eyes. The cellular components of the glial cells appeared to have migrated through the thinner parts of the retina or through a defect of the ILM in 2 eyes.

CONCLUSIONS

Cells that migrate onto the surface of the ILM synthesize new collagen, which can create tangential traction. This may explain the success of vitrectomy with ILM peeling in treating MTM in highly myopic eyes.

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.

Treatment of myopic foveoschisis via macular buckling and vitrectomy

The aim of the present study was to evaluate the efficacy and safety of the treatment of myopic foveoschisis patients using the macular buckling with L-shaped titanium plate and silicon sponge combined with vitrectomy. The data of the patients who underwent macular buckling combined with vitrectomy was collected. The study recorded the following parameters: best corrected visual acuity (BCVA), axial length, intraocular pressure, central macular thickness, and the position of the titanium plate. Following the surgery, the BCVA of the included patients were improved, whereas the axial lengths were reduced followed by resolution of the foveoschisis compared with that noted prior to the operations. All patients had orbital CT examination and the results indicated that the titanium plates were appropriately placed and were not in contact with the optic nerve. Therefore, it is effective to treat myopic foveaschisis by macular buckling using the L-shaped titanium plate and silicon sponge in the presence of vitrectomy.

Clinical Investigation of the Posterior scleral contraction to Treat Macular Traction Maculopathy in Highly Myopic Eyes

Myopic traction maculopathy (MTM) can cause vision disabilities in highly myopic eyes. This retrospective case series investigated the clinical outcomes of posterior scleral contraction (PSC) using genipin-cross-linked sclera as the material to treat MTM in highly myopic eyes. In total, 32 eyes from 29 highly myopic patients who underwent PSC for MTM were recruited. The changes in best-corrected visual acuity (BCVA) and axial length were evaluated, macular reattachment and macular hole (MH) closure was assessed by optical coherence tomography, and complications were evaluated. At the final follow-up, the retina was completely reattached in 25 eyes (78.1%), essentially reattached in 4 eyes (12.5%), and partially reattached in 3 eyes (9.4%). The logMAR BCVA improved significantly from 1.18 ± 0.45 preoperatively to 0.87 ± 0.45 postoperatively (P < 0.001). The 32 eyes were further divided into the MH group (16 eyes) and the non-MH group (16 eyes) for comparison. The MH was closed in 9 eyes (56.3%). The retinal reattachment rate was 75.0% in the MH group and 81.25% in the non-MH group, and the logMAR BCVA improved significantly in both groups. The PSC using genipin-cross-linked sclera as the material can effectively treat MTM in highly myopic eyes, and significant visual improvement can be achieved with minimal complications.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

VITRECTOMY WITHOUT INNER LIMITING MEMBRANE PEELING FOR MACULAR RETINOSCHISIS IN HIGHLY MYOPIC EYES

PURPOSE

To determine if it is necessary to peel inner limiting membrane during vitrectomy for macular retinoschisis in highly myopic eyes.

METHODS

This retrospective noncomparative interventional case series included 112 eyes of 84 patients with myopic foveoschisis who were treated by 23-gauge 3-port pars plana vitrectomy. During vitrectomy, triamcinolone acetonide was injected into the vitreous cavity to visualize the vitreous. The inner limiting membrane was not peeled, but the posterior hyaloid membrane was removed from the macular surface with active suction or a flute needle. A fluid-gas exchange was carried out using 16% perfluoropropane gas.

RESULTS

A total of 106 eyes (95%) exhibited collapse of the foveoschismatic intermediary zone after surgery. Best-corrected visual acuity at baseline and at the end of the follow-up did not differ significantly (1.06 ± 0.74 logarithm of the minimum angle of resolution versus 0.92 ± 0.56 logarithm of the minimum angle of resolution, P = 0.18). An improvement in best-corrected visual acuity of greater than 2 lines was achieved in 84 eyes (75%). A macular hole with retinal detachment was found in 6 eyes (5%) 1 to 8 months after surgery. Intraoperatively, all 112 eyes exhibited vitreous liquefaction. The posterior hyaloid membranes were tightly adherent to the posterior retinal surface and vessels except for 1 eye that had a complete posterior vitreous detachment. There were no or only a very small amount of triamcinolone acetonide particles attached to the surface of posterior retina in 38 eyes, which seemed that a completely posterior vitreous detachment had happened. But these membranes on the surface of the posterior retina can be removed easily, which indicated these membranes were posterior hyaloid membranes instead of internal limiting membranes.

