Efficacy of inverted inner limiting membrane flap technique for macular holes of ≤400 μm: A systematic review and meta-analysis

PURPOSE

To evaluate the efficacy of inverted internal limiting membrane (ILM) flap technique in full-thickness macular holes (MHs) with a size of ≤400 μm compared to the ILM peeling technique.

METHODS

Related literatures that compared inverted ILM flap and ILM peeling in MHs ≤ 400 μm were reviewed by searching electronic databases including Pubmed, EMbase, ClinicalTrials.gov, and Cochrane Library up to April 2023. The primary outcome measure was hole closure rate, and the secondary outcome measures were the mean postoperative best-corrected visual acuity (BCVA), retinal sensitivity, and outer status of the retinal layers, including the external limiting membrane and ellipsoid zone. The quality of the articles was assessed according to the revised version of the Cochrane risk-of-bias tool for randomized trials or the Newcastle-Ottawa scale. In the case of heterogeneity, a sensitivity analysis was conducted, and publication bias was visually evaluated using a funnel plot.

RESULTS

This review included six studies with 610 eyes for the primary outcome and 385 eyes for the secondary outcomes, which were two randomized control trials and four retrospective studies. Pooled data revealed that the overall MH closure rate was 99.4% in the inverted ILM flap group and 96.2% in the ILM peeling group, without significant difference between the two groups (odds ratio = 3.91; 95% confidence interval, 0.82~18.69; P = 0.09). The inverted ILM flap technique did not have a favorable effect on the BCVA, retinal sensitivity, or recovery of the outer retinal layers. These results were consistent with those of the subgroup analysis of the different follow-up periods. No significant publication bias was observed.

CONCLUSION

In eyes with MHs of ≤400 μm, both techniques demonstrated excellent surgical outcomes without significant differences. Therefore, surgical techniques can be selected according to surgeon preferences.

Macular hole surgery follow-up with spectral domain-optical coherence tomography-guided facedown posturing

PURPOSE

The main treatment for macular hole (MH) is pars plana vitrectomy, with or without internal limiting membrane (ILM) peeling, followed by gas tamponade and face-down positioning (FDP). This study aims to present the anatomical and visual outcomes following MH repair with optical coherence tomography (OCT)-guided FDP.

METHODS

Thirty-two patients who underwent surgery for idiopathic MH were enrolled. The requirement for the prone position was lifted for those with MH closure observed under gas on postoperative day one OCT. Patients with unclosed MHs were instructed to maintain FDP until the 3rd day. Best-corrected visual acuity at preoperative, postoperative 1st month, and the last visit, closure time post-surgery, duration of prone position, and surgical success rate were recorded.

RESULTS

Among the patients, 21 underwent phacovitrectomy + ILM peeling + gas tamponade, while 11 had vitrectomy + ILM peeling + gas tamponade. On postoperative day one, 28 out of 32 MHs closed, with 3 closures on day 3 and one on day 5. There were 18 stage two (56.3%), 13 stage three (40.6%) and 1 stage four (3.1%) MHs. The mean minimum MH diameter was 381.75 ± 68.07 (min 260-max 517) microns. All patients with MH closure time over postoperative day one had non-combined vitrectomy instead of phacovitrectomy. No late complications were observed.

CONCLUSIONS

OCT-guided FDP approach yields excellent closure rates with no late complications and ensures good patient comfort.

Face-down positioning or posturing after macular hole surgery

BACKGROUND

Macular holes cause severe impairment of sight. With the aim of improving the outcome of surgery for macular holes, particularly larger macular holes (those measuring over 400 μm), a variable period of face-down positioning may be advised. This review is an update of a Cochrane Review published in 2011.

OBJECTIVES

To evaluate the effect of postoperative face-down positioning on the outcome of surgery for macular hole.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 5), which contains the Cochrane Eyes and Vision Trials Register, Ovid MEDLINE, Ovid Embase, the ISRCTN registry, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform. There were no date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 25 May 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which postoperative face-down positioning was compared to no face-down positioning following surgery for macular holes. The primary outcome of interest was closure of the macular hole. Other outcomes of interest included visual outcomes, quality of life outcomes, and the occurrence of adverse events. Pairs of review authors independently selected studies for inclusion, extracted data, assessed risk of bias, and evaluated the certainty of evidence using GRADE.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We analysed dichotomous data as risk ratios (RRs), and continuous data as mean differences (MDs), with 95% confidence intervals (CI). The unit of analysis was eyes.

