Different modes of foveal regeneration after closure of full-thickness macular holes by (re)vitrectomy and autologous platelet concentrate

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.

Temporal inverted internal limiting membrane flap technique for myopic macular hole retinal detachment reconstruction

OBJECTIVE

To examine the effects of the temporal inverted internal limiting membrane (ILM) flap technique for foveal reconstruction in patients with highly myopic macular hole-associated retinal detachment (MHRD).

METHODS

A retrospective case series analysis of four patients (four eyes) with MHRD was conducted. The foveal optical coherence tomography changes following treatment using the temporal inverted ILM flap technique were evaluated.

RESULTS

In Patient 1, the ILM bridged the macular hole and residual subretinal fluid on postoperative day 6, and complete retinal reattachment was achieved at 19 months. Patient 2 exhibited reduced retinal detachment, with visible ILM inversion and macular hole closure after 14 days. In Patient 3, macular hole closure and fovea formation had occurred by day 25, and the ILM flap was visible. At 2 months, the outer collagenous layer connection in the central fovea and recovery of the external limiting membrane and ellipsoid zone were observed. Patient 4 had a "white hole" MHRD, with macular hole closure achieved on postoperative day 20, albeit with a suboptimal foveal shape.

CONCLUSION

The temporal inverted ILM flap technique in conjunction with vitrectomy facilitates foveal reconstruction in patients with successful treatment of MHRD, and this reconstruction process can be observed by optical coherence tomography.

Macular buckling alone versus combined inverted ILM flap on macular hole-associated macular detachment in patients with high myopia

PURPOSE

To compare the efficacy of macular buckling (MB) alone against a combined internal limiting membrane (ILM) inversion flap for full-thickness macular hole (FTMH)-associated macular detachment (MD) in patients with high myopia.

METHODS

This was a prospective interventional case series of patients with high myopia surgically treated with MB alone or combined with an inverted ILM flap for FTMH- associated MD. Best-corrected visual acuity (BCVA) at the 24-month postoperative follow-up, rate of initial retinal reattachment and macular hole closure were measured.

RESULTS

A total of 62 eyes from 62 participants (33 in the MB group, 29 in the combination group) were studied. Postoperative BCVA improved significantly in both the combination group (P < 0.001) and the MB group (P = 0.027). The postoperative BCVA at 12 months (P = 0.021) and 24 months (P = 0.041) was significantly better in the combination group than in the MB group. The postoperative BCVA was not significantly different between the eyes with closed and unclosed MH at each follow-up time point (P > 0.05). In the combination group, we observed earlier retinal reattachment and closure of the MH as well as a higher rate of MH closure (82.8% vs. 66.7%) than in the MB group, although this difference was insignificant (P = 0.248).

CONCLUSION

MB combined with the ILM flap inversion technique achieved better postoperative BCVA and a higher success rate of MH closure than MB alone. We believe that combination surgery should be preferentially recommended.

Comparison of long-term visual and anatomical outcomes between internal limiting membrane flap and peeling techniques for macular holes with a propensity score analysis

OBJECTIVES

To compare visual and anatomical outcomes between internal limiting membrane (ILM) flap (IF) and peeling (IP) techniques for full-thickness macular holes (FTMHs).

METHODS

A retrospective case series with propensity-score matching (PSM). Patients with a minimum 12 months follow-up were divided into IF and IP groups and matched based on FTMH size and preoperative best-corrected visual acuity (BCVA). BCVA and optical coherence tomography (OCT) findings were obtained to assess outer retinal layer integrity, foveal thickness, and foveal displacement.

RESULTS

Twenty-six eyes were included in each group after PSM. The IF group showed significantly greater BCVA after 1 month, its corresponding change from preoperative BCVA, proportions of eyes with ellipsoid zone defects <250 μm after 1 month, and interdigitation zone restoration after 6 and 12 months (P = 0.007, 0.038, 0.048, 0.025, and 0.023, respectively), as well as less foveal gliosis after 1, 3, 6, and 12 months (P = 0.020, 0.017, 0.050, and 0.024, respectively). In the IP group, the mean outer nuclear layer thickness significantly decreased at 3 (P = 0.019) and 12 months (P = 0.016) compared to 1 month, and the foveal displacement toward the optic disc was significant after 1, 3, 6, and 12 months (P = 0.049, 0.006, 0.001, and <0.001, respectively).

CONCLUSIONS

Compared to IP, IF promoted faster recovery of BCVA and outer retinal layers and was more protective against postoperative foveal thinning and displacement; hence, it should be considered for small and large FTMHs.

