Pathogenesis and Management of Macular Hole: Review of Current Advances

Scoping review of nonsurgical treatment options for macular holes

Macular holes (MH) are full-thickness retinal defects affecting central vision. While vitrectomy with inner limiting membrane (ILM) peel is the conventional MH treatment, non-surgical alternatives are gaining interest to mitigate surgical risks. This study conducted a comprehensive literature review and analysis of nonsurgical MH management. A systematic literature search was conducted on PubMed, Embase, Scopus, and the Cochrane Library from January 1, 1973, to September 13, 2023. Treatments included laser therapy, carbonic anhydrase inhibitors (CAIs), nonsteroidal antiinflammatory drugs (NSAIDs), steroids (topical, subtenons, peribulbar, intravitreal), intravitreal gas, anti-vascular endothelial growth factors and ocriplasmin injections. Data extraction covered study details, patient characteristics, MH features, treatment outcomes, and recurrence rates. The initial search yielded 3352 articles, refined to 83 articles that met inclusion criteria following screening. Overall reported anatomical closure rates were 36% with laser photocoagulation, 37% with intravitreal ocriplasmin, 55% with intravitreal gas. Closures were more frequently observed with topical NSAIDs (79%), steroids (84%) and CAIs (73%). Closures were more often observed in patients with smaller MH and in the presence of cystic macular oedema. Although non-surgical MH management approaches show potential for conservative therapy, evidence is limited to support routine use. Stage 1 and traumatic MH may benefit from a short period of observation, but the gold standard approach for full-thickness MH remains to be vitrectomy with ILM peel.

Large macular hole and autologous retinal transplantation: a systematic review and meta-analysis

INTRODUCTION

Macular holes are breaks in the retinal tissue at the center of the macula, affecting central vision. The standard treatment involves vitrectomy with membrane peeling and gas tamponade. However, for larger or chronic holes, alternative techniques like autologous retinal graft have emerged. This meta-analysis evaluates the efficacy and safety of retinal transplantation in managing large macular holes.

METHODS

We conducted a systematic review and meta-analysis following PRISMA guidelines. The study was prospectively registered in PROSPERO (CRD42024504801). We searched PubMed, Web of Science, Cochrane, and Embase databases for observational studies including individuals with large macular holes with or without retinal detachments and retinal transplantation as the main therapy. We used a random-effects model to compute the mean difference with 95% confidence intervals and performed statistical analysis using R software.

RESULTS

We conducted a comprehensive analysis of 19 studies involving 322 patients diagnosed with various types of macular holes (MHs). These included cohorts with refractory MH, high myopia associated with MH, primary MH, and MH with retinal detachment (RD). The findings were promising, revealing an overall closure rate of 94% of cases (95% CI 88-98, I2 = 20%). Moreover, there was a significant improvement in postoperative visual acuity across all subgroups, averaging 0.45 (95% CI 0.33-0.58 ; I2 = 72%; p < 0.01) overall. However, complications occurred with an overall incidence rate of 15% (95% CI 7-25; I2 = 59%).

CONCLUSION

ART for large MH shows promising results, including significant improvements in visual acuity and a high rate of MH closure with low complication risks overall and for subgroups.

Artificial intelligence in individualized retinal disease management

Owing to the rapid development of modern computer technologies, artificial intelligence (AI) has emerged as an essential instrument for intelligent analysis across a range of fields. AI has been proven to be highly effective in ophthalmology, where it is frequently used for identifying, diagnosing, and typing retinal diseases. An increasing number of researchers have begun to comprehensively map patients' retinal diseases using AI, which has made individualized clinical prediction and treatment possible. These include prognostic improvement, risk prediction, progression assessment, and interventional therapies for retinal diseases. Researchers have used a range of input data methods to increase the accuracy and dependability of the results, including the use of tabular, textual, or image-based input data. They also combined the analyses of multiple types of input data. To give ophthalmologists access to precise, individualized, and high-quality treatment strategies that will further optimize treatment outcomes, this review summarizes the latest findings in AI research related to the prediction and guidance of clinical diagnosis and treatment of retinal diseases.

Topical dorzolamide for macular holes: A randomised, double-blind, placebo-controlled trial

BACKGROUND

To assess topical dorzolamide as medical therapy for idiopathic full-thickness macular holes (FTMHs).