MAIN RESULTS

We included eight studies allocating a total of 709 eyes (699 participants). There was heterogeneity in study design, including the control group treatment (from no positioning to strict maintenance of other 'face-forward' postures) and surgical procedures (with or without inner limiting membrane peeling, with or without cataract surgery). There were also different durations of positioning, with two studies using 3 days, two studies using 5 days, and three studies using 10 days of face-down positioning. Whilst the overall risk of bias was low, all included studies were judged to be at high or unclear risk of bias due to absence of assessment of adherence to the 'prescribed' intervention of face-down positioning or posturing. The primary outcome of successful anatomical hole closure at one to six months following surgery was reported in 95 of every 100 eyes of participants advised to position face-down for at least three days after surgery, and in 85 of every 100 eyes of participants not advised to position face-down (RR 1.05, 95% CI 0.99 to 1.12, 709 eyes, 8 studies, I² = 44%). Amongst the 327 eyes of participants with macular holes of at least 400 μm, hole closure was noted in 94 of every 100 eyes of participants advised to position face-down, and in 84 of every 100 eyes of participants not advised to position face-down (RR 1.08, 95% CI 0.93 to 1.26, 5 studies, I² = 62%). Amongst the 129 eyes of participants with macular holes of less than 400 μm, hole closure was noted in 100 of every 100 eyes of participants advised to position face-down, and in 96 of every 100 eyes of participants not advised to position face-down (RR 1.03, CI 0.97 to 1.11, 4 studies, I² = 0%). The certainty of the evidence was low, downgraded for imprecision (CIs including no effect) and study design limitations (with different durations of face-down posturing used in the absence of a dose-response gradient, and limitations in measuring the exposure). Meta-analysis of visual acuity data was challenging given the use of different definitions of postoperative visual outcome across studies. Three studies reported findings by gain in Early Treatment Diabetic Retinopathy Study (ETDRS) letters (MD 2.04, 95% CI -0.01 to 4.09, very low-certainty evidence). Meta-analyses of quality of life data were not possible because of inconsistency in outcome metrics across studies. One study reported no difference between groups in quality of life, as reported on a validated quality of life metric scale (the National Eye Institute Visual Function Questionnaire - 25 (NEI VFQ-25), between face-down positioning for five days and non-face-down positioning (median NEI VFQ-25 score was 89 (interquartile range (IQR) 76 to 94) in the face-down group versus 87 (IQR 73 to 93) in the non-face-down group (adjusted mean difference on a logistic scale 0.02, 95% CI -0.03 to 0.07, P = 0.41)). Two studies reported increased ease of positioning and less pain in non-face-down positioning groups on non-validated 0-to-10-point visual analogue scores. On an ease-of-positioning score running from 0 (very difficult) to 10 (very easy), there were consistent reports of the discomfort associated with face-down positioning: the median participant-reported ease-of-positioning score was 6 (IQR 4 to 8) in those undergoing 5 days of face-down positioning versus 9 (IQR 7 to 10) in the comparator group (P = 0.01). On a pain score with 0 being pain-free and 10 being in severe pain, mean pain score was 6.52 ± 2.48 in the face-down positioning group versus 2.53 ± 2.6 in the non-face-down positioning group. The adverse event of postoperative nerve compression occurred in less than 1 in every 100 (3 per 1000) participants advised to position face-down, and 0 in every 100 participants not advised to position face-down (699 participants, 8 studies, moderate-certainty evidence).

AUTHORS' CONCLUSIONS

We identified eight RCTs evaluating face-down positioning following surgery for macular hole. The included studies were not all directly comparable due to differences in the surgical techniques used and the durations of postoperative positioning advised. Low-certainty evidence suggests that face-down positioning may have little or no effect on macular hole closure after surgery. Face-down positioning is a low-risk intervention, with serious adverse events affecting fewer than 1 in 300 people. We suggest that any future trials focus on patients with larger macular holes, with interventions and outcome measures used in previous trials (i.e. with inner limiting membrane peeling, positioning durations of three to five days, and validated quality of life metrics) to allow future meta-analyses to determine any effect with greater precision and confidence.