The effect comparison of ILM flap and traditional ILM peeling in iMH

Purpose

To compare the changes in anatomical structure and visual function after idiopathic macular hole (iMH) treatment with internal limiting membrane (ILM) peeling and inverted ILM flap and determine the value of the inverted ILM flap for the treatment of iMH.

Methods

Forty-nine patients with iMH (49 eyes) were included in this study and followed up for 1 year (12 months) after treatment with inverted ILM flap and ILM peeling respectively. The main foveal parameters assessed included the preoperative minimum diameter (MD), intraoperative residual fragments, and postoperative ELM reconstruction. Visual function was assessed using best-corrected visual acuity.

Results

The hole closure rate was 100% for 49 patients; 15 patients were treated with the inverted ILM flap, and 34 patients underwent ILM peeling. There were no differences between the postoperative best-corrected visual acuities and the rates of ELM reconstruction for the flap and peeling groups with different MDs. In the flap group, ELM reconstruction was associated with the preoperative MD, presence of an ILM flap, and hyperreflective changes in the inner retina 1 month after surgery. In the peeling group, ELM reconstruction was associated with the preoperative MD, intraoperative residual fragments at the hole edge, and hyperreflective changes in the inner retina.

Conclusion

The inverted ILM flap and the ILM Peeling were both able to obtain high closure rate. However, the inverted ILM flap showed no obvious advantages related to anatomical morphology and visual function over ILM peeling.

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.

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.

The Role of Internal Limiting Membrane Flap for Highly Myopic Macular Hole Retinal Detachment: Improving the Closure Rate but Leading to Excessive Gliosis

Purpose: To investigate the surgical outcomes of the inverted internal limiting membrane (ILM) flap technique for macular hole retinal detachment (MHRD) in high myopia.

Methods: This was a retrospective interventional study on 45 highly myopic eyes with MHRD after ILM peeling (n = 24, peeling group) or the inverted ILM flap technique (n = 21, inverted group). The inverted group was consisted of autologous blood (AB) subgroup (n = 10) and perfluorocarbon liquid (PFCL) subgroup (n = 11). MH closure, best-corrected visual acuity (BCVA), foveal microstructures, and excessive gliosis were analyzed during a follow-up of over 12 months.

Results: The inverted group achieved a higher MH closure rate (95.24%) than the peeling group (41.67%; p < 0.001). No significant difference was found in postoperative BCVA between the two groups (p = 0.98) or between the closed MH with or without excessive gliosis (p = 0.60). Excessive gliosis was identified in 9 eyes in the inverted group, and there was no difference in the incidence of excessive gliosis between the AB subgroup (4 in 10 eyes, 40%) and the PFCL subgroup (5 in 11 eyes, 45.45%) (p > 0.999).

Conclusion: The inverted ILM flap technique was effective in MH closure but had no advantage in postoperative BCVA and microstructural restoration. Excessive gliosis was only detected in the inverted group but did not affect the postoperative BCVA. Additionally, the incidence of excessive gliosis was not affected by adjuvants.

Foveal reorganization after treatment of acute foveal toxoplasmic retinochoroiditis

Purpose

To report a patient with impaired vision due to foveal involvement of toxoplasmic retinochoroiditis, who was successfully treated with intravitreal clindamycin and dexamethasone and oral therapy with azithromycin, trimethoprim-sulfamethoxazole, and prednisolone and led to successful visual and anatomic recovery.

Case presentation

A 32-year-old man presented with three-day history of gradually decreasing visual acuity, redness, pain and photophobia of the right eye. Anterior chamber cellular reaction, vitritis and a white retinochoroiditis patch with adjacent retinal vasculitis in the fovea was suggestive of the toxoplasmic retinochoroiditis. He was treated with intravitreal clindamycin and dexamethasone injection followed by six-week regimen of azithromycin, trimethoprim-sulfamethoxazole, and prednisolone. In serial optical coherence tomography imaging, retinitis patch changed to cavitary foveal destruction. Fovea reorganized gradually, and visual acuity concurrently improved from counting finger 3 m to 20/25.

Conclusion

In foveal toxoplasmic retinochoroiditis lesions, timely treatment is associated with retinal reorganization and visual improvement.