METHODS

Randomised, double-blinded, placebo-controlled, single-centre clinical trial involving 32 patients with idiopathic small FTMHs (<400μm $$ \upmu \mathrm{m} $$ ). Participants in both arms used topical dorzolamide 2% or saline thrice daily for 8 weeks with monthly OCT. Those with persisting FTMH underwent vitrectomy with ILM peel and gas tamponade. The primary outcome was the rate of FTMH closure at the end of treatment.

RESULTS

Between 6 March 2020 and 16 June 2023, 32 eligible patients were enrolled: 16 participants in each arm. All participants in both groups were included in the final analysis. At the final visit, 3 of 16 (18.8%) patients in both the topical dorzolamide and placebo group demonstrated closure. There was no statistically significant difference in the proportion of FTMH closure between the control and treatment group (p = 1.00), nor statistically significant difference in the mean change in best corrected visual acuity (BCVA; p = 0.909). There was no difference in the change in FTMH diameter between groups (p = 0.225). No serious adverse events were reported in either group.

CONCLUSION

Topical dorzolamide was safe but not superior to placebo in the functional and anatomical outcomes of FTMH.

Platelet concentrates in macular hole surgery. A journey through the labyrinth of terminology, preparation, and application: a comprehensive review

The surgical management of macular holes is undergoing continuous evolution, with recent focus on the utilization of platelet concentrates as a promising adjunctive intervention. Currently, they present a valid surgical approach for achieving anatomical and functional success with a non-inferiority comparably to the alternative surgical techniques. Nonetheless, the utilization of varied platelet concentrates terminologies, coupled with the lack of standardization in their preparation methodologies, engenders both lexical confusion and challenges in comparing scientific studies published up until now. In this review, we summarized the published evidence concerning the application of platelet concentrates in macular holes surgery, aiming to clarify the terminology and methodologies employed and to establish a common consensus facilitating further development and diffusion of this promising technique.

Self-supervised contrastive learning improves machine learning discrimination of full thickness macular holes from epiretinal membranes in retinal OCT scans

There is a growing interest in using computer-assisted models for the detection of macular conditions using optical coherence tomography (OCT) data. As the quantity of clinical scan data of specific conditions is limited, these models are typically developed by fine-tuning a generalized network to classify specific macular conditions of interest. Full thickness macular holes (FTMH) present a condition requiring urgent surgical repair to prevent vision loss. Other works on automated FTMH classification have tended to use supervised ImageNet pre-trained networks with good results but leave room for improvement. In this paper, we develop a model for FTMH classification using OCT B-scans around the central foveal region to pre-train a naïve network using contrastive self-supervised learning. We found that self-supervised pre-trained networks outperform ImageNet pre-trained networks despite a small training set size (284 eyes total, 51 FTMH+ eyes, 3 B-scans from each eye). On three replicate data splits, 3D spatial contrast pre-training yields a model with an average F1-score of 1.0 on holdout data (50 eyes total, 10 FTMH+), compared to an average F1-score of 0.831 for FTMH detection by ImageNet pre-trained models. These results demonstrate that even limited data may be applied toward self-supervised pre-training to substantially improve performance for FTMH classification, indicating applicability toward other OCT-based problems.

Effect of internal limiting membrane surgical techniques on the idiopathic and refractory management of macular holes: a systematic review and meta-analysis

Macular holes (MHs), including atraumatic idiopathic and refractory MHs, affect central vision acuity due to full-thickness defects in the retinal tissue. The existing controversy regarding the pathophysiology and management of MHs has significantly improved with the implementation of internal limiting membrane (ILM) surgical techniques and improved MH closure rates. Thus, to determine the effect of ILM techniques on large idiopathic and refractory MH management, the present study systematically reviewed 5910 original research articles extracted from online literature databases, including PubMed, Cochrane, Google Scholar, and Embase, following the PRISMA guidelines. The primary outcome measures were MH closure rate and postoperative visual acuity. A total of 23 randomized controlled trials (RCTs) with adequate patient information and information on the effect of ILM peeling, inverted ILM flaps, autologous retinal transplantation (ART), and ILM insertion techniques on large idiopathic and refractory MH patients were retrieved and analyzed using RevMan software (version 5.3) provided by the Cochrane Collaboration. Statistical risk of bias analysis was also conducted on the selected sources using RoB2, which showed a low risk of bias in the included studies. A meta-analysis indicated that the inverted ILM flap technique had a significantly greater MH closure rate for primary MH than the other treatment methods (OR = 3. 22, 95% CI 1.34-7.43; p = 0.01). Furthermore, the findings showed that the inverted ILM flap group had significantly better postoperative visual acuity than did the other treatment options for patients with idiopathic MH (WMD = - 0.13; 95% CI = 0.22-0.09; p = 0.0002). The ILM peeling technique had the second highest statistical significance for MH closure rates in patients with idiopathic MH (OR = 2. 72, 95% CI: 1.26-6.32; p = 0.016). In refractory MHs, autologous retinal transplant (ART) and multilayer ILM plug (MIP) techniques improve the closure rate and visual function; human amniotic membrane grafting (hAMG) provides a high degree of anatomical outcomes but disappointing visual results. This study demonstrated the reliability and effectiveness of ILM techniques in improving the functional and anatomical outcomes of large idiopathic and refractory MH surgery. These findings will help clinicians choose the appropriate treatment technique for patients with idiopathic and refractory MH.

