Pars Plana Vitrectomy with Internal Limiting Membrane Peeling in Traumatic Macular Hole: 14% Perfluoropropane (C3F8) versus Silicone Oil Tamponade

Pediatric and Adolescent Traumatic Macular Hole: A Systematic Review

PURPOSE

The optimal management of pediatric traumatic macular holes (TMH) is unclear from lack of prospective randomized trials. The literature is divided into early (≤1month post-trauma), delayed (>1 month) pars plana vitrectomy (PPV), and observation. Our aim is to find which group can achieve best-superior spectacle corrected visual acuity (VA), visual gain, and time for hole closure.

DESIGN

Systematic review.

METHODS

This systematic review was registered with PROSPERO (ID:CRD42022383134). The databases searched from inception until July 31, 2023, were MEDLINE OVID, Scopus, Web of Science, Embase, and Google Scholar. The articles were screened for title and abstract then for full text. Risk of bias was also assessed. Three outcome measures were analyzed: final VA, visual gain, and time to closure of macular hole (MH). MH size was divided into small (≤250 µm), medium (>250-500 µm), and large (>500 µm).

RESULTS

Ninety eight (98) studies with 234 patients in the PPV group and 87 patients in the observation group were included in the review. Final VA (logarithm of the minimum angle of resolution) and visual gain were respectively in PPV vs observation groups: (1) small MH 0.37 ± 0.52 vs 0.42 ± 0.56 (P = .484) and -0.96 ± 0.83 vs -0.49 ± 0.40 (P = .005); (2) medium MH 0.58 ± 0.39 vs 0.34 ± 0.34 (P = .06) and -0.36 ± 0.42 vs -0.74 ± 0.44 (P < .001); (3) large MH 0.62 ± 0.42 vs 0.59 ± 0.35 (P = .337) and -0.31 ± 0.48 vs -0.62 ± 0.37 (P = .11). Small TMH had comparable closure time: 3.21 ± 2.52 months vs 3.49 ± 4.43 (P = .954) in the PPV and observation groups. Early and late PPV yielded comparable final VA 0.67 ± 0.66 vs 0.54 ± 0.35 (P = .576) and visual gain -0.58 ± 0.69 vs -0.49 ± 0.48 (P = .242) in the PPV and observation groups.

CONCLUSIONS

PPV was very effective in closing TMH and VA gain in children throughout a wide range of hole size. Early and delayed PPV yielded similar anatomic and visual results. Observation and PPV yielded comparable final VA and closure time. Clinicians can choose either early PPV or delayed PPV when healing biomarkers are absent on periodic optical coherence tomography.

Vitrectomy vs. Spontaneous Closure for Traumatic Macular Hole: A Systematic Review and Meta-Analysis

Objective: This systematic review and meta-analysis aimed to determine the traumatic macular hole (TMH) closure rate and visual acuity (VA) improvement rate by comparing two treatment methods for TMH: vitrectomy and observation for spontaneous closure. Methods: PubMed, Cochrane, Web of Science Library, Embase, CNKI, Wanfang, VIP, and Sino Med were systematically searched from their inception to June 10, 2021. Studies in the surgery group (n = 32) and studies in the observation group (n = 12) were meta-analyzed. The primary outcomes were the TMH closure and VA improvement rates in the surgery and observation groups. The secondary outcomes were best-corrected visual acuity (BCVA) improvement in the surgery group. Stata software (version 15.1) was used for the analyses. Results: Thirty-six studies that included 1,009 eyes were selected for this meta-analysis, among which 33 were retrospective studies and 3 were prospective studies. The meta-analysis showed that the random-model pooled event rate for TMH closure was 0.37 (95% confidence interval [CI], 0.26-0.48) in the observation group, while it was 0.9 (95% CI, 0.85-0.94) in the surgery group. The fixed-model pooled event rate for VA improvement was 0.39 (95% CI, 0.33-0.45) in the observation group, while the random-model pooled event rate of VA improvement for the surgery group was 0.72 (95% CI, 0.63-0.80). The pooled event rate for BCVA improvement in the surgery group was 0.39 (95% CI, 0.33-0.46). Conclusions: This meta-analysis suggests that TMH hole closure and VA improvement rates in the surgery group were significantly higher than those in the observation group. Vitrectomy is an effective method for treating TMH. However, further randomized controlled trials (RCTs) are required to evaluate the efficacy and safety of surgery and observation for TMH treatment. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/#recordDetails, identifier: CRD42021276684.

A structured exercise to relieve musculoskeletal pain caused by face-down posture after retinal surgery: a randomized controlled trial

Face-down posture after vitrectomy physically burdens patients. Despite being of significant concern for patients, the intraoperative pain and discomfort has not been of great interest to retinal surgeons or researchers. This randomized controlled trial evaluated the effect of a 3-day novel structured exercise on reducing musculoskeletal pain from the face-down posture in 61 participants (31 in the exercise group) who underwent vitrectomy. Among the subjects, the median age was 62 years, 42 were female, 42 had macular holes, and 19 had retinal detachments. Participants in the exercise group received initial education on the exercise and performed three daily active exercise sessions. After the sessions, the exercise group had median numeric pain scores of 2, 1, and 1 at the back neck, shoulder, and lower back, respectively, while the control group had corresponding scores of 5, 3, and 4, respectively. The exercise group reported significantly lower pain scores (P = .003, .039, and .006 for the back neck, shoulder, and lower back, respectively). Application of the structured exercise would alleviate the patients' position-induced postoperative physical burden, by reducing pain and discomfort.

