Postoperative anatomical and functional outcomes of different stages of high myopia macular hole

Biofeedback Training after Successful Inverted Internal Limiting Membrane (ILM)-Flap Technique for High Myopic Macular Hole

BACKGROUND

Microperimetric biofeedback training improved visual acuity and fixation stability in patients who previously underwent macular surgery. We aimed to compare the functional results of biofeedback training with the standard of care in patients who underwent successful inverted Internal Limiting Membrane (ILM)-flap technique for high myopic macular holes (hMMH).

METHODS

This was a retrospective, comparative, cohort study. Patients with hMMH after surgical hole closure underwent microperimetric biofeedback using structured light stimulus plus acoustic tone (n = 12; Biofeedback) or standard of care with scheduled visits (n = 11; Control). Best-corrected visual acuity, retinal sensitivity at central 12° (RS) and 4° (CRS) with a mean deviation at central 12° (MD), and fixation stability as bivariate contour ellipse area (BCEA 68%, 95%, and 99%) were assessed at baseline and month 1, 3, 6, and 12. The Mann-Whitney test was used to test the difference between the groups.

RESULTS

Baseline functional parameters were not significantly different among the groups. BCVA significantly improved in each group (Biofeedback, p = 0.002; Control, p ≤ 0.02) at all follow-up visits. CRS significantly improved at 6 (p = 0.03) and 12 (p = 0.01) months in the Biofeedback group and at month 12 (p = 0.01) in the Control group. RS (p = 0.001) and MD (p = 0.005) improved at the last follow-up only in the trained group. After training, BCEA 68% and 95% significantly improved (6 and 12 months, p < 0.05). The Biofeedback group had better results in RS (p ≤ 0.02), CRS (p ≤ 0.02), and BCEA 68%, 95%, and 99% (p ≤ 0.01) compared to the Control at all follow-ups. BCVA and MD were better in the Biofeedback group at month 3 (p = 0.01), and month 3 (p = 0.01) and 12 (p = 0.003), respectively.

CONCLUSIONS

Microperimetric biofeedback can increase retinal sensitivity and stabilize fixation better than the standard care over months after a successful inverted ILM-flap for hMMH.

Aspiration of viscous plug in macular hole surgery: a case series

Macular hole surgery has been revolutionized since the 1990s’ with the advent of pars plana vitrectomy with internal limiting membrane peeling and gas tamponade, which is now extensively practiced and regarded as the gold standard procedure for surgical treatment of macular hole. Here, we report a simple adjunctive maneuver to conventional PPV with ILM peel and gas tamponade. We observed presence of a viscous fluid in the base of the macular hole in our series. In all, 40 eyes of 39 patients consecutively operated on from June 2019 to December 2020 for PPV with ILM peel and gas tamponade, were included in this study. The viscous plug was aspirated passively using a 25 gauge cannula with its tip above the macular hole, approaching only until a fluid-wave was visualized, which resulted in flattening of the fluid cuff area aiding the macular hole closure in a concentric pattern. Macular hole closure and complete success was seen in 39 out of 40 eyes (97.5%) and only 1 failure (2.5%) observed in this series. In our case series, we have observed the presence of a viscous fluid plug in the macular hole. We demonstrated that aspirating this thick fluid from the hole results in the flattening of the cuff of fluid and subsequent closure of the macular hole in a concentric manner in almost all cases in our series. The lack of concurrent control group means we cannot state a definitive effect of the intervention, but it does suggest the utility of a prospective randomized controlled trial.

PERFLUOROCARBON LIQUID-ASSISTED INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE VERSUS INTERNAL LIMITING MEMBRANE PEELING FOR HIGHLY MYOPIC MACULAR HOLE RETINAL DETACHMENT

PURPOSE

To compare the efficacy of a modified perfluorocarbon liquid-assisted inverted internal limiting membrane (ILM) flap technique with the standard ILM peeling for the treatment of macular hole retinal detachment in highly myopic eyes.

METHODS

This was a retrospective, consecutive, nonrandomized comparative study. Forty-two macular hole retinal detachment eyes of 42 patients were included into either a perfluorocarbon liquid-assisted inverted ILM flap technique group (n = 22, inverted group) or standard ILM removal group (n = 20, peeling group). Outcomes measured were macular hole closure, retinal reattachment, and best-corrected visual acuity at least 6 months after surgery.

