Short-Term Results of Platelet-Rich Plasma as Adjuvant to 23-G Vitrectomy in the Treatment of High Myopic Macular Holes

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.

The Short-Term Results of Autologous Platelet-Rich Plasma as an Adjuvant to Re-Intervention in the Treatment of Refractory Full-Thickness Macular Holes

The purpose of this study was to investigate the short-term efficacy and safety of autologous platelet-rich plasma (a-PRP) as an adjuvant to revisional vitrectomy for refractory full-thickness macular holes (rFTMHs). We conducted a prospective, non-randomized interventional study including patients with rFTMH after a pars plana vitrectomy (PPV) with internal limiting membrane peeling and gas tamponade. We included 28 eyes from 27 patients with rFTMHs: 12 rFTMHs in highly myopic eyes (axial length greater than 26.5 mm or a refractive error greater than -6D or both); 12 large rFTMHs (minimum hole width > 400 μm); and 4 rFTMHs secondary to the optic disc pit. All patients underwent 25-G PPV with a-PRP, a median time of 3.5 ± 1.8 months after the primary repair. At the six-month follow-up, the overall rFTMH closure rate was 92.9%, distributed as follows: 11 out of 12 eyes (91.7%) in the highly myopic group, 11 out of 12 eyes (91.7%) in the large rFTMH group, and 4 out of 4 eyes (100%) in the optic disc pit group. Median best-corrected visual acuity significantly improved in all groups, in particular from 1.00 (interquartile range: 0.85 to 1.30) to 0.70 (0.40 to 0.85) LogMAR in the highly myopic group (p = 0.016), from 0.90 (0.70 to 1.49) to 0.40 (0.35 to 0.70) LogMAR in the large rFTMH group (p = 0.005), and from 0.90 (0.75 to 1.00) to 0.50 (0.28 to 0.65) LogMAR in the optic disc pit group. No intraoperative or postoperative complications were reported. In conclusion, a-PRP can be an effective adjuvant to PPV in the management of rFTMHs.

Platelet-rich plasma and macular hole surgery: A clue to their mode of action and the influence of anti-platelet agents

PURPOSE

To present a case of refractory full-thickness macular hole (FTMH), in which autologous platelet-rich plasma (aPRP) was used on two consecutive occasions, and associated with successful closure only after complete cessation of anti-platelet therapy.

METHODS

Interventional case report.

RESULTS

A 63-year-old male with Alport syndrome underwent pars plana vitrectomy with internal limiting membrane peeling and gas for a large FTMH. The patient was on systemic anti-platelet agents for coronary disease. Post-operatively, the FTMH remained open and repeated surgery, augmented with aPRP, was performed. Although a thick pre-retinal coagulum was evident on optical coherence tomography on day one post-surgery, the second surgery failed. Ultimately, successful aPRP-augmented surgical closure of the FTMH was achieved only after complete cessation of systemic anti-platelet agents.

CONCLUSION

Appropriate management of anti-platelet therapy may be relevant when planning aPRP use, though further large-scale studies are needed to assess the precise effect of anti-platelet therapy on the efficacy of aPRP, and to confirm the potential role of aPRP in patients with Alport syndrome.

Application of Platelet-rich Fibrin Transplantation for Large Macular Hole

Purpose Large idiopathic macular hole (MH) has a lower closure rate and poor visual prognosis. To increase the closure rate and the visual outcome in patients with large MH, we evaluate a technique of platelet-rich fibrin (PRF) membrane transplantation for the treatment of large MH.Methods This was a prospective interventional study. Seventeen eyes of 17 patients (8 males and 9 females) with large MH (654.94 ± 188.08 μm) underwent pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peeling followed by PRF transplantation between January 2019 to December 2020. The patients were followed up for at least 6 months. Preoperatively and postoperatively, all patients underwent comprehensive ophthalmic examinations, including best-corrected visual acuity (BCVA), intraocular pressure, slit-lamp biomicroscopy, indirect ophthalmoscopy, ultra-widefield retinal imaging, optical coherent tomography (OCT), and optical coherent tomography angiography (OCTA).Results All the patients achieved complete and consistent hole closure after the surgery (100%). At six months follow-up, the external limiting membrane (ELM) defects were observed in 3 eyes (17.64%), and the ellipsoid zone (EZ) defects were observed in 10 eyes (58.82%). The preoperative BCVA was 1.21 ± 0.33 in logMAR. Postoperatively, the BCVA was significantly improved to 0.64 ± 0.22 in logMAR at 6 months (P < 0.001). The foveal avascular zone (FAZ) reduced significantly from 0.41 ± 0.08 mm² to 0.26 ± 0.07 mm² (P < 0.001). No complications were observed during or after the operation.Conclusions All patients in this study have achieved good anatomic and functional results, which indicate that the application of PRF transplantation is an effective and safe technique for large MH.