CONCLUSION

In the treatment of macular retinoschisis in highly myopic eyes, vitrectomy associated with posterior hyaloid membranes peeling may achieve successful anatomical results. Internal limiting membrane peeling seems unnecessary.

RISK FACTORS FOR DEVELOPMENT OF MACULAR HOLE RETINAL DETACHMENT AFTER PARS PLANA VITRECTOMY FOR PATHOLOGIC MYOPIC FOVEOSCHISIS

PURPOSE

To identify the risk factors for the development of macular hole retinal detachment (MHRD) after vitrectomy without internal limiting membrane peeling for pathologic MF.

METHODS

We retrospectively reviewed the records of 131 eyes (115 patients) treated with vitrectomy for pathologic MF from 2009 to 2014. The best-corrected visual acuity (BCVA), refractive error, axial length, and spectral-domain optical coherence tomography findings were analyzed.

RESULTS

Postoperative MHRD developed in 7 eyes (5.3%). Between patients with or without secondary MHRD after vitrectomy, there were no significant differences in age, sex, axial length, preoperative BCVA, refractive error, lens status, and presence of posterior staphyloma. Spectral-domain optical coherence tomography showed all 7 eyes (100%) had foveal detachment, while only 47 patients (37.9%) of 124 eyes had foveal detachment (P = 0.004). There was no significant difference between preoperative and postoperative BCVA in the 7 eyes with MHRD. The postoperative BCVA in the 124 eyes without MHRD was significantly improved (P < 0.001). Among the 124 eyes, both preoperative and postoperative BCVA of eyes with foveal detachment was worse than the eyes without foveal detachment (P < 0.001, respectively).

CONCLUSION

Preoperative foveal detachment is a risk factor for the development of MHRD after vitrectomy for pathologic MF.

Complications of Pathologic Myopia

Pathologic myopia (PM) is one of the leading causes of visual impairment worldwide. The pathophysiology of PM is not fully understood, but the axial elongation of the eye followed by chorioretinal thinning is suggested as a key mechanism. Pathologic myopia may lead to many complications such as chorioretinal atrophy, foveoschisis, choroidal neovascularization, rhegmatogenous retinal detachment, cataract, and glaucoma. Some complications affect visual acuity significantly, showing poor visual prognosis. This article aims to review the types, pathophysiology, treatment, and visual outcome of the complications of PM.

LONG-TERM OUTCOMES OF 23-GAUGE PARS PLANA VITRECTOMY WITH INTERNAL LIMITING MEMBRANE PEELING AND GAS TAMPONADE FOR MYOPIC TRACTION MACULOPATHY: A Prospective Study

PURPOSE

To investigate the long-term safety and efficacy of microincisional 23-gauge pars plana vitrectomy with internal limiting membrane (ILM) peeling and gas tamponade in the treatment of myopic traction maculopathy.

METHODS

A prospective nonrandomized multicenter study was designed. Patients with myopic traction maculopathy without macular hole and retinal detachment were included in the study between January 2009 and May 2012. All patients underwent microincisional 23-gauge pars plana vitrectomy with ILM peeling and 12% C3F8 gas tamponade. In all cases, brilliant blue G staining of the ILM was performed. All patients were prospectively evaluated. The evolution of best-corrected visual acuity (BCVA) and macular thickness were recorded.

RESULTS

Myopic traction maculopathy resolved in 28 of the 30 patients (93%) included. Mean follow-up was 33.8 ± 13 months (range, 24-60 months). Mean time of myopic traction maculopathy resolution after surgery was 2.65 ± 1.4 months. At 1 month after surgery, one patient developed a macular hole and another one a rhegmatogenous retinal detachment. After 2 years, another patient developed a retinal detachment. Statistically significant improvements in macular thickness compared with baseline were found at all follow-up visits (P < 0.001, Student's t-test). At final visit, BCVA improved significantly compared with baseline (P = 0.044, Wilcoxon's test). However, a statistically significant improvement in visual acuity was achieved only in eyes with a preoperative Snellen visual acuity ≥ 20/63 (P = 0.027). In contrast, the final BCVA of eyes with worse preoperative visual acuity (<20/63) did not improve significantly (P = 0.41, Wilcoxon's test).