RESULTS

Macular hole closure was achieved in 20 eyes (90.9%) in the inverted group and in eight eyes (40%) in the peeling group (P < 0.01). Reattachment rates were 100% in the inverted group and 95% in the peeling group (P = 0.476). The mean best-corrected visual acuity improvement from baseline was 27.4 ± 19.9 Early Treatment Diabetic Retinopathy Study letters in the inverted group while the best-corrected visual acuity improvement was 13.6 ± 22.5 Early Treatment Diabetic Retinopathy Study letters in the peeling group (P = 0.044).

CONCLUSION

The perfluorocarbon liquid-assisted inverted ILM flap technique was effective in sealing the macular hole, reattaching retina, and improving visual function postoperatively in highly myopic macular hole retinal detachment.

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.

Autologous neurosensory retinal transplantation for recurrent macular hole retinal detachment in highly myopic eyes

PURPOSE

To investigate the morphological and functional reconstruction of the macular fovea after autologous neurosensory retinal transplantation for recurrent macular hole retinal detachment (MHRD) in highly myopic eyes.

METHODS

Ten consecutive cases of recurrent MHRD with high myopia were retrospectively reviewed. All eyes underwent pars plana vitrectomy combined with autologous neurosensory retinal transplantation and were followed up for at least 3 months after silicone oil extraction. The main outcomes were whether or not the retina was reattached and the macular hole (MH) was closed, morphological changes in the retinal graft, best-corrected visual acuity (BCVA), the sensitivity threshold and blood flow signal in the macula.

RESULTS

At the one month postoperative visit, there was an obvious boundary between the graft and the surrounding retinal tissue, and some retinal structural layers could be seen in the graft on optical coherence tomography scans. At the final follow-up, eight eyes (80%) showed retinal reattachment and closure of the MH. Optical coherence tomography revealed blurring of the boundary between the graft and surrounding retinal tissue and that the retinal structure in the graft was disordered. The MH was not closed in two eyes (20%), in one case because of partial displacement of the graft and in the other because of incomplete coverage of the MH as a result of a smaller graft. The post-BCVA was significantly better than the pre-BCVA (1.32 ± 0.33 versus 2.01 ± 0.29 logMAR; p = 0.000, paired t-test).

CONCLUSION

Autologous neurosensory retinal transplantation can be an effective treatment for recurrent MHRD in highly myopic eyes. 'Fusion' between the neurosensory retinal graft and the original retinal tissue may be the mechanism involved in the closure of the MH and reconstruction of the macular fovea.

Comparison of intrinsic brain activity in individuals with low/moderate myopia versus high myopia revealed by the amplitude of low-frequency fluctuations

Background

Previous neuroimaging studies demonstrated that individuals with high myopia are associated with abnormalities in anatomy of the brain.

Purpose

The purpose of this study was to explore alterations in the intrinsic brain activity by studying the amplitude of low-frequency fluctuations.

Material and Methods

A total of 64 myopia individuals (41 with high myopia with a refractive error <–600 diopter [D], 23 with low/moderate myopia with a refractive error between –100 and –600 D, and similarly 59 healthy controls with emmetropia closely matched for age) were recruited. The amplitude of low-frequency fluctuations method was conducted to investigate the difference of intrinsic brain activity across three groups.

Results

Compared with the healthy controls, individuals with low/moderate myopia showed significantly decreased amplitude of low-frequency fluctuation values in the bilateral rectal gyrus, right cerebellum anterior lobe/calcarine, and bilateral thalamus and showed significantly increased amplitude of low-frequency fluctuation values in left white matter (optic radiation), right prefrontal cortex, and left primary motor cortex (M1)/primary somatosensory cortex (S1). In addition, individuals with high myopia showed significantly decreased amplitude of low-frequency fluctuation values in the right cerebellum anterior lobe/calcarine/bilateral parahippocampal gyrus, bilateral posterior cingulate cortex, and bilateral middle cingulate cortex and significantly increased amplitude of low-frequency fluctuation values in left white matter (optic radiation), bilateral frontal parietal cortex, and left M1/S1. Moreover, we found that the amplitude of low-frequency fluctuation values of the different brain areas was closely related to the clinical features in the high myopia group.