Successful anatomical closure of a photographically documented 30-year-old idiopathic full-thickness macular hole following surgery for concurrent repair of an acute macula-on rhematogenous retinal detachment

A 62-year-old man with a 30-year-old photographically documented idiopathic full-thickness macular hole and visual acuity of 6/45 developed an acute macula-on rhegmatogenous retinal detachment in his left eye. A pars plana vitrectomy, internal limiting membrane peeling around the macular hole, fluid-air exchange, endolaser retinopexy around the peripheral retinal break and perfluoropropane (C3F8) internal tamponade were performed to repair the detached retina and macular hole. One month postoperatively, the patient developed a large peripheral circumferential retinal tear with shallow retinal detachment which necessitated scleral buckling, repeat vitrectomy, endolaser photocoagulation and C3F8 tamponade. The retina was successfully re-attached and the macula hole was closed. Three years post-vitrectomy, the repaired 30-year-old macular hole remained closed although the visual acuity remained unchanged at 6/45. In summary, we describe the successful anatomical closure of a 30-year-old idiopathic full-thickness macular hole which we believe to be the longest duration photographically documented macular hole closed following surgery.

Microperimetry-guided inverted internal limiting membrane flap site selection to preserve retinal sensitivity in macular hole with glaucoma

Purpose

In cases of macular hole (MH) that is difficult to close, including large, chronic, or highly myopic cases, the inverted internal limiting membrane (ILM) flap technique is often preferred and yields favorable surgical outcomes as compared to those yielded by conventional ILM peeling. However, no consensus exists on the optimal location and area for peeling and inverting the ILM, since multiple alternative methods have been reported alongside the original method. Several adverse effects associated with ILM peeling have been documented, including mechanical impairment of the retinal nerve fiber layer and decreased retinal sensitivity. Particularly, when glaucoma is concomitant, the retinal nerve fiber layer is fragile, raising concerns about a decrease in retinal sensitivity. Consequently, in patients with large MH alongside glaucoma, the goal is to select a procedure that maximizes the closure rate of the MH while minimizing any negative impact on glaucomatous visual field impairment. However, a technique for this purpose has not yet been validated.

Observations

A woman in her 60s presented with visual impairment (20/50), metamorphopsia, and central scotoma of unknown onset in the right eye. A full-thickness MH accompanied by epiretinal proliferation (EP) was identified, with a minimum diameter of 506 μm. Although a retinal nerve fiber layer defect was not evident on ophthalmoscopy, thinning of the ganglion cell complex (GCC), extending from the superotemporal aspect of the optic disc, was observed on optical coherence tomography. Both microperimetry and static visual field testing revealed reduced retinal sensitivity in the thinned GCC areas. A pars plana vitrectomy combined with cataract surgery was performed to address her condition. The EP was embedded into the foveal cavity. On the basis of the microperimetry results, the ILM within the absolute scotoma region was peeled on the superotemporal side of the fovea to create a flap, which was then placed over the MH. A gas tamponade was applied, and the patient was maintained in a prone position postoperatively. The MH was successfully closed after the surgery, resulting in visual improvement (20/25). No decline in retinal sensitivity after the surgery was observed.

Conclusions and importance

Determining the location and area of the inverted ILM flap on the basis of microperimetry results is a promising patient-tailored strategy for treating MH concomitant with glaucoma while preventing further ILM peeling-associated reduction in the retinal sensitivity.

Prognostic factors for visual recovery after successful large macular hole surgery using the inverted flap technique

PURPOSE

The goal of our study is to describe the functional results and preoperative factors predicting visual recovery after successful inverted flap technique and closure of large full-thickness macular holes (FTMH) and to evaluate the correlations between microstructural foveal changes and final visual acuity.