Plasma Rich in Growth Factors in Macular Hole Surgery

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

Vitrectomy With Internal Limiting Membrane Transplants in the Closure of 2 Adjacent Macular Holes

Purpose:

Two adjacent macular holes (MHs), which were noted in the highly myopic left eye of an 85-year-old woman, is an uncommon clinical presentation. This case report presents the successful closure of the 2 adjacent MHs using internal limiting membrane (ILM) transplants during vitrectomy that included.

Methods:

ILM transplants were placed within both MHs during vitrectomy that included ILM peeling and fluid gas exchange with 18% perfluoropropane (C3F8) and postoperative facedown positioning for 1 week.

Results:

Both MHs were successfully closed following surgery with improvement in vision and decrease in metamorphopsia.

Conclusions:

This case suggested that relief of traction by ILM peeling and placement of ILM transplants within both MHs to provide a scaffold and stimulate glial tissue proliferation may have facilitated closure of the 2 adjacent MHs, which is a difficult management problem to manage and not previously reported to the best of our knowledge.

Surgical treatment of macular holes with and without the use of autologous platelet-rich plasma

PURPOSE

To compare the results of treatment of idiopathic full-thickness macular holes (MHs) with and without the use of autologous platelet-rich plasma (APRP).

METHODS

This partially retrospective study included 152 patients (152 eyes) with MHs operated in the years 2010-2014 using conventional technology with internal limiting membrane peeling (control group) and 62 patients (62 eyes), operated by the same surgeons in 2015-2017 with additional application of APRP on MH (platelet group). Pre and postoperative best-corrected visual acuities (BCVA) were recorded, and retinal microstructure was studied using optical coherence tomography. Thirty-seven patients in the platelet group and 80 controls were followed for at least 12 months (for visual outcomes 15 controls were followed for 15-24 months). The data of 72 controls (72 eyes) were analyzed retrospectively.

RESULTS

The minimum diameter of the MH in the platelet group was larger than in controls: 454 ± 186 vsersus 381 ± 148 μm (P = 0.003). Despite this, all MHs in the platelet group were closed, while in the control group 11 holes (7.2%) remained open (P = 0.036). The final mean BCVA, standardized by the minimum diameter of the macular hole, was higher in the platelet group by 3.9 ETDRS letters (P = 0.012). After surgery with APRP, foveal hyperreflective lesion (presumably glial proliferation) was found, which persisted in most large MHs, but gradually disappeared in small and most medium MHs.

CONCLUSION

The use of APRP significantly improves the anatomical and functional results of treatment of idiopathic MHs. In very large MHs, APRP presumably enhances glial proliferation, which ensures their closure.

Initial positive first-hand experience of acute keratoconus treatment using platelet-rich serums

Presentation of a clinical case of acute keratoconus treatment by the intracameral platelet-rich plasma administration. Clinical and morphological improvement was registered from the first postoperative day, corneal edema and bullous changes completely resolved during 3 weeks. No side effects were observed. The outcome is confirmed by anterior segment optical coherence tomography data Intracameral platelet-rich autologous plasma administration is a safe and effective method of acute keratoconus treatment.

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.

Human amniotic membrane patch and platelet-rich plasma to promote retinal hole repair in a recurrent retinal detachment

PURPOSE

To present a modified surgical technique, based on a combination of human amniotic membrane (hAM) patch and autologous Platelet-rich plasma (PRP) in a case of recurrent retinal detachment (RRD) due to a perivascular retinal hole over an area of staphyloma in an eye with pathologic myopia.

METHODS

Presenting the surgical technique with the disposal of surgical video. After performing 23-gauge pars plana vitrectomy (PPV) the hAM patch was inserted under the neuroretina through the perivascular hole and PRP was injected on top to speed up the closure of the hole. To complete the surgical procedure High Viscosity Silicon oil (5000cst) was used as tamponade. The patient was prescribed to maintain a face-down position for the first 3 days after the operation. Follow-up was evaluated through Optical coherence tomography (OCT) scans.

RESULTS

The 3 days postoperative OCT showed a flat retina with the filling of the myopic staphyloma. The hAM patch was well positioned and the retinal hole could not be identified. At 6 weeks from intervention, the site of the retinal hole at OCT scan was covered by new tissue. Silicone oil was removed 3 months later with no recurrence.