CONCLUSION

Microincisional 23-gauge pars plana vitrectomy with ILM peeling and gas tamponade is effective in the treatment of myopic traction maculopathy, with low postoperative complications. Globally, both BCVA and macular thickness improved significantly during the follow-up period. However, greater visual acuity improvements were only seen in eyes with preoperative BCVA equal to or better than 20/63 Snellen equivalent. Some concerns remain about the risk of macular hole formation after ILM peeling. Further studies are necessary to investigate this issue.

Retinal Damage Induced by Internal Limiting Membrane Removal

The internal limiting membrane (ILM), the basement membrane of the Müller cells, serves as the interface between the vitreous body and the retinal nerve fiber layer. It has a fundamental role in the development, structure, and function of the retina, although it also is a pathologic component in the various vitreoretinal disorders, most notably in macular holes. It was not until understanding of the evolution of idiopathic macular holes and the advent of idiopathic macular hole surgery that the idea of adjuvant ILM peeling in the treatment of tractional maculopathies was explored. Today intentional ILM peeling is a commonly applied surgical technique among vitreoretinal surgeons as it has been found to increase the rate of successful macular hole closure and improve surgical outcomes in other vitreoretinal diseases. Though ILM peeling has refined surgery for tractional maculopathies, like all surgical procedures it is not immune to perioperative risk. The essential role of the ILM to the integrity of the retina and risk of trauma to retinal tissue spurs suspicion with regard to its routine removal. Several authors have investigated the retinal damage induced by ILM peeling and these complications have been manifested across many different diagnostic studies.

Posterior scleral reinforcement and vitrectomy for myopic foveoschisis in extreme myopia

PURPOSE

To evaluate the effect of surgical posterior scleral reinforcement in extremely myopic patients (axial length ≥30 mm) with myopic foveoschisis.

METHODS

The retrospective interventional case series study included patients with an axial length ≥30 mm, posterior scleral staphyloma, and myopic foveoschisis, who were treated either by posterior scleral reinforcement and 23-gauge 3-port pars plana vitrectomy (posterior scleral reinforcement group) or by vitrectomy (vitrectomy group) alone. All eyes additionally underwent cataract surgery.

RESULTS

The study included 28 patients (28 eyes) with no significant (all P > 0.05) difference between the posterior scleral reinforcement group (n = 14) and the vitrectomy group (n = 14) in age, refractive error, axial length, and preoperative best-corrected visual acuity (BCVA). In addition to posterior scleral staphyloma and foveoschisis, a macular hole, a macular hole-associated retinal detachment, and a macular detachment without macular hole were present in three eyes, five eyes, and one eye, respectively in the study group and in three eyes, three eyes, and six eyes, respectively in the control group. In the study group, BCVA was significantly better after surgery than at baseline (P = 0.005) with an improvement in BCVA in 13 eyes, whereas BCVA was unchanged in 1 eye. In the control group, BCVA at baseline and at the end of follow-up did not differ significantly (P = 0.22). Gain in BCVA was marginally significantly higher in the study group than that in the control group (improvement by 0.69 ± 0.76 logMAR vs. 0.19 ± 0.54 logMAR; P = 0.05). The number of eyes with any improvement in BCVA (13 [93%] eyes vs. 11 [79%] eyes; P = 0.289) did not differ between both groups; an improvement in BCVA by more than 2 lines (10 [71%] eyes vs. 3 [21%] eyes; P = 0.009) was significantly higher in the study group than that in the control group. Anatomical success (defined as closure of macular holes and collapse of the foveoschisis) was achieved earlier in the study group (3.7 ± 3.2 months vs. 6.2 ± 3.0 months; P = 0.04).