Vitrectomy with sulfur hexafluoride versus air tamponade for idiopathic macular hole: a retrospective study

BACKGROUND

To evaluate the effect of room air and sulfur hexafluoride (SF6) gas in idiopathic macular hole(MH)surgery.

METHODS

Retrospective, interventional, and comparative study. 238 eyes with the idiopathic macular hole that underwent pars plana vitrectomy, internal limiting membrane peeling, fluid-air exchange, and 20% SF6 (SF6 group:125 eyes) or room air tamponade (air group: 113 eyes) were reviewed. The primary outcome measure was the closure rate of primary surgery.

RESULTS

The baseline characteristics of the SF6 group and air group were comparable except for the hole size (479.90 ± 204.48 vs. 429.38 ± 174.63 μm, P = 0.043). The anatomical closure rate was 92.8% (116 / 125) with the SF6 group and 76.1% (86 / 113) with the air group (P < 0.001). A cut-off value of MH size to predict primary anatomical closure was 520 μm, which is based on the lower limit of 95% confidential interval of the MH size among the unclosed patients in the air group. There was no significant difference in anatomical closure rates between SF6 and air group (98.7% vs. 91.9%, P = 0.051) for MH ≤ 520 μm, whereas a significantly lower anatomical closure rate was shown in the air group than SF6 group (46.2% vs. 84.0%, P < 0.001) for MH > 520 μm.

CONCLUSION

SF6 exhibited more effectiveness than air to achieve a good anatomical outcome for its longer tamponade when MH > 520 μm.

Surgical classification for large macular hole: based on different surgical techniques results: the CLOSE study group

BACKGROUND

The CLOSE study group proposes an updated surgical classification for large macular holes based on a systematic review of new treatments. Recently, many new techniques have been introduced to treat large full-thickness macular holes (FTMH); although the indications are not clear. An updated surgical classification is needed to help surgical decision-making.

METHODS

We gathered published series by the CLOSE Study Group members and from literature search until June 2021. Techniques included: internal limiting membrane peeling (ILM peeling), ILM flaps, macular hydrodissection (macular hydro), human amniotic membrane graft (hAM), and autologous retinal transplantation (ART). Within each technique, chi-square test assessed association between the minimal linear diameter (MLD) (in µm) and closure rate; the postoperative best-corrected visual acuity (BCVA) gains were compared among groups.

RESULTS

Data extraction included 31 published articles: total of 1135 eyes. Eyes were divided into the following groups: ILM peel (n: 683), ILM Flap (n: 233), macular hydrodissection (n: 64), hAM (n: 59), and ART (n: 96). The initial BCVA and size were heterogenous between the groups. ILM peel showed the best results in large FTMH ≤ 535 µm (closure rate 96.8%); adjusted mean BCVA: 0.49 (LogMAR) with a statistical difference among groups. Large FTMH between 535 and 799 µm: ILM flap technique showed better results (closure rate 99.0%); adjusted mean BCVA: 0.67(LogMAR); also with a statistical difference. For large FTMH ≥ 800 µm more invasive techniques are required. Use of hAM, macular hydrodissection and ART showed higher closure rates for this category (100%, 83.3% and 90.5% respectively), and adjusted mean BCVA varied from 0.76 to 0.89. Although there was no statistical difference between those techniques for this group due to the smaller number of cases.

CONCLUSIONS

The CLOSE study group demonstrated the potential usefulness of a new surgical classification for large FTMHs and propose OCT biomarkers for use in clinical practice and future research. This new classification demonstrated that Large (400-550 µm) and X-Large (550-800 µm) holes can be treated highly successfully with ILM peel and ILM flap techniques, respectively. Further studies are necessary for the larger FTMHs (XX-Large and Giant), using the CLOSE classification, in order to determine which technique is better suited for each hole size and characteristics.

Internal Limiting Membrane Peeling and Gas Tamponade For Full-Thickness Macular Holes of Different Etiology - Is It Still Relevant?

Background

Despite the abundance of novel surgical approaches proposed for full thickness macular hole (FTMH) treatment, the choice of the optimal technique remains debatable Vitrectomy with «classic» internal limiting membrane peeling and gas tamponade remains the standard of FTMH surgery in many cases, but there are still very limited recent publications on the outcomes of such surgery.