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

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

Results of Pars Plana Vitrectomy for Different Types of Macular Holes

Purpose

To compare different types of macular holes regarding the anatomic and functional success following pars plana vitrectomy (PPV) and internal limiting membrane (ILM) removal.

Methods

A retrospective review of all patients with macular holes treated by PPV, ILM removal with gas tamponade from January 2014 to July 2017 in Magrabi Eye Hospital.

Results

One hundred fifty-seven eyes of 153 patients were analyzed. The eyes were classified according to the etiology of macular hole into four groups: 79 eyes with idiopathic macular hole (IMH), 51 eyes with traumatic macular hole (TMH), 16 eyes with macular hole in diabetic patients (DMH) and 11 eyes with myopic macular hole (MMH). We classified the IMH group based on the International Vitreomacular Traction Study Classification according to size into 3 subgroups; subgroup 1: ≤250µ, subgroup 2: >250 to 400µ and subgroup 3: ≥400 µ. All types of macular hole showed statistically significant postoperative improvement in BCVA compared to the baseline except cases with MMH. Anatomic postoperative hole closure was achieved in 86.1%, 60.7%, 43.65%, an 45.46% of eyes with IMH, TMH, DMH and MMH, respectively. In eyes with IMH, closure rate in subgroup 1 was significantly higher than in subgroups 2, and 3.

Conclusion

PPV, ILM peel and C2F6 technique yielded variable anatomic and functional outcomes in different types of macular holes. Anatomic results were most favorable in IMH and least favorable in MMH. The smaller the diameter of the hole the better the results. The underlying pathogenetic mechanisms that lead to different types of macular holes are pivotal in determining the final outcome.

Surgical Treatment for Traumatic Macular Holes: Reconstructive Changes in Foveal Microstructures and Visual Predictors Analysis

PURPOSE

To investigate the reconstructive changes in foveal microstructures postoperatively and analyze the visual predictors in eyes with surgically closed traumatic macular holes (TMHs).

METHODS

Seventy-one eyes with TMHs that underwent vitrectomy, internal limiting membrane (ILM) peeling, and gas tamponade were reviewed. Clinical data, best-corrected visual acuity, and spectral-domain optical coherence tomography (SD-OCT) images were recorded. The length of the ellipsoid zone (EZ) defect and the integrity of postoperative external limiting membrane (ELM) were measured. Preoperative and 1-month postoperative features were analyzed, respectively, as potential predictors of visual acuity at 6 months postoperatively.

RESULTS

The primary hole closure rate was 90.14% (64/71). In 43 cases of initially closed TMHs with SD-OCT scans preoperatively and at 1 and 6 months postoperatively, the number of eyes with intact ELM increased from 18 (41.86%) at 1 month to 26 (60.47%) at 6 months (p = 0.08), while the number of eyes with a restored EZ band remained the same in 2 eyes (4.65%). The mean length of the EZ defect progressively decreased postoperatively (p < 0.001). Poorer preoperative visual acuity (p = 0.002), lower mean macular hole (MH) height (p = 0.012), and greater preoperative mean length of EZ defect (p < 0.001) were associated with worse visual acuity 6 months postoperatively, but only the preoperative length of the EZ defect was proved to be a predictor, with the cutoff value of 1,800 μm provided by the receiver-operating characteristics (ROC) curve. Worse visual acuity and greater mean length of the EZ defect at 1 month were also associated with worse final visual acuity.

CONCLUSIONS

The mean length of the EZ defect both preoperatively and 1 month postoperatively were predictors of visual outcomes at 6 months postoperatively.

Traumatic Macular Hole: Diagnosis, Natural History, and Management

Traumatic macular hole occurs most often in young men and can present after various types of injuries. Traumatic macular holes result from anteroposterior and tangential vitreoretinal traction and may exhibit concurrent additional pathologies such as Berlin's edema and subretinal fluid. Optical coherence tomography can play an essential role in patient management both at presentation and during follow-up. Initial management consists of observation, but macular hole repair can be performed if spontaneous resolution does not occur. Upon macular hole closure, vision may improve, on average, by two lines or more but may be limited by associated macular pathology.

A Combination of Surgical Techniques to Repair a Giant Traumatic Macular Hole

A 38-year-old man with a traumatic full-thickness macular hole (FTMH) presented to our eye casualty department with a sudden deterioration of his right eye vision to hand movements over the past one week. The suspected traumatic FTMH was present since he was 13 years old from a direct impact of a golf ball in his right eye and his best-corrected visual acuity (BCVA) has always remained at 1/60 Snellen vision. On examination, he had a very large FTMH measuring 1635 µm with central foveal retinal detachment. Pars plana vitrectomy combined with large inverted internal limiting membrane (ILM) peel flap, 5000 Cs silicone oil tamponade, and autologous platelets implantation was performed. Follow-up visits revealed that the FTMH was closed under silicone oil. The silicone oil was removed six months after the surgery and the FTMH remained close with the retina remaining attached. His BCVA was restored to his previous baseline level of 1/60 Snellen vision. With the advent of multiple techniques to repair FTMH such as the ILM flaps, we have combined this technique with older proven techniques such as silicone oil tamponade and autologous platelets implantation to close the giant traumatic FTMH. This case study demonstrates that combining techniques can help close a FMTH that is otherwise deemed impossible in the past.