CONCLUSION

Posterior scleral reinforcement in association with vitrectomy, as compared with vitrectomy alone, was associated with a higher improvement in visual acuity in extremely myopic eyes with foveoschisis.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Myopic foveoschisis: a clinical review

To review the literature on epidemiology, clinical features, diagnostic imaging, natural history, management, therapeutic approaches, and prognosis of myopic foveoschisis. A systematic Pubmed search was conducted using search terms: myopia, myopic, staphyloma, foveoschisis, and myopic foveoschisis. The evidence base for each section was organised and reviewed. Where possible an authors' interpretation or conclusion is provided for each section. The term myopic foveoschisis was first coined in 1999. It is associated with posterior staphyloma in high myopia, and is often asymptomatic initially but progresses slowly, leading to loss of central vision from foveal detachment or macular hole formation. Optical coherence tomography is used to diagnose the splitting of the neural retina into a thicker inner layer and a thinner outer layer, but compound variants of the splits have been identified. Vitrectomy with an internal limiting membrane peel and gas tamponade is the preferred approach for eyes with vision decline. There has been a surge of new information on myopic foveoschisis. Advances in optical coherence tomography will continually improve our understanding of the pathogenesis of retinal splitting, and the mechanisms that lead to macular damage and visual loss. Currently, there is a good level of consensus that surgical intervention should be considered when there is progressive visual decline from myopic foveoschisis.

Late recurrence of myopic foveoschisis after successful repair with primary vitrectomy and incomplete membrane peeling

PURPOSE

To report three cases of late recurrence of myopic foveoschisis (MF) after initial successful repair with pars plana vitrectomy and membrane peeling to assess the importance of internal limiting membrane peeling.

METHODS

A retrospective noncomparative case series was performed of patients who underwent a primary pars plana vitrectomy by a single surgeon with successful resolution of MF, but eventually underwent repeat pars plana vitrectomy for recurrent MF. Best-corrected visual acuity, fundus photography, and optical coherence tomography were obtained at each examination.

RESULTS

Three eyes of three patients underwent pars plana vitrectomy for recurrent MF. Myopic foveoschisis recurrence occurred 6, 3.5, and 12 years after the primary vitrectomy, respectively. Repeat vitrectomy with staining and additional peeling of the internal limiting membrane resulted in good anatomical outcome and stabilization of visual acuity in all cases.

CONCLUSION

Late recurrence of MF after successful primary vitrectomy is described. Fibrocellular proliferation on residual cortical vitreous or incomplete internal limiting membrane peeling during the initial vitrectomy may underlie recurrence.

Favorable anatomic and visual outcomes with 25-gauge vitrectomy for myopic foveoschisis

Purpose

To report the surgical outcomes of 25-gauge vitrectomy in eyes with myopic foveoschisis (MF).

Methods

The medical records of 40 eyes of 36 patients that had undergone 25-gauge vitrectomy with internal limiting membrane peeling for MF were studied. The main outcome measures were the best-corrected visual acuity (BCVA) and the optical coherence tomography (OCT) findings. The eyes were divided into two groups: 1) those with a foveal detachment (FD; FD group); and 2) those without a FD (no-FD group).

Results

The postoperative OCT images showed a resolution of the MF with a significant reduction in the central foveal thickness from the preoperative values in both the FD group (479±150 μm to 196±56 μm; P=0.002, mean ± standard deviation) and in the no-FD group (369±116 μm to 245±50 μm; P=0.001). The final mean BCVA significantly improved from the preoperative values in the FD group (0.96±0.53 logarithm of the minimum angle of resolution [logMAR] units to 0.70±0.56 logMAR units; P=0.009) and in the no-FD group (0.46±0.38 logMAR units to 0.34±0.36 logMAR units; P=0.007). The final BCVA in the FD group improved in 63%, remained unchanged in 31%, and worsened in 6%. In the no-FD group, the final BCVA improved in 21%, remained unchanged in 71%, and worsened in 8% of the eyes. A better final BCVA was significantly correlated with a better preoperative BCVA in both groups (P<0.001).

Conclusion

Twenty five-gauge vitrectomy results in favorable visual and anatomic outcomes for MF. We recommend that 25-gauge vitrectomy be used to treat eyes with MF.

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.

Natural course and surgical management of high myopic foveoschisis

PURPOSE

To describe the spectral-domain optical coherence tomographic characteristics, natural course and surgical management for eyes with myopic foveoschisis.

