Risk factors for glial cell proliferation after idiopathic macular hole repair with internal limiting membrane flap

Visual Improvement Despite Macular Pucker After Inverted Internal Limiting Membrane Flap Technique for Idiopathic Macular Hole

Purpose: To report a case of a macular pucker forming after macular hole (MH) repair with the inverted internal limiting membrane (ILM) flap technique, with resolution after secondary inverted ILM flap peeling. Methods: A single case was evaluated. Results: A 76-year-old woman presented with reduced central vision (28 letters) in the right eye. Optical coherence tomography (OCT) identified an idiopathic full-thickness MH measuring 629 µm in diameter. The patient had pars plana vitrectomy with inverted ILM flap formation. One month postoperatively, the visual acuity (VA) in the right eye was 47 letters and OCT confirmed MH closure. However, the patient developed deterioration in the central vision 10 months postoperatively. A macular pucker in the inverted ILM flap region was found on OCT. Repeat vitrectomy with inverted ILM flap peeling was performed. Postoperatively, the VA in the right eye improved to 60 letters and OCT showed resolution of the macular pucker. Conclusions: A complication of the inverted ILM flap technique for MH is formation of a macular pucker in the region of the inverted ILM flap. Secondary inverted ILM flap peeling results in resolution of the macular pucker.

EXCESSIVE GLIOSIS AFTER VITRECTOMY FOR THE HIGHLY MYOPIC MACULAR HOLE: A Spectral Domain Optical Coherence Tomography Study

PURPOSE

To investigate different modes of foveal regeneration after the closure of idiopathic macular hole (IMH) or highly myopic macular hole (HMMH) by vitrectomy with internal limiting membranes peeling or flap techniques.

METHODS

This retrospective observational study followed 47 IMH and 50 HMMH eyes for at least 6 months. Twenty four IMH and 25 HMMH eyes underwent internal limiting membrane peeling, whereas 23 IMH and 25 HMMH eyes received inverted internal limiting membrane flap technique. Spectral domain optical coherence tomography was used to analyze macular hole closure, foveal microstructures, and excessive gliosis as a foveal "peak-like" protuberance.

RESULTS

A single procedure closed all IMH (n = 47). For HMMH, the inverted group (n = 25, 100%) closed more macular hole than the peeling group (n = 14, 56.00%) (P < 0.001). Excessive gliosis only occurred in the inverted group, and there was a significant difference (P = 0.005) in incidence between IMH (three in 23 eyes, 13.04%) and HMMH (13 in 25 eyes, 52.00%). The axial length more than 29.985 mm enhanced the risk of excessive gliosis.

CONCLUSION

The inverted internal limiting membrane flap efficiently treated refractory MHs but was prone to cause excessive gliosis in highly myopic eyes. Excessive elongation of the globe (axial length > 29.985 mm) was linked to excessive gliosis growth.

Clinical Observation of Anatomical and Visual Outcomes of Macular Hole after Inverted Internal Limiting Membrane Flap in Patients with Idiopathic Macular

Objective

To investigate anatomical and visual outcomes of macular hole (MH) after inverted internal limiting membrane (ILM) flap technique for idiopathic macular hole (IMH).

Methods

A total of 13 IMH cases diagnosed in Shanxi Eye Hospital between January 2015 and June 2016 were included in the study. All patients underwent vitrectomy combined with indocyanine green-assisted inverted ILM flap technique. The MH closure rate, best-corrected visual acuity (BCVA), changes of ellipsoid zone (EZ), and external limiting membrane (ELM) were examined before operation and one, three, and six months after operation. Furthermore, 488 nm fundus autofluorescence (FAF) and spectral domain optical coherence tomography (SD-OCT) were used to observe the dynamic changes in function of macular area after surgery.

Results

One month after the surgery, the MH closure rate was 100% and the visual acuity (VA) was stable, with no recurrence. Additionally, the average logMAR BCVA before operation was 1.208 ± 0.158, and this value became 0.877 ± 0.105 one month after the operation, showing a significant decrease. Three months after surgery, the average logMAR BCVA was 0.792 ± 0.103, which was significantly lower than the level one month after the surgery but much higher than that six months after surgery (0.708 ± 0.131). Besides, the diameter of the EZ defect of the postoperative one month, three months, and six months was (1377.46 ± 198.65) μm, (964.62 ± 336.26) μm, and (817.08 ± 442.99) μm, respectively. In postoperative one month, three months, and six months, the diameter of the ELM defect diameter was (969.62 ± 189.92) μm, (649.92 ± 413.15) μm, and (557.62 ± 412.50) μm, respectively. The diameter of both EZ and ELM defects was significantly reduced with the passage of time after surgery.