METHODS

Retrospective, descriptive, analytical study including 80 eyes of 78 patients with large FTMH; operated by inverted flap technique with successful closure of the macular hole after surgery. All eyes underwent a full preoperative ophthalmic examination and macular B-scan SD-OCT. We performed the classic inverted flap technique for all patients. Postoperatively, all patients were examined at 7 days, 1, 3, 6, 9 and 12 months after surgery. SD-OCT was performed for all patients on each follow-up. Preoperatively, best-corrected visual acuity (BCVA), FTMH size and basal hole diameter were the main outcome measures. Postoperatively, BCVA, macular thickness, integrity of the external limiting membrane (ELM) and ellipsoid zone (EZ) were recorded.

RESULTS

Mean age was 62±8.42 years with female predominance. Mean size of the FTMH was 692.59μm, and mean basal hole diameter was 1436.06μm. Mean BCVA improved from 1.06±0.491 LogMAR preoperatively to 0.52±0.32 at 9 months following surgery (P<0.001). At 9 months, the ELM was absent, partial or fully restored in 6.67, 10 and 83.33% respectively. The EZ was absent, partial or fully restored in 6.67, 33 and 63.33% respectively. ELM regeneration always preceded EZ regeneration at every point of follow-up. Final BCVA was statistically correlated with initial hole size (P=0.006, OR=1.056; CI [1.016-1.098]) and mean symptom duration prior to surgery (P=0.001. OR=0.987; CI [0.976-0.998]). Analysis of the ROC curve demonstrated that a hole diameter>478.5μm and symptom duration>5 weeks were correlated with non-improvement of visual acuity, with 81.3% sensibility and 18.7% specificity.

CONCLUSION

We report tomographic microstructural foveal changes and functional results following successful large idiopathic FTMH surgery using the classic inverted flap technique. Preoperative parameters such as initial FTMH diameter and mean symptom duration prior to surgery are crucial prognostic factors influencing final visual results.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Roles of Vitreous Biomechanics in Ocular Disease, Biomolecule Transport, and Pharmacokinetics

PURPOSE

The biomechanical properties of the vitreous humor and replication of these properties to develop substitutes for the vitreous humor have rapidly become topics of interest over the last two decades. In particular, the behavior of the vitreous humor as a viscoelastic tissue has been investigated to identify its role in a variety of processes related to biotransport, aging, and age-related pathologies of the vitreoretinal interface.

METHODS

A thorough search and review of peer-reviewed publications discussing the biomechanical properties of the vitreous humor in both human and animal specimens was conducted. Findings on the effects of biomechanics on vitreoretinal pathologies and vitreous biotransport were analyzed and discussed.

RESULTS

The pig and rabbit vitreous have been found to be most mechanically similar to the human vitreous. Age-related liquefaction of the vitreous creates two mechanically unique phases, with an overall effect of softening the vitreous. However, the techniques used to acquire this mechanical data are limited by the in vitro testing methods used, and the vitreous humor has been hypothesized to behave differently in vivo due in part to its swelling properties. The impact of liquefaction and subsequent detachment of the vitreous humor from the posterior retinal surface is implicated in a variety of tractional pathologies of the retina and macula. Liquefaction also causes significant changes in the biotransport properties of the eye, allowing for significantly faster movement of molecules compared to the healthy vitreous. Recent developments in computational and ex vivo models of the vitreous humor have helped with understanding its behavior and developing materials capable of replacing it.

CONCLUSIONS

A better understanding of the biomechanical properties of the vitreous humor and how these relate to its structure will potentially aid in improving clinical metrics for vitreous liquefaction, design of biomimetic vitreous substitutes, and predicting pharmacokinetics for intravitreal drug delivery.

Analysis of Retinal Microstructure in Eyes with Dissociated Optic Nerve Fiber Layer (DONFL) Appearance following Idiopathic Macular Hole Surgery: An Optical Coherence Tomography Study