Purpose

To investigate the anatomical and functional result and to analyze the significance of outcome-related risk factors of the classic 25-gauge pars plana vitrectomy (PPV) with ILM peeling and gas tamponade (GT) for treatment of FTMH of different etiology.

Patients and methods

Thirty-eight eyes of thirty-seven patients with FTMH who underwent 25-gauge PPV, ILM peeling and GT were recruited for this retrospective, consecutive, interventional study. Four eyes with persistent holes underwent a re-operation. Outcome-related factors were discussed.

Results

The primary closure rate was 89.5% (34/38). All eyes that underwent the repeated surgery (4 cases) obtained final closure. A hole size of >500 μm has a statistically significant effect on the primary macular hole closure (F = 0.048; φ = 0.38; p ˂ 0.05). In the general group (N = 38), the duration of symptoms directly correlated with age (ρ = 0.34; p = 0.04), size of the hole (ρ = 0.66; p ˂ 0.001) and BCVA before surgery (ρ = 0.59; p ˂ 0.001), after 1 month (ρ = 0.36; p = 0.03), and after 3 months (ρ = 0.35; p = 0.03). Preoperative BCVA was better in initially closed cases (Group 1) (U = 26.0; p = 0.05). In the Group 2 with primary unclosed holes, 75% of the eyes (3/4) had an axial length (AL) >26 mm, while in Group 1 such eyes were 12.5 times less (2/34) 5.9% (F = 0.004; φ = 0.63; р ˂ 0.01). The ELM recovery rate at 3 months was 92% (35/38 eyes) and the restoration of EZ at 3 months was 47% (18/38 eyes). Best-corrected visual acuity of all individuals improved significantly from 0.72 ± 0.35 (logMAR) (Me = 0.7; IQR: 0.5-0.8) to 0.25±0.14 (logMAR) (Me = 0.2; IQR: 0.2 - 0.3) at 1 month and 0.17 ± 0.13 (logMAR) (Me = 0.2; IQR: 0.1 - 0.2) at 3 months after surgery (P = 0.0001).

Conclusion

25G PPV with ILM and GT for FTMH of different etiology provide satisfactory morphologic and functional outcomes. Elongated AL, large diameter of MH and long duration of symptoms are the risk factors for initial closure. Proper second surgery can obtain satisfactory outcomes for persistent holes.

Non-vasogenic cystoid maculopathies

Besides cystoid macular edema due to a blood-retinal barrier breakdown, another type of macular cystoid spaces referred to as non-vasogenic cystoid maculopathies (NVCM) may be detected on optical coherence tomography but not on fluorescein angiography. Various causes may disrupt retinal cell cohesion or impair retinal pigment epithelium (RPE) and Müller cell functions in the maintenance of retinal dehydration, resulting in cystoid spaces formation. Tractional causes include vitreomacular traction, epiretinal membranes and myopic foveoschisis. Surgical treatment does not always allow cystoid space resorption. In inherited retinal dystrophies, cystoid spaces may be part of the disease as in X-linked retinoschisis or enhanced S-cone syndrome, or occur occasionally as in bestrophinopathies, retinitis pigmentosa and allied diseases, congenital microphthalmia, choroideremia, gyrate atrophy and Bietti crystalline dystrophy. In macular telangiectasia type 2, cystoid spaces and cavitations do not depend on the fluid leakage from telangiectasia. Various causes affecting RPE function may result in NVCM such as chronic central serous chorioretinopathy and paraneoplastic syndromes. Non-exudative age macular degeneration may also be complicated by intraretinal cystoid spaces in the absence of fluorescein leakage. In these diseases, cystoid spaces occur in a context of retinal cell loss. Various causes of optic atrophy, including open-angle glaucoma, result in microcystoid spaces in the inner nuclear layer due to a retrograde transsynaptic degeneration. Lastly, drug toxicity may also induce cystoid maculopathy. Identifying NVCM on multimodal imaging, including fluorescein angiography if needed, allows guiding the diagnosis of the causative disease and choosing adequate treatment when available.

A Comparison of Face-Down Positioning and Adjustable Positioning After Pars Plana Vitrectomy for Macular Hole Retinal Detachment in High Myopia

Purpose

To compare the anatomical and functional outcomes of macular hole retinal detachment (MHRD) in high myopia after pars plana vitrectomy (PPV) with face-down positioning and adjustable positioning.