Conclusion

Inverted ILM flap technique can reconstruct macular anatomical structure and improve VA. This technique is effective for the treatment of IMH with large MH minimum diameter and base diameter.

Comparison of Idiopathic Macular Hole Interventions Using Frequency Domain Optical Coherence Tomography and Optical Coherence Tomography Angiography

Objective

We aimed to determine the efficacy of different idiopathic macular hole treatment methods to improve recovery time and patient outcomes using Frequency Domain Optical Coherence Tomography (SD-OCT) and Optical Coherence Tomography Angiography (OCTA).

Methods

This retrospective study included patients with idiopathic macular hole who were admitted to our hospital between 1st January 2019 and 31st October 2021. The control group was treated with internal limiting membrane tamponade, and the study group was treated with clamshell therapy. Treatment conditions (internal limiting membrane treatment duration and hole closure rate), best corrected visual acuity (BCVA) before and after surgery, OCTA measurements, and SD-OCT were assessed. The retinal nerve fiber layer (RNFL), retinal ganglion cell layer (GCL), and retinal pigment epithelium (RPE) thicknesses were also analyzed.

Results

The treatment time and hole closure rate of the internal limiting membrane in the study group were higher than those in the control group. The curative effect of the study group was better than that of the control group. The postoperative DCP blood vessel density in both groups was higher than that before operation, and the study group was higher than the control group. The FAZ area and circumference were lower than those before surgery, and the study group was lower than the control group. At 3 months after operation, the thickness of DIOA, nasal temporal RNFL, and GCL were decreased in both groups, and the observed values in the study group were lower than those in the control group. At 3-month follow-up, there was no significant difference in RPE thickness between the two groups.

Conclusion

Flip and cover therapy is the most effective treatment. SD-OCT and OCTA provide an objective basis for clinical intervention by comparing the effects of different procedures on the retinal condition of patients.

Correlation of retinal alterations with vascular structure of macular neovascularisation in swept-source optical coherence tomography angiography in age-related macular degeneration

Purpose

The aim of this study was to find out whether the vascular architecture of untreated macular neovascularisations (MNV) in neovascular age-related macular degeneration (nAMD) as visualised with optic coherence tomography angiography (OCTA) is associated with functional and known morphological alterations of the retina in optic coherence tomography (SD-OCT).

Methods

The study design was retrospective with consecutive patient inclusion. In 107 patients with newly diagnosed nAMD, MNV were detected by means of OCTA and automated quantitative vascular analysis was performed. The MNV characteristics measured were area, flow density, total vascular length (sumL), density of vascular nodes (numN), fractal dimension (FD) and average vascular width (avgW). These parameters were assessed for associations with vision (BCVA), central retinal thickness (CRT), fluid distribution, the elevation of any pigment epithelial detachment (PED), the occurrence of subretinal haemorrhage and atrophy.

Results

BCVA was significantly worse with greater MNV area and sumL. Fluid distribution differed significantly in relation to area (p < 0.005), sumL (p < 0.005) and FD (p = 0.001). Greater PED height was significantly associated with higher numN (p < 0.05) and lower avgW (p < 0.05). Atrophy was present significantly more often in MNV with larger area (p < 0.05), higher sumL (p < 0.05) and higher flow density (p = 0.002). None of the MNV parameters had a significant association with CRT or the occurrence of haemorrhage.

Conclusion

OCTA is not restricted to evaluation of secondary changes but offers the opportunity to analyse the vascular structure of MNV in detail. Differences in vascular morphology are associated with certain secondary changes in retinal morphology. There are thus grounds for optimism that further research may identify and classify OCTA-based markers to permit more individualised treatment of nAMD.