Conclusion

Our results demonstrated that individuals with low/moderate myopia and high myopia had abnormal intrinsic brain activities in various brain regions related to the limbic system, default mode network, and thalamo-occipital pathway.

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

OBJECTIVE

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

METHODS

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

MAIN OUTCOMES MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

Floating flap of internal limiting membrane in myopic macular hole surgery

PURPOSE

To evaluate the surgical results of macular hole (MH) in patients with high myopia treated with pars plana vitrectomy (PPV) leaving the internal limiting membrane (ILM) flap floating in vitreous fluid at the edge of the MH.

METHODS

Nine highly myopic eyes with MH of nine consecutive patients who underwent PPV were retrospectively evaluated. Three eyes were accompanied by retinal detachment (RD). ILM peeling was performed around the MH and some part of the ILM flap was left attached to the edge of the MH. Further manipulation of the ILM flap to cover the MH was not performed. Fluid-gas exchange was performed to the retinal vessel arcade level. Patients maintained a face down position for 3 to 7 days postoperatively.

RESULTS

Complete MH closure was confirmed using optical coherence tomography in all eyes and three eyes with RD showed reattachment of the retina after the initial surgery. Visual acuity significantly improved (P = 0.02) and no eyes experienced MH reopening or RD occurrence during the follow-up period of 8.33 ± 3.61 months after the surgery.

CONCLUSIONS

MH with or without RD in highly myopic eyes could be successfully treated with PPV leaving ILM flap floating in vitreous fluid at the edge of the MH. After the ILM peeling, further manipulation of the ILM flap to cover the MH would not be necessary for the treatment of MH in high myopia.

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

Purpose

To evaluate the outcome of 23 G PPV and ILM peeling with 14% C₃F₈ compared with silicone oil tamponade in cases of TMHs without spontaneous closure.

Methods

A retrospective comparative study included 33 eyes with TMHs; 7 eyes healed spontaneously, and the remaining 26 eyes have been treated with PPV and ILM peeling. Silicone oil was used as a tamponade for children or adults who refused to adopt face-down position (10 cases). In all other cases (16 cases), 14% C₃F₈ was used. These cases were followed up for 6 months postoperatively.

Results

26 cases (22 males and 4 females) were reviewed, including 10 cases treated with silicone oil and 16 cases treated with 14% C₃F₈. Patients' age ranged from 9 to 54 years. The success rate was 90% in the silicone-filled (9/10) and 94% in the gas-filled (15/16) eyes. At 6 months, the mean BCVA was 0.3 ± 0.25 in the silicone group and 0.2 ± 0.13 in the gas group (p < 0.05).

Conclusions

Cases of TMHs should be observed for spontaneous closure. PPV with ILM peeling should be conducted for nonclosing cases. Gas and silicone oil tamponades are equally successful in anatomical and visual outcomes. This trial is registered with CTRI/2017/06/008765.

Long-term surgical outcomes of the inverted internal limiting membrane flap technique in highly myopic macular hole retinal detachment

BACKGROUND

Pars plana vitrectomy (PPV) procedures are used for the surgical treatment of macular hole retinal detachment (MHRD) associated with high myopia. Re-detachment of the retina has been reported in MHRD associated with high myopia. Our aim was to evaluate the 1-year outcomes of vitrectomy, performed using an inverted internal limiting membrane (ILM) flap technique with gas tamponade, in five cases of MHRD associated with high myopia.

METHODS

We performed a retrospective review of medical records of five consecutive cases of highly myopic MHRD. The following postoperative data were collected: refractive error, best-corrected visual acuity, intraocular pressure, ophthalmic fundus examination findings, ocular coherence tomography at 1, 3, 6, and 12 months postoperatively; duration of the follow-up period; and intra- and postoperative complications. The primary endpoint of the study was the rate of postoperative retinal reattachment and macular hole (MH) closure. Paired t-tests were conducted to evaluate postoperative changes.

RESULTS

Mean visual acuity improved significantly (P = 0.008), with an improvement of ≥2 lines on LogMAR value gained in three of the five eyes. Retinal reattachment was maintained in all cases, with no cases of MH reopening identified over the mean follow-up period of 20.2 months. No complications were identified in any eye.

CONCLUSIONS

The inverted ILM flap technique and gas tamponade provided primary retinal reattachment and MH closure over the ≥12-month follow-up period.