(1) Purpose: This study aimed to evaluate morphological changes of the retina in eyes with dissociated optic nerve fiber layer (DONFL) appearance following internal limiting membrane (ILM) peeling for full-thickness idiopathic macular hole (IMH) on spectral-domain optical coherence tomography (SD-OCT). (2) Methods: We retrospectively analyzed 39 eyes of 39 patients with type 1 macular hole closure after a vitrectomy with ILM peeling procedure at a six-month minimum postoperative follow-up. The retinal thickness maps and cross-sectional OCT images were obtained from a clinical OCT device. The cross-sectional area of the retinal nerve fiber layer (RNFL) on cross-sectional OCT images was manually measured by ImageJ software. (3) Results: The inner retinal layers (IRLs) thickness thinned down much more in the temporal quadrant than in nasal quadrants at 2 and 6 months postoperatively (p < 0.001). However, the cross-sectional area of the RNFL did not change significantly at 2 and 6 months postoperatively (p > 0.05) when compared to preoperative data. In addition, the thinning of the IRL did not correlate with the best-corrected visual acuity (BCVA) at 6 months postoperatively. (4) Conclusions: The thickness of the IRL decreased in eyes with a DONFL appearance after ILM peeling for IMH. The thickness of the IRL decreased more in the temporal retina than in the nasal retina, but the change did not affect BCVA during the 6 months after surgery.

Ocular Manifestations and Potential Treatments of Alport Syndrome: A Systematic Review

Objectives. Alport syndrome (AS) is a severe, rare hereditary disorder that can lead to end-stage renal disease, auditory degeneration, and ocular abnormalities. Despite extensive research on AS in relation to auditory and renal disorders, more research is needed on the ocular presentations of AS. This systematic review aims to summarize the common ocular abnormalities in patients with AS and to explore the potential treatment options for these irregularities. Methods. The PubMed, MEDLINE, and EMBASE databases were systematically searched from January 1977 to April 2022. Only papers that were published in the English language and explored the ocular abnormalities in AS patients were selected. We manually searched reference lists of included papers for additional studies. Results. A total of 23 articles involving 195 patients were included in this review. The common ocular manifestations in AS patients are lenticonus, macular holes, fleck retinopathy, and thinning of the macula. Although published literature has described the use of cataract surgeries and vitrectomies as standard surgical techniques to alleviate ocular abnormalities in non-AS patients, it must be noted that surgical techniques have not been evaluated in a large research study as a solution for AS abnormalities. Another prospective treatment for AS is gene therapy through the reversion of causative COL4 variants to wild type or exon-skipping therapy for X-linked AS with COL4A5 truncating mutations. Gene therapy, however, remains unable to treat alterations that occur in the fetal and early development phase of the disease. Conclusions. The review found no definitive conclusions regarding the efficacy and safety of surgical techniques and gene therapy in AS patients. Recognition of ocular abnormalities through an ophthalmic examination with an optical coherence tomography (OCT) and slit-lamp examination is critical to the medical field, as ophthalmologists can aid nephrologists and other physicians in diagnosing AS. Early diagnosis and care can minimize the risk of detrimental ocular outcomes, such as blindness and retinal detachment.

Comparison of outcomes of idiopathic macular holes treated by vitrectomy with air or silicone oil tamponade based on the hole size

AIM

To compare the efficacy of vitrectomy combined with air or silicone oil in the treatment of idiopathic macular hole (IMH).

METHODS

According to the results of high-definition optical coherence tomography (HD-OCT), 75 cases (75 eyes) of IMH in stage II-IV (Gass stage) in the General Hospital of Chinese PLA from January 2017 to December 2019 were collected for this retrospective study. The best corrected visual acuity (BCVA) and minimum diameter of IMH (MMHD) were measured. Eyes underwent vitrectomy combined with internal limiting membrane peeling operation, and were divided into disinfection air group (30 eyes) and silicone oil group (45 eyes) according to the intraocular tamponade. For MMHD≤400 µm (MMHD1), there were 23 eyes in air group and 16 eyes in silicone oil group. For MMHD2>400 µm (MMHD2), there were 7 eyes in air group and 29 eyes in silicone oil group. One month after surgery, the closure rates of IMH and BCVA were compared and analyzed. According to HD-OCT, the closure shape was graded with A (bridge closure) and B (good closure).

RESULTS

The closure rates of air group and silicone oil group were 86.67% and 95.56% respectively with no significant difference (P>0.05); For MMHD1, those of air group and silicone oil group were 95.65% and 100% respectively with no significant difference (P>0.05); For MMHD2, those of air group and silicone oil group were 57.14% and 93.10% respectively, and those of the silicone oil group were higher than the air group (P<0.05). There was no significant difference in the closure shape grade between MMHD1 air group and silicone oil group (P>0.05). The proportion of Grade B in MMHD2 silicone oil group was higher than that in the air group (P<0.05). BCVA of each group after operation was better than that before operation, and there was no significant difference between air group and silicone oil group. While among them, MMHD1 air group was better than silicone oil group (P<0.05), and there was no significant difference between MMHD2 air group and silicone oil group (P>0.05).