Müller cells and astrocytes in tractional macular disorders

Tractional deformations of the fovea mainly arise from an anomalous posterior vitreous detachment and contraction of epiretinal membranes, and also occur in eyes with cystoid macular edema or high myopia. Traction to the fovea may cause partial- and full-thickness macular defects. Partial-thickness defects are foveal pseudocysts, macular pseudoholes, and tractional, degenerative, and outer lamellar holes. The morphology of the foveal defects can be partly explained by the shape of Müller cells and the location of tissue layer interfaces of low mechanical stability. Because Müller cells and astrocytes provide the structural scaffold of the fovea, they are active players in mediating tractional alterations of the fovea, in protecting the fovea from such alterations, and in the regeneration of the foveal structure. Tractional and degenerative lamellar holes are characterized by a disruption of the Müller cell cone in the foveola. After detachment or disruption of the cone, Müller cells of the foveal walls support the structural stability of the foveal center. After tractional elevation of the inner layers of the foveal walls, possibly resulting in foveoschisis, Müller cells transmit tractional forces from the inner to the outer retina leading to central photoreceptor layer defects and a detachment of the neuroretina from the retinal pigment epithelium. This mechanism plays a role in the widening of outer lameller and full-thickness macular holes, and contributes to visual impairment in eyes with macular disorders caused by conractile epiretinal membranes. Müller cells of the foveal walls may seal holes in the outer fovea and mediate the regeneration of the fovea after closure of full-thickness holes. The latter is mediated by the formation of temporary glial scars whereas persistent glial scars impede regular foveal regeneration. Further research is required to improve our understanding of the roles of glial cells in the pathogenesis and healing of tractional macular disorders.

Degenerative lamellar macular holes: tractional development and morphological alterations

Purpose

The development of degenerative lamellar macular holes (DLH) is largely unclear. This study was aimed at documenting with spectral-domain optical coherence tomography the tractional development and morphological alterations of DLH.

Methods

A retrospective case series of 44 eyes of 44 patients is described.

Results

The development of DLH is preceded for months or years by tractional deformations of the fovea due to the action of contractile epiretinal membranes (ERM) and/or the partially detached posterior hyaloid, or by cystoid macular edema (CME). DLH may develop after a tractional stretching and thickening of the foveal center, from a foveal pseudocyst, after a detachment of the foveola from the retinal pigment epithelium, a disruption of the foveal structure due to CME, and after surgical treatment of tractional lamellar or full-thickness macular holes (FTMH). The foveal configuration of a DLH can be spontaneously reestablished after short transient episodes of CME and a small FTMH. A DLH can evolve to a FTMH by traction of an ERM. Surgical treatment of a DLH may result in an irregular regeneration of the foveal center without photoreceptors.

Conclusions

Tractional forces play an important role in the development of DLH and in the further evolution to FTMH. It is suggested that a DLH is the result of a retinal wound repair process after a tractional disruption of the Müller cell cone and a degeneration of Henle fibers, to prevent a further increase in the degenerative cavitations.

Different modes of full-thickness macular hole formation

Full-thickness macular holes (FTMH) are an important cause of visual deterioration. However, different modes of FTMH formation are less investigated. It is also not clear whether the development of edematous cysts contributes to FTMH formation. In this retrospective case series of 30 eyes of 30 patients, we describe using spectral-domain optical coherence tomography different modes of FTMH formation. Morphological alterations of established FTMH are shown in 5 eyes of 5 patients. We found in 2 of 30 eyes investigated that anterior hyaloidal traction induced a hyperreflectivity of the inner Müller cell layer of the foveola prior to FTMH formation. In 3 eyes, FTMH were caused by anterior hyaloidal traction which produced foveal pseudocysts that developed to an outer lamellar hole (OLH) characterized by a disruption of the central outer retina. The OLH developed to a FTMH by the disruption of the inner layer of the foveola. FTMH formation from an OLH by hyaloidal traction was observed also in further 7 eyes. In 2 eyes, the OLH, which preceded FTMH formation, was generated by a serous retinal detachment. In 3 eyes, anterior hyaloidal traction caused a detachment of the fovea from the retinal pigment epithelium (RPE); the subsequent disruption of the foveola resulted in a FTMH. Six eyes showed the development of a FTMH from a degenerative lamellar hole (DLH). In 5 eyes with macular pucker, FTMH were formed by traction of epiretinal membranes (ERM) or hyaloidal traction. Two eyes showed the development of a FTMH by anterior or tangential hyaloidal traction likely without a formation of an OLH. FTMH formation from an OLH proceeded with or without an enlargement of cystic cavities in the foveal walls. The formation of FTMH from a DLH, after a detachment of the fovea, and in macular pucker eyes was associated with a formation of cystic cavities in the foveal walls. The best-corrected visual acuity (BCVA) of eyes with an OLH or FTMH was inversely correlated to the base and minimum diameters of the holes, and with the height of the foveal walls; the highest correlation coefficients were found between the BCVA and the base diameter. The data show that FTMH may be formed via different modes by hyaloidal traction and/or traction of ERM, or after a serous retinal detachment. It is suggested that, after FTMH formation, the impaired fluid clearance through the RPE after detachment of the central outer retina causes the development of edematous cysts in the foveal walls which enlarges the FTMH. The BCVA of eyes with an OLH or FTMH mainly depends on the size of the central photoreceptor-free area.