Methods

Fifty-three eyes from 53 patients with MHRD were analyzed in this study. All patients received PPV with silicon oil for tamponade and then subdivided into 2 groups: 28 were included in a face-down positioning group and 25 were included in the adjustable positioning group. Patients were followed up for at least 6 months. The main outcome was the rate of anatomical macular hole (MH) closure and retinal reattachment. Secondary outcome measures were the best-corrected visual acuity and postoperative complications.

Results

There was no significant difference in the rate of MH closure (53.6 vs. 72.0%, p = 0.167) and retinal reattachment (100 vs. 96%, p = 0.472) between the face-down group and adjustable group. Compared with the mean preoperative best-corrected visual acuity (BCVA), the mean postoperative BCVA at the 6-month follow-up improved significantly in both groups (p = 0, both). But there was no significant difference in the mean postoperative BCVA (p = 0.102) and mean BCVA improvement (p = 0.554) at 6 months after surgery between the two groups. There was no significant difference in the high intraocular pressure (IOP) after surgery between the two groups (53.6 vs. 44%, p = 0.487). There were no other complications that occurred during the follow-up.

Conclusion

Adjustable positioning after PPV with silicon oil tamponade for MHRD repair is effective and safe. Face-down positioning does not seem to be necessary for all patients with MHRD.

Effects of refractive accommodation on subfoveal choroidal thickness in silicone oil-filled eyes

Purpose

To investigate the effects of refractive accommodation on subfoveal choroidal thickness (SFCT) in silicone oil (SO)-filled eyes.

Methods

This retrospective, self-comparative study was conducted on 40 patients with unilateral macula-on rhegmatogenous retinal detachment, who underwent vitrectomy and SO tamponade. The SFCT of SO-filled eyes and the fellow control eyes were measured using optical coherence tomography at their one-month visit after surgery. The patients wore soft contact positive lenses for 24 h in the SO-filled eyes, to correct their refractive error. SFCT and choroidal vascularity index (CVI) were measured before and after wearing the contact lenses. Mean SFCT was compared between SO-filled eyes and the fellow control eyes, and SFCT and CVI were compared before and after refractive error correction in the SO-filled eyes.

Results

Mean SFCT of SO-filled eyes (221.52 ± 38.41 um) was less than that of the fellow eyes (273.41 ± 31.30 um) (P < 0.001). After refractive error correction, the mean SFCT increased to 269.28 ± 36.90 um(P < 0.001). However, CVI decreased from 57.01 ± 2.41 to 55.39 ± 2.39 (P < 0.05).

Conclusions

SFCT reduction in SO-filled eyes was primarily due to the hyperopia status. The non-uniform change in CVI suggests that changes in CT are mainly attributed to a greater expansion of the stromal area instead of the choroidal vascular area.

Trial registration

This study protocol was reviewed and approved by the Ethics Committee of the Central Theater General Hospital, approval number No. [2020]058–1, retrospectively registered.

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.

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.

Retinal applications of swept source optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA)

The advent of optical coherence tomography (OCT) revolutionized both clinical assessment and research of vitreoretinal conditions. Since then, extraordinary advances have been made in this imaging technology, including the relatively recent development of swept-source OCT (SS-OCT). SS-OCT enables a fast scan rate and utilizes a tunable swept laser, thus enabling the incorporation of longer wavelengths than conventional spectral-domain devices. These features enable imaging of larger areas with reduced motion artifact, and a better visualization of the choroidal vasculature, respectively. Building on the principles of OCT, swept-source OCT has also been applied to OCT angiography (SS-OCTA), thus enabling a non-invasive in depth-resolved imaging of the retinal and choroidal microvasculature. Despite their advantages, the widespread use of SS-OCT and SS-OCTA remains relatively limited. In this review, we summarize the technical details, advantages and limitations of SS-OCT and SS-OCTA, with a particular emphasis on their relevance for the study of retinal conditions. Additionally, we comprehensively review relevant studies performed to date to the study of retinal health and disease, and highlight current gaps in knowledge and opportunities to take advantage of swept source technology to improve our current understanding of many medical and surgical chorioretinal conditions. We anticipate that SS-OCT and SS-OCTA will continue to evolve rapidly, contributing to a paradigm shift to more widespread adoption of new imaging technology to clinical practice.