CONCLUSION

For smaller IMH (≤400 µm), the efficacy of vitrectomy combined with air should be considered better than silicone oil; for larger IMH (>400 µm), the efficacy of silicone oil may be better than air.

Plasma Rich in Growth Factors in Macular Hole Surgery

The aim of this study was to evaluate the use of PRGF (plasma rich in growth factors) as an adjuvant to PPV (pars plana vitrectomy) in recurrent, persistent, or poor prognosis MH (macular hole). Patients with MH were treated with PPV plus adjuvant therapy (PRGF membrane (mPRGF) and injectable liquid PRGF (iPRGF)). The anatomical closure of MH and postoperative BCVA (best-corrected visual acuity) were evaluated. Eight eyes (eight patients) were evaluated: myopic MH (MMH, n = 4), idiopathic MH (IMH, n = 2), iatrogenic n = 1, traumatic n = 1. The mean age was 53.1 ± 19.3 years. Hence, 66.7% (n = 4) of patients previously had internal limiting membrane peeling. Five patients (62.5%) received mPRGF and iPRGF, and three patients (37.5%) received iPRGF. Gas tamponade (C3F8) was placed in seven cases and one case of silicone oil. Anatomic closure of MH was achieved in seven eyes (87.5%) and BCVA improved in six cases. In the MMH group, visual acuity improved in two lines of vision. Follow-up time was 27.2 ± 9.0 months. No adverse events or MH recurrences were recorded during follow-up. The use of PRGF as an adjuvant therapy to PPV can be useful to improve anatomical closure and visual acuity in MH surgery.

Displacement of the retina after idiopathic macular hole surgery with different internal limiting membrane peeling patterns

AIM

To explore retinal displacement after surgical treatment for idiopathic macular hole (IMH) with different internal limiting membrane (ILM) peeling patterns.

METHODS

Totally 22 eyes from 20 patients with IMH were randomly allocated into two groups, N-T group (11 eyes) and T-N group (11 eyes). For patients in N-T group, ILM was peeled off from nasal to temporal retina. For patients in T-N group, ILM was peeled off from temporal to nasal retina. Preoperative, postoperative 1, 3, and 6mo, autofluorescence fundus images were collected for manual measurement of distances of fixed nasal (N), temporal (T), superior (S), and inferior (I) retinal points (bifurcation or crossing of retinal vessels) around the macula to the optic disc (OD). These were respectively defined as N-OD, T-OD, S-OD, and I-OD. The retinal displacement, macular hole closure rate, and best corrected visual acuity (BCVA) were compared between the two groups after surgery.

RESULTS

At postoperative 1, 3, and 6mo, the macula slipped toward the OD, manifested by the decreased T-OD, N-OD, S-OD, and I-OD (P<0.05). No significant difference was found in the T-OD, N-OD, S-OD, and I-OD between N-T group and T-N group. IMH closure rate was 100% both in N-T group and T-N group. There was no significant difference in BCVA between two groups (P<0.05).

CONCLUSION

The macula slips toward the OD after successful macular hole surgery. The two different ILM peeling pattern show similar visual outcome and retinal displacement, which means ILM peeling directions are not the influencing factor of postoperative retinal displacement.

Anatomical and functional outcomes one year after vitrectomy and retinal massage for large macular holes

Purpose

The aim of this study was to report results of macular hole closure, visual benefit and longitudinal changes in foveal architecture over 1 year following macular hole surgery with retinal massage.

Methods

Records of patients with full thickness macular hole (FTMH) with minimum basal diameter of 550 μ who underwent vitrectomy, internal limiting membrane (ILM) peeling and retinal massage were drawn up. Retinal massage was performed after dye assisted ILM peeling, using a 27G flute needle with a long and soft silicone tip under air in a centripetal direction around the FTMH. At the end, 10% C₃F₈ gas was used as tamponade. The foveal contour at 1 year follow up was recorded based on its cross sectional appearance on OCT and was classified into U, V and irregular types of closure as previously described.

Results

Forty-one eyes of 41 patients with a mean age of 70.4 ± 6.9 years were included. The mean preoperative vision was 0.99 ± 0.07 logMAR and mean maximum basal diameter of the FTMH was 835 ± 208 μ. Macular hole closure was seen in all patients at 1-month follow up. The BCVA improved to 0.5 ± 0.1 log MAR at 6 months (P < 0.001) and then stabilized. The U shaped closure was the commonest pattern (n = 22, 54%), followed by V-shaped closure (n = 16, 39%) while irregular closure was seen in 3 eyes (7%).