Characteristics of fixation patterns and their relationship with visual function of patients with idiopathic macular holes after vitrectomy

To analyze the relationships between the fixation location and the visual function of idiopathic macular hole (IMH) patients with macular integrity assessment (MAIA) examination preoperatively and 3 months postoperatively. This was a retrospective case analysis. Forty-three eyes of 43 patients diagnosed with IMH were included in this study. The best corrected visual acuity (BCVA) assessments, optical coherence tomography (OCT) and MAIA examinations were performed before surgery and 1 week, 1 month and 3 months after surgery. The relationships between MAIA parameters and visual acuity were assessed by correlation analysis. Grouping by fixation location with the foveola (2°) as the centre, the locations could be divided into five groups, including foveolar, temporal, nasal, inferior and superior fixation. The mean macular sensitivity (MMS) of the macular area was correlated with the BCVA in the IMH patients before and 3 months after surgery (before surgery P = 0.00, after surgery P = 0.00). The MMS could be used as a good indicator for evaluating visual function in IMH patients. There was a significant difference in fixation location before and after the operation (P = 0.01). The preoperative fixation location of IMH patients was mainly in the superior area, while postoperatively moved to the foveola and nasal areas. Paying attention to the changes of fixation locations in IMH patients may provide new clues for further improving postoperative visual function.

Inverted internal limiting membrane flap technique in eyes with large idiopathic full-thickness macular hole: long-term functional and morphological outcomes

Purpose

To investigate morphological and functional outcomes of the inverted internal limiting membrane (I-ILM) flap technique in large (≥ 400 μm) idiopathic full-thickness macular holes (FTMH) over a follow-up period of 12 months.

Methods

In this retrospective study, 55 eyes of 54 consecutive patients were enrolled. Best-corrected visual acuity (BCVA) and spectral-domain optical coherence tomography (SD-OCT, Heidelberg, Spectralis) were performed preoperatively as well as 1, 3, 6, 9, and 12 months postoperatively. Special focus was put on the reintegration of outer retinal layers and the different ILM flap appearances.

Results

FTMH closure rate was 100% (55/55). BCVA significantly improved over the follow-up period of 12 months from 0.98 ± 0.38 LogMAR preoperatively to 0.42 ± 0.33 LogMAR at 12 months postoperatively (p < 0.001). There was no significant correlation between the three different ILM flap appearances and BCVA. Better preoperative BCVA, complete restoration of the external limiting membrane (ELM), higher macular hole index (MHI), and smaller MH base diameter were associated with higher improvement of BCVA.

Conclusion

Our study highlights the favorable morphological and functional outcomes of the I-ILM flap technique in the short as well as in the long term. While complete ELM restoration revealed to be an important factor for improvement in BCVA, the different postoperative ILM flap appearances seem not to be related to BCVA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00417-021-05082-7.

Inverted internal limiting membrane flap technique in the surgical treatment of macular holes: 8-year experience

PURPOSE

To evaluate the ellipsoid zone (EZ) structural recovery, hole closure rate, and visual acuity improvement after inverted internal limiting membrane (ILM) flap technique.

METHODS

Retrospective cohort of eyes affected by idiopathic macular holes (MH) that underwent pars plana vitrectomy combined with inverted ILM flap technique in a tertiary center, over an 8-year period (2011-2019). The main outcomes were the postoperative qualitative analysis of EZ structure on spectral-domain optical coherence tomography, hole closure rate, and best-corrected visual acuity (BCVA) improvement of ≥ 0.3 units in the logarithm of minimal angle of resolution (logMAR) scale.

RESULTS

Our study included 76 eyes of 72 patients; 65% were female, with a mean age of 70 ± 8 years-old. Median (range) follow-up was 21 (3-92) months. Hole closure rate was 92%. Structural defects in EZ were observed in 66% of closed holes (EZ atrophy in 33%, EZ disruption in 22%, and EZ thinning in 11%). The mean final BCVA was 0.5 ± 0.4 logMAR (Snellen 20/63), but visual acuity improvement occurred in 80% of the eyes. Final BCVA was significantly worse in eyes with EZ atrophy compared with eyes with EZ disruption (0.75 vs. 0.36 logMAR, p = 0.004) and EZ thinning (0.75 vs. 0.32 logMAR, p = 0.015). In multivariate regression, minimum linear diameter (OR 1.01; IC 95% 1.01-1.02) independently predicted a final BCVA (logMAR) < 0.3 units.

CONCLUSION

Inverted ILM flap technique provided a hole closure rate above 90%, similar to previous studies. Although the modest value of the final BCVA, a significant visual acuity improvement occurred in most eyes. Structural defects of EZ were found in more than half of closed MHs after surgery. Evidence of postoperative retinal atrophy was associated with a worse visual outcome.