Surgical Treatment of Idiopathic Macular Hole Using Different Types of Tamponades and Different Postoperative Positioning Regimens

Purpose

To compare the effect of different types of intraocular tamponade and different types of postoperative positioning on the closure of idiopathic macular hole (IMH).

Methods

Prospective randomized clinical trial enrolling 104 eyes of 100 patients (age, 57–87 years) undergoing MH surgery. All patients were operated on by an experienced surgeon using 25-gauge pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peeling. Patients were randomized according to the type of intraocular tamponade and postoperative positioning into the following four groups: SF6 + nonsupine reading position (n = 26) (group 1), air + nonsupine reading position (n = 25) (group 2), air + prone position (n = 26) (group 3), or SF6 + prone position (n = 27) (group 4). The follow-up period was 6 months.

Results

MH closure was achieved in 87 eyes (83.7 %) in the overall sample after the first surgery, with closure rates of 100%, 56%, 84.6%, and 92.6% in groups 1, 2, 3, and 4, respectively. The group 2 was significantly less successful compared to the other three groups (p < 0.05). MH of sizes ≤400 µm was closed in 97.2% of cases after the first surgery, with no significant differences between groups (p = 0.219). MH with sizes over 400 µm was closed in 70.9% of cases after the first surgery, with both groups with air tamponade being significantly less successful than group 1. The nonsupine reading position was subjected to a better subjective evaluation in terms of postoperative comfort and quality of sleep, with no differences between air and SF6 tamponade tolerance.

Conclusion

PPV with ILM peeling, intraocular tamponade, and positioning remains the basic surgical approach in the treatment of IMH. For MH ≤ 400 µm, a high closure rate can be achieved by combining air tamponade and nonsupine reading position. For macular holes >400 µm, the greatest anatomical success can be achieved by using the SF6 tamponade in combination with the nonsupine reading position.

Macular hole surgery recovery with and without face-down posturing: a meta-analysis of randomized controlled trials

Background

After pars plana vitrectomy with internal limiting membrane (ILM) peeling and gas tamponade, patients are often required to remain in a face-down position (FDP) to allow the gas bubble to push against the macular hole (MH) to promote hole closure. However, this position may be uncomfortable and inconvenient for the elderly and those with medical comorbidities; it may also lead to certain postoperative complications. Hence, this study aimed to evaluate and compare the effect of postoperative FDP and non-face-down position (nFDP) on the closure rate of MHs following MH surgery.

Methods

Randomized controlled trials (RCTs) were selected through an electronic search of the Cochrane Library, Pubmed, and Embase databases. Trial eligibility and risk of bias were assessed according to Cochrane review methods. The primary measures included overall MH closure rate and subgroup analysis based on MH size. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. Statistical analysis was performed using RevMan 5.0 software and Stata software 15.0.

Results

Five RCTs composed of a total of 183 eyes in the FDP group and 175 eyes in the nFDP group were included in this meta-analysis. Statistical meta-analysis revealed that the overall MH closure rate in the FDP group was significantly higher than that in the nFDP group (OR = 2.27, 95% CI: 1.02 to 5.05, P = 0.04). For MH sizes smaller than 400 μm, the subgroup meta-analysis indicated that the closure rate of the FDP group was not significantly higher than that of the nFDP group (OR = 1.32, 95% CI: 0.39 to 4.49, P = 0.66). However, when MH size was larger than 400 μm, there was a significantly higher closure rate in the FDP group (OR = 2.95, 95% CI: 1.10 to 7.94, P = 0.03).

Conclusions

Our results provide evidence that a face-down postoperative position seems to be unnecessary when MHs are smaller than 400 μm but may be highly recommended for MHs larger than 400 μm. Further RCTs with large sample sizes are warranted to validate these findings in future.

Pathogenesis and Management of Macular Hole: Review of Current Advances

Macular hole has been believed to be a disorder of vitreomacular interface, which forms as a result of abnormal vitreous traction from incomplete vitreous detachment. However, our recent studies demonstrated that dynamic forces, caused by mobile posterior cortical vitreous with fluid currents, exist already at early stages of macular hole development. Therefore, in eyes with flexible vitreous, the contributions of tractional forces due to vitreous shrinkage are unlikely. These facts indicate that in the development of idiopathic macular holes, there is a greater contribution of dynamic forces than has been previously reported. This review also evaluates the recent findings in the assessment of the idiopathic macular holes and the recent therapeutic strategies for optimal management. Inner limiting membrane is considered to improve anatomical closure rate; however, it is still questionable if peeling is necessary in holes less than 250 µm. There are plenty of publications indicating that in the management of small and medium size hole (less than 400 µm), use of long-lasting gas and face-down position is not always required; however, it may be necessary for the treatment of large holes. Ocriplasmin and expansile gas had been reported to be successful for management of small- and medium-sized holes and vitreomacular attachment.