Conclusion

Retinal massage after ILM peeling is a very simple, and as yet under-utilized manoeuvre that may improve hole closure rates and lead to potentially greater improvement in vision compared to existing techniques for large holes.

Intraoperative Observation of a Macular Holes Using Optical Coherence Tomography

PURPOSE

This study aimed to observe intraoperative changes in macular hole (MH) form using intraoperative optical coherence tomography (iOCT).

METHODS

A total of 10 eyes from 10 patients with MH who underwent vitrectomy using iOCT from May 2015 to October 2015 at the Yamagata University Hospital were retrospectively evaluated. Accordingly, 25-gauge pars plana vitrectomy using iOCT with internal limiting membrane (ILM) peeling and sulfur hexafluoride gas tamponade was performed on each patient. During surgery, MHs were observed using iOCT over four points, namely, before posterior vitreous detachment (PVD) formation, after PVD formation, after ILM peeling, and after fluid-gas exchange. Thereafter, basal MH diameter and minimum aperture MH diameter were postoperatively analyzed.

RESULTS

Before PVD formation, after PVD formation, after ILM peeling, and after fluid-gas exchange, the mean basal MH diameters were 690.7 ± 268.4, 683.3 ± 274.2, 683.7 ± 269.5, and 668.3 ± 261.4 μm, while the mean minimum aperture MH diameters were 278.3 ± 165.2, 283.0 ± 170.2, 257.0 ± 127.8, and 188.0 ± 105.0 μm, respectively. The mean minimum aperture MH diameter decreased significantly after fluid-gas exchange (one-way repeated measures ANOVA, p < 0.05). None of the patients exhibited intraoperative closure of the MHs. However, MH closure was confirmed in all patients after the surgery.

CONCLUSION

None of the patients demonstrated intraoperative MHs closure. Accordingly, the minimum aperture MH diameter was the first change formation to close after fluid-gas exchange.

Vital dyes in macular hole surgery

Currently, surgical techniques, such as internal limiting membrane peeling, are used widely for macular holes, macular puckers, epiretinal membranes, diabetic macular edema, retinal detachment, retinal vein occlusions, vitreomacular traction, optic pit maculopathy, and Terson syndrome. This study aimed to highlight any differences regarding visual acuity and ocular tomography coherence changes after staining the internal limiting membrane with dilutions of Brilliant Blue G vs. lutein/zeaxanthin-based dyes. This study involved 30 eyes of 30 patients who had undergone posterior pole vitrectomy for idiopathic stage 4 macular hole. The study lot was divided in two subgroups, 15 eyes colored with Brilliant Blue and the other 15 eyes colored with lutein and zeaxanthin dyes. The association between visual prognosis, ocular tomography coherence changes and intraocular pressure was analyzed. The surgical treatment with required endoillumination levels and a 2-min period of dye using the Alcon Constellation Vision System had no negative impact on cell viability and improved visual acuity by 30%. Staining makes it easier to remove, to be quick and precise while performing macular surgeries. In has been observed that lutein and zeaxanthin dyes offer an intraoperative protective screen that protects photoreceptors more than Brilliant Blue while performing pars plana vitrectomy. Both study groups had good results in time. Surgical visualization is an evolving technology.

Decreased expression of TIPE2 in the eye under high-glucose conditions tested in vivo and in vitro

AIMS

Inflammation is important in the development of angiogenesis diabetic retinopathy (DR). Anti-inflammation is promising strategy in early DR management. This study aimed to evaluate the level of tumour necrosis factor (TNF)-α-induced protein-8 like-2 (TIPE2), a formerly anti-inflammatory factor, under high-glucose conditions.

METHODS

TIPE2 was detected in the ① retina from db/db and streptozotocin-induced diabetic mice; ② vitreous fluid of patients with proliferative diabetic retinopathy (PDR) and ③ mouse retinal microendothelial cells (RMEC) cultured in glucose of varying concentrations. In situ expression was evaluated by immunohistochemistry and immunofluorescence assay. The expression of protein was analysed by Western blot or ELISA and mRNA by qRT-PCR.