CONCLUSION

hAM transplantation is a novel technique in case of retinal detachment recurrences to seal retinal holes over high myopic chorioretinal atrophy. The adjunctive use of PRP and high viscosity silicon oil allows to reducing the standard face-down positioning timing, representing a valid solution for elderly patients who have difficulties maintaining the position for long periods.

Quantification of Growth Factors and Fibronectin in Diverse Preparations of Platelet-Rich Plasma for the Treatment of Ocular Surface Disorders (E-PRP)

Purpose

The purpose of this study was to quantify the presence of growth factors (GFs) and fibronectin in autologous platelet-rich plasma for topical ocular use (E-PRP) comparing their concentration when different preparation and preservation procedures were applied.

Methods

E-PRP was prepared with blood from healthy volunteers. The count of platelets, leukocytes, and red blood cells in the whole blood and E-PRP were performed. The concentration of the GFs platelet-derived growth factor BB (PDGF-BB), transforming growth factor β1 (TGF-β1), epidermal growth factor (EGF), vascular endothelial growth factor A (VEGF-A), and fibronectin was determined in each of the four procedures applied including fresh, frozen at −20°C for 3 months, fresh-spin, and frozen-spin at −20°C E-PRP samples. Posterior statistical analysis was performed to establish significant differences between groups and between GFs in relation to the amounts of platelets.

Results

Platelets in the E-PRP doubled in the number of basal values of whole blood (P ≤ 0.01). The blood cells in the E-PRP decreased drastically in red cells (99%) and also in leukocytes (82%). The concentration of PDGF-BB and EGF was significantly higher (P < 0.01) when the E-PRP samples were frozen at −20°C. However, no significant differences were observed for TGF-β1, VEGF-A, and fibronectin (P > 0.05). The concentration of GFs in the E-PRP did not necessarily correlate with the number of platelets.

Conclusions

Freezing the E-PRP for 3 months at −20°C increased the concentration of important proteins, such as PDGF-BB and EGF, and maintained the levels of others. These findings are essential because treatments, such as E-PRP, used by patients with ocular surface dysfunctions tend to prolong it in time. In addition, subsequent centrifugation of the E-PRP decreased the values of TFG-β1, but not the other GFs, which would allow adjusting the concentration of TFG-β1, as necessary. This procedure guarantees their correct conservation and viability.

Translational Relevance

This work demonstrates how clinical application can be improved by starting from basic research. The quantification of GFs and fibronectin in platelet-rich plasma (PRP) helps to clarify which is the best mode of preparation and preservation of PRP for clinical applications. This allows to optimize the product that is delivered to the patients as a treatment for the dysfunctions of the ocular surface, guaranteeing that the conservation does not affect at all the quality of the PRP that it is going to be used.

Treatment of Severe Keratoconus Hydrops With Intracameral Platelet-Rich Plasma Injection

PURPOSE

To present successful management of severe corneal hydrops by corneal optical coherence tomography (OCT) guidance and intracameral application of eye platelet-rich plasma (E-PRP) in a case with Down syndrome.

METHODS

A 36-year-old woman with Down syndrome presented with acute vision loss, pain, photophobia, and corneal edema in the left eye. Clinical examination revealed keratoconus in the right eye and extreme keratoconus with severe corneal hydrops in the left eye. Anterior segment OCT (MS-39, Costruzione Strumenti Oftalmici, Firenze, Italy) showed intrastromal cystic fluid collection and ruptured and detached Descemet membrane. The OCT-guided management of hydrops is first described in this case report.

RESULTS

Medical treatment and intracameral sulfur hexafluoride injection failed. A sterile 0.3 mL of E-PRP was injected into the anterior chamber. Clinical and anatomical improvement began from the first postoperative day, and corneal edema totally resolved at 1 week. Postoperatively, no significant side effect was noted except an early transient moderate (28 mm Hg) intraocular pressure peak. Anterior segment-OCT demonstrated dramatic normalization in corneal morphology with total disappearance of fluid in the cystic intracorneal space, closure of the DM rupture, and DM reattachment. The patient was stable during the 6-month follow-up.

CONCLUSIONS

In this case, intraocular E-PRP was a promising, apparently safe, and effective treatment option in management of corneal hydrops, in which conventional approaches failed. This is the first case in the literature to describe OCT appearance of corneal hydrops and intracameral use of E-PRP for the resolution of DM rupture in acute corneal hydrops.