METHODS

The medical records of 39 consecutive patients (56 eyes) with myopic foveoschisis were retrospectively reviewed. Pars plana vitrectomy with internal limiting membrane peeling and Brilliant Blue G staining was performed on 16 symptomatic eyes (14 patients).

RESULTS

Optical coherence tomography at baseline showed an isolated foveoschisis in 62.5%, foveal detachment in 21.4%, and a lamellar hole in 16.1% of the eyes. After a mean follow-up period of 15.7 months, 1.8% of the eyes developed a full-thickness macular hole and 28.5% of the eyes required surgery. The mean preoperative visual acuity (VA) was 20/63 and the mean central retinal thickness (CRT) was 507.6 µm. The mean postoperative VA was 20/40 and the mean CRT 282.9 µm. Anatomical success was achieved in 75% of the eyes at a mean of 3.3 months after surgery, and 81.2% of the eyes had an improvement of 2 lines of VA.

CONCLUSION

Myopic foveoschisis remained stable in most eyes; however, 28.5% of the eyes had decreases in VA secondary to progression of the foveoschisis and required surgery.

Postoperative optical coherence tomographic appearance and relation to visual acuity after vitrectomy for myopic foveoschisis

PURPOSE

To investigate the appearance of postoperative spectral-domain optical coherence tomography (SD-OCT) and the relationship of the findings to visual acuity in myopic foveoschisis.

DESIGN

Retrospective observational case series.

METHODS

We studied 17 eyes (17 women; mean age, 66.4 years) with myopic foveoschisis. SD-OCT was performed preoperatively and 1, 3, 6, and 12 months after vitrectomy. The average central foveal thickness and choroidal thickness and the integrity of the foveal photoreceptor inner segment/outer segment junction as well as the external limiting membrane were correlated with the postoperative best-corrected visual acuity (BCVA).

RESULTS

The mean refractive error was -11.9 diopters, axial length 29.7 mm, choroidal thickness 29.9 μm, and logarithm of the maximum angle of resolution (logMAR) visual acuity 0.52 at baseline. The mean preoperative central foveal thickness was 470.8 μm, which was not associated with age, refractive error, symptom duration, or BCVA. The mean postoperative retinal thicknesses at 1, 3, 6, and 12 months were 310.4, 251.8, 218.2, and 218.7 μm, respectively (P < 0.01 at all time points). The final BCVA improved significantly (P < 0.001). The preoperative BCVA (P < 0.0001) difference in central foveal thickness between 3 and 12 months postoperatively (P < 0.05), the final integrity of the inner segment/outer segment junction (P < 0.05), and the ELM (P < 0.05) were significantly associated with the final BCVA. The preoperative choroidal thickness was negatively associated with axial length (P < 0.05) but not with postoperative central foveal thickness or BCVA.

CONCLUSIONS

The final BCVA in myopic foveoschisis is associated with the retinal thickness changes postoperatively and recovery of the photoreceptor cells as seen in OCT images.

Suprachoroidal buckling: technique and indications

The authors herein report the feasibility of suprachoroidal buckling (SCB) procedure as a new approach for treating different forms of retinal detachment (RD) by creating suprachoroidal indentation (buckling effect). With this technique, specially designed devices, i.e. a catheter or cannula, are guided in the suprachoroidal space to reach the target area. Then, a suprachoroidal filler (long lasting hyaluronic acid) is injected to indent the choroid creating SCB, thereby closing retinal tears and supporting the overlying retina. This procedure was performed to treat both myopic tractional maculopathy (MTM), including myopic macular holes, as well as peripheral retinal breaks. SCB may be used alone or in conjunction with vitrectomy. In myopic patients, restoration of retinal layers was achieved in all eyes with myopic foveoschisis. Most eyes with macular hole detachments demonstrated closure of the holes. All peripheral retinal breaks were adequately buckled and closed in a single procedure. The buckling effect was long enough in duration to seal the tears and promote adequate chorioretinal scarring. The procedure was safe and relatively simple in terms of reaching the treatment area and injecting the filler. SCB adds to our surgical options for treating selected cases of peripheral retinal tears and rhegmatogenous RD, and avoids potential problems of episcleral buckles. Moreover it may avoid vitrectomy in selected cases of rhegmatogenous RD.