RESULTS

TIPE2 was down-regulated in the retina of the mice with diabetes. TIPE2 was present in the cytoplasm of RMEC and down-regulated in high-glucose conditions in line with concentration and time. The expression of TIPE2 in the vitreous fluid of patients with PDR was significantly lower than that without diabetes. Silencing TIPE2 by an siRNA resulted in increased expression of vascular endothelial growth factor (a vital factor in the development of DR), TNF-α and IL-1β.

CONCLUSIONS

TIPE2 down-expressed and exerted anti-VEGF and anti-inflammatory function in the high-glucose environment. TIPE2 was verified to be involved in the process of DR and might be a potential regulator for DR development.

Retinal Fundus Multi-Disease Image Dataset (RFMiD): A Dataset for Multi-Disease Detection Research

The world faces difficulties in terms of eye care, including treatment, quality of prevention, vision rehabilitation services, and scarcity of trained eye care experts. Early detection and diagnosis of ocular pathologies would enable forestall of visual impairment. One challenge that limits the adoption of computer-aided diagnosis tool by ophthalmologists is the number of sight-threatening rare pathologies, such as central retinal artery occlusion or anterior ischemic optic neuropathy, and others are usually ignored. In the past two decades, many publicly available datasets of color fundus images have been collected with a primary focus on diabetic retinopathy, glaucoma, age-related macular degeneration and few other frequent pathologies. To enable development of methods for automatic ocular disease classification of frequent diseases along with the rare pathologies, we have created a new Retinal Fundus Multi-disease Image Dataset (RFMiD). It consists of 3200 fundus images captured using three different fundus cameras with 46 conditions annotated through adjudicated consensus of two senior retinal experts. To the best of our knowledge, our dataset, RFMiD, is the only publicly available dataset that constitutes such a wide variety of diseases that appear in routine clinical settings. This dataset will enable the development of generalizable models for retinal screening.

Macular Pigment in Eyes With Macular Hole Formation and Its Change After Surgery

Purpose

To observe the macular pigment (MP) appearances in eyes with macular hole (MH) and clarify the origin of the appearances. The mechanisms underlying the development of MH are discussed based on the observation of MP.

Methods

This observational case series included 33 eyes of 31 patients with MH who underwent vitrectomy. The MP optical density was measured using the two-wavelength fundus autofluorescence technique. The exact localization of MP was evaluated by comparing MP distribution images and optical coherent tomography B-scan images.

Results

MP was missing at the MH. The area of the MP defect corresponded with the area of the defect of outer plexiform layer. MP was present in the retinal flap in stage 2 MH that included glia (Müller cells) and plexiform layers and in the operculum in stage 3 MH, which mainly comprised Müller cells. Cystic spaces in the outer plexiform layer surrounding stage 3 and 4 MHs showed a honeycomb appearance on MP images. MP reappeared to form an irregularly shaped pigment plane after surgical closure of MH. The MP optical volume did not change before and after surgery. Fellow eyes with a central dip in MP distribution subsequently developed MH.

Conclusions

The characteristic appearances of MP at the MH were attributed to MP in the plexiform layers and Müller cell cones. A central dip of MP distribution might be a sign of Müller cell cone damage that proceeds with MH formation.

Translational Relevance

Observation of MP was useful for understanding the mechanisms of MH formation.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Internal limiting membrane dragging and peeling: a modified technique for macular holes closure surgery

AIM

To introduce a modified technique of internal limiting membrane (ILM) centripetal dragging and peeling to treat idiopathic macular hole (IMH) and to observe the ILM-retina adhesive forces.

METHODS

Twenty-six consecutive patients with stage 3 to 4 IMH and followed up at least six months were enrolled. All patients underwent complete par plana vitrectomy, ILM dragging and peeling, fluid and gas exchange, 15% C₃F₈ tamponade and 2-week prone position. The best corrected visual acuity, macular hole evaluation by optical coherence tomography, and complications were evaluated.

RESULTS

The mean diameter of IMH was 524±148 µm (range: 201-683 µm), with 21 cases (80.8%) greater than 400 µm. ILM dragging and peeling were successfully performed in all cases. Most of the ILM-retina adhesive forces are severe (42.3%, 11/26), followed by mild (38.5%, 10/26), and moderate (19.2%, 5/26). The mean follow-up duration was 21.2±6.1mo. The IMH was closed in 25 (96.3%) eyes. Visual acuity (logMAR) improved significantly from 1.2±0.6 preoperatively to 0.7±0.5 postoperatively (P<0.001).

CONCLUSION

Preexisting ILM-retina adhesive force is found in IMH patients. With assistance of this force, this modified technique may help to release the IMH edges and improve the closure rate of large IMH.