Silicone oil tamponade for persistent macular holes

BACKGROUND

A variety of treatment strategies have been proposed for macular holes that persist or recur after surgery, and the debate about the best re-treatment approach is ongoing. To allow for a comparison with alternative surgical therapies, we assessed the anatomical and functional outcome of a temporary tamponade with conventional silicone oil in persistent or recurrent full-thickness macular holes.

METHODS

We retrospectively investigated consecutive patients with full-thickness macular holes that persisted or recurred following vitrectomy with internal limiting membrane peeling and gas tamponade. All patients received re-treatment by temporary tamponade of silicone oil and were allowed free postoperative positioning. Anatomical closure rate was assessed by optical coherence tomography, and change of best-corrected visual acuity (BCVA) was analyzed.

RESULTS

A total of 33 eyes of 33 consecutive patients were included. Macular hole closure following silicone oil tamponade was achieved in 30 of 33 eyes (90.9%). Median BCVA improved from 1.00 logMAR (interquartile range, 0.60-1.00) to 0.65 logMAR (0.49-1.00; p = 0.010) after silicone oil removal. In patients with macular hole closure, 61.3% exhibited functional improvement with median BCVA changing from 1.00 logMAR (0.70-1.00) to 0.60 logMAR (0.49-1.00; p = 0.0005). Mean minimal linear diameter of macular holes before primary surgery was 391.0 µm (±137.8; range 133-630), and 48.5% of macular holes were >400 µm in diameter.

CONCLUSIONS

Treatment of persistent or recurrent full-thickness macular holes by temporary conventional silicone oil tamponade without postoperative positioning results in a high closure rate and a significant mean improvement of visual acuity.

Long-term results of autologous plasma as adjuvant to pars plana vitrectomy in the treatment of high myopic full-thickness macular holes

Background:

To analyse the feasibility and efficacy of a novel autologous plasma rich in growth factor (PRGF) preparation as adjuvant to pars plana vitrectomy and internal limiting membrane peel in high myopic full-thickness macular hole (FTMH).

Methods:

Single-centre, single-surgeon retrospective chart review of consecutive patients with high myopic FTMH who underwent surgery with a minimum follow-up of 12 months. Patients were divided in group 1 (naïve) and group 2 (persistent). Quantitative and qualitative variables were analysed, compared among groups and correlated with best corrected visual acuity (BCVA).

Results:

Postoperatively, FTMH resolved in 28/31 eyes in group 1 (90%) and in 10/11 eyes in group 2 (91%), without significant differences ( p = 0.954). None of the preoperative anatomical variables analysed showed significant association with preoperative BCVA. Intraoperatively, no significant complications were registered. Postoperatively, BCVA improved significantly in the studied population ( p < 0.001). Preoperative factors associated with better postoperative BCVA were the presence of intraretinal cystoid spaces ( p = 0.028) and elevated FTMH borders ( p = 0.005). Preoperative dome-shaped macula was associated with significantly worse postoperative BCVA ( p = 0.049).

Conclusion:

The use of PRGF as adjuvant to vitrectomy showed to be reproducible, straightforward and efficient, with primary anatomical success rate comparable to other surgical approaches and lower risk of complications.

Two different populations of Müller cells stabilize the structure of the fovea: an optical coherence tomography study

PURPOSE

To document with spectral-domain optical coherence tomography the structural stabilization of the fovea and the sealing of outer macular defects by Müller cells.

METHODS

A retrospective case series of 45 eyes of 34 patients is described.

RESULTS

In cases of a cystic disruption of the foveola as in macular telangiectasia type 2 and vitreomacular traction, the Müller cell cone provides the structural stability of the fovea. In cases of a detachment or disruption of the Müller cell cone, e.g., in foveal pseudocysts, outer lamellar holes, and degenerative and tractional lamellar holes, Müller cells of the foveal walls may provide the structural stability of the fovea by the formation of a hyperreflective external limiting membrane (ELM) which bridges the holes in the central outer nuclear layer (ONL). Müller cells of the foveal walls and parafovea mediate the regeneration of the foveal architecture in cases of outer lamellar and full-thickness macular holes. The regeneration proceeds by a centripetal displacement of photoreceptor cell somata which closes the holes in the central ONL. The closure may be supported by the formation of a glial tissue band at the ELM which seals the hole.

CONCLUSIONS

The Müller cell cone provides the foveal stability in cases of a cystic disruption of the foveola. The structural stability of the outer foveal layers is mainly provided by the Müller cells of the foveal walls and parafovea; these cells also mediate the regeneration of the outer fovea in cases of a defect of the central ONL.