Sulfur Hexafluoride (SF6) versus Perfluoropropane (C3F8) in the Intraoperative Management of Macular Holes: A Systematic Review and Meta-Analysis

Purpose

A systematic literature search was conducted to identify and review studies comparing SF₆ to C₃F₈ as a tamponade agent in the intraoperative management of macular holes.

Methods

Publications up to October 2018 that focused on macular hole surgery in terms of primary closure, complications, and clinical outcomes were included. Forest plots were created using a weighted summary of proportion meta-analysis. Analysis was performed separately for SF₆ and C₃F₈. A random effects model was used, and corresponding I² heterogeneity estimates were calculated.

Results

Nine pertinent publications studying a total of 4,715 patients were identified in 2000 to 2017, including two randomized studies (n=206), two prospective studies (n=170), and five retrospective or registry-based studies. Similar rates of closure between SF₆ and C₃F₈ were reported in eight out of nine studies, regardless of subgroup analyses. All studies reporting visual outcomes showed similar results when comparing SF₆ to C₃F₈ at one to six months of follow-up. Neither agent was clearly associated with increased risk of ocular hypertension, cataract formation, or other adverse events. Meta-analytic pooling of the closure rates in the SF₆ group resulted in 91.73% (95% confidence interval: 88.40 to 94.55, I²: 38.03%), and for C₃F₈, the closure rate was 88.36% (95% confidence interval: 85.88 to 90.63, I²: 0.0%).

Conclusions

Both SF₆ and C₃F₈ appear to have achieved similar visual outcomes and primary closure rates and neither was associated with an increased risk of adverse events. Considering the more rapid visual recovery with SF₆, there appears to be no evidence to support C₃F₈ as the tamponade agent of choice for macular hole surgery.

Nonsupine Positioning after Macular Hole Surgery: A Prospective Multicenter Study

PURPOSE

To evaluate the postoperative closure rate of full-thickness macular holes (MHs) after nonsupine positioning, which means that the patients avoid upward gaze and a supine sleeping position, and to investigate the correlation between postoperative positioning compliance and closure rate.

DESIGN

Prospective, multicenter study (ClinicalTrials.gov identifier, NCT02295943).

PARTICIPANTS

Patients undergoing primary surgery for primary MH.

METHODS

Patients underwent pars plana vitrectomy with internal limiting membrane peeling and sulfur hexafluoride gas tamponade followed by 3 to 5 days of nonsupine positioning. A positioning measuring device that recorded the time spent in the supine position was attached to patients' forehead after surgery for 24 hours.

MAIN OUTCOME MEASURES

Anatomic closure rate of MH at 2 weeks or more after surgery and the time spent in supine position during the first 24 hours after surgery.

RESULTS

A total of 205 participants were included, of whom 2 were lost to follow-up. Two hundred two of 203 MHs closed after a single operation, giving a closure rate of 99.5% (95% confidence interval, 97.3%-99.9%). The median time of supine positioning during the first 24 hours was 28 seconds (range, 0:00:00-01:52:28). Because of the very high closure rate, a correlation between positioning compliance and closure rate could not be established.

CONCLUSIONS

Pars plana vitrectomy with internal limiting membrane peeling followed by a short-term nonsupine positioning accomplished a very high MH closure rate. Thus, face-down positioning was not necessary to achieve excellent closure rates in this study.

AIR TAMPONADE COMBINED WITH NONSUPINE POSITIONING IN MACULAR HOLE SURGERY FOR PSEUDOPHAKIC EYES

PURPOSE

To investigate the closure rate of primary full-thickness macular hole, following intraocular air tamponade combined with a nonsupine positioning regimen.

METHODS

A prospective study of patients with full-thickness macular hole, who underwent pars plana vitrectomy with internal limiting membrane peeling and intraocular air tamponade followed by 3 days of nonsupine positioning. Outcome measures were primary full-thickness macular hole closure and improvement in best-corrected visual acuity after 6 months.

RESULTS

A total of 34 eyes were included. In the group of full-thickness macular hole ≤400 μm, primary closure occurred in 95% (19/20), whereas only 57% (8/14) of those >400 μm closed (P = 0.01). The mean gain in best-corrected visual acuity was 3.5 ETDRS (Early Treatment Diabetic Retinopathy Study) lines (SD = 1.5) (P < 0.01). The air bubble meniscus height at the first postoperative day was estimated to a mean of 59% (range, 50-70%), at the second postoperative day it was 46% (range, 40-55%), and the third day it was 39% (range, 30-45%). Mean intraocular air bubble duration was 10 days (range, 8-13 days).

CONCLUSION

The combination of air tamponade and nonsupine positioning regimen leads to high closure rates for small/medium macular holes (≤400 μm), but not for large macular holes (>400 μm).

Changes in the size of the foveal avascular zone after vitrectomy with internal limiting membrane peeling for a macular hole

PURPOSE

To determine the size of the foveal avascular zone (FAZ) before and after vitrectomy for a macular hole (MH).

STUDY DESIGN

Retrospective case series study.

METHODS

Twenty-five eyes of 25 patients with a unilateral MH that had undergone vitrectomy with internal limiting membrane peeling were studied. The unaffected 17 fellow eyes were studied in the same way. En face images of the parafoveal region were obtained by optical coherence tomography angiography, and the images were used to measure the FAZ before and 1 month after the vitrectomy. The relationships between the different FAZ sizes and the ocular parameters were determined by Pearson product moment correlation analysis.

RESULTS

Compared with the preoperative superficial FAZ (sFAZ), the postoperative sFAZ was significantly reduced (P < 0.001). The postoperative sFAZ was significantly smaller than that of the fellow eye (P < 0.001). The size of the postoperative sFAZ was significantly correlated with that of the preoperative sFAZ, the postoperative foveal thickness (FT), and the sFAZ of the fellow eyes (r = 0.520, P = 0.008; r = -0.515, P = 0.012; and r = 0.702, P = 0.002, respectively). The size of the postoperative deep FAZ (dFAZ) was significantly correlated with the postoperative FT and the dFAZ of the fellow eyes (r = -0.441, P = 0.035; and r = 0.499, P = 0.049, respectively). However, no significant correlation was found between the size of the postoperative FAZ and the size of the preoperative MH.

CONCLUSIONS

MH closure leads to a significant decrease in the size of the FAZ symmetrical to the size of the fellow eye. The size of the postoperative FAZ is influenced by the postoperative FT independently of the size of the MH.

Minification of fundus optical coherence tomographic images in gas-filled eye

BACKGROUND

Optical coherence tomography (OCT) is being used increasingly to evaluate and manage a variety of retinal diseases, but not much is known about the minification of the OCT images in gas-filled eyes. The purpose of this study was to investigate the effect of gas-filled eyes on the size of the OCT images.

METHODS

This was retrospective case series of 81 consecutive eyes of 79 patients who had macular hole surgery between April 2012 and September 2014. Images of the optic disc were taken with a spectral domain-OCT instrument 2 days after surgery in gas-filled, pseudophakic eyes and from the same eyes but fluid-filled one month after the surgery. The vertical length, horizontal width, and the area of the optic disc were measured in the OCT images.

RESULTS

Clear images were obtained from 50 eyes of 49 patients (mean age 66.4 ± 5.9 years). The mean vertical length and mean horizontal width of the optic disc in the gas-filled eyes were about 25 % shorter than that of fluid-filled eyes (vertical, 1213.8 ± 170.5 and 1650.6 ± 195.9 μm, P < 0.01; horizontal, 1169.4 ± 143.1 and 1526.4 ± 219.9 μm, P < 0.01). The mean area of the optic disc was 1.12 ± 0.34 mm(2) in gas-filled eyes which was significantly smaller than that in fluid-filled eyes (1.88 ± 0.37 mm(2)) by 40.4 %.

CONCLUSIONS

The fundus images of gas-filled eyes are significantly smaller than that in the same fluid-filled eyes. The minification of the OCT images should be considered when analyzing images obtained from gas-filled eyes.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

UMIN000007517 . Date of registration: 3/21/2012.