Visual Loss after Platelet-rich Plasma Injection into the Face

Platelet-rich plasma has become one of the most widely used facial cosmetics fillers. We evaluated four patients treated by cosmetologists with platelet-rich plasma injections who developed irreversible blindness due to iatrogenic occlusion of the ophthalmic artery; immediately after the injection in the glabellar area in three cases and in the nasolabial fold in one case. Early after the injections the fundi of all patients demonstrated central retinal artery and choroidal occlusions. Later, two patients developed retinal pigment dispersion and one of them a pigmented optic disc. The scars on the skin showed similar characteristics in all patients, which could constitute an important marker in the presumptive diagnosis of platelet-rich plasma injection associated complications.

Autologous Platelet-Rich Fibrin in the Treatment of Refractory Macular Holes

Purpose

To describe a novel method for the treatment of refractory macular holes.

Methods

Two case reports on the use of autologous platelet rich fibrin (PRF), followed by sulfur hexafluoride gas tamponade to facilitate closure of refractory macular holes.

Results

Macular holes were succesfully closed within a week in both cases. Best corrected Snellen visual acuities improved from counting fingers to 0.16 in the first case, and from 0.05 to 0.2 in the second case. No complication occurred during or after the procedures.

Conclusion

The use of autologous PRF seems to be a safe and effective alternative method for the treatment of refractory macular holes. Further experience and studies are required to assess the value of autologous PRF in the management of challenging macular hole cases of different etiologies. To the best of our knowledge, this is the first use of autologous PRF in the treatment of macular holes.

Treatment of recurrent myopic macular hole using membrane of plasma rich in growth factors

Purpose

To describe the case of a patient with a recurrent large myopic macular hole (MH), who was successfully treated with a plasma rich in growth factors (PRGF) membrane.

Case Report

A 71-year-old patient presented a myopic MH in his right eye. One month later, pars plana vitrectomy with internal limiting membrane (ILM) peeling was performed, achieving closure of the MH. Three months later a recurrence was observed (700 µm) without visual acuity (VA) improvement. A new surgery was carried out placing an autologous PRGF-membrane into the MH, and performing a fluid-gas exchange at the end of the surgery. After two months of follow-up, the MH was completely closed, obtaining the anatomic recovery of the foveal depression, and improving the VA to 0.1. No adverse reactions were associated with the use of PRGF and there were no new recurrences of the MH in a follow-up period of six months.

Conclusion

The use of PRGF-membrane can be used as adjunctive therapy in the surgical repair of recurrent large myopic MHs, thus improving anatomic and visual outcomes.

Use of autologous platelet rich fibrin-based bioactive membrane in pressure ulcer healing in rats

OBJECTIVE

To verify the feasibility of treating pressure ulcers (PUs) with autologous platelet-rich fibrin-based (PRF) bioactive membrane, both in vitro and in vivo.

METHOD

An animal model using adult male Sprague-Dawley rats was used. Pressure was periodically exerted on the skin to induce localised ischaemia by using an external magnet and transplanted metal disc. After a PU developed, the rats were divided into two groups: a treatment group and a control group. Rats in the treatment group were then treated with PRF bioactive membrane every three days.

RESULTS

A total of 20 rats were used in this study. At days three and seven, the PU area in the PRF bioactive membrane-treated group was significantly smaller than that in the control group, and after 14 days of treatment, the PUs in the PRF bioactive membrane treatment group had healed. Haemotoxylin and eosin staining, immunohistochemistry and Western blot results indicated that PRF bioactive membrane induced wound healing by increasing the thickness of the regenerated epidermis and by upregulating vascular endothelial growth factor expression. Further, we found that different concentrations of rat autologous PRF soluble factors extraction components could significantly promote rat aortic endothelial cell proliferation, wound healing and migration ability in vitro.

CONCLUSION

Overall, results indicate that PRF bioactive membrane promotes PU healing in rats. Thus, it may represent a natural and effective wound-healing tool for use in the treatment of clinical skin PUs in humans in the future.

Macular Hole in Myopic Eyes: A Narrative Review of the Current Surgical Techniques

Macular hole (MH) in myopic eyes is a disease arising from complex tractional forces exerted by vitreomacular interface, epiretinal tissue, and progressive scleral ectasia of the posterior ocular globe wall. This retinal disease requires vitreoretinal treatment for its repair, and the surgical intervention remains a challenge also for experienced surgeons. The aim of this review is to describe the current knowledge regarding the pathogenesis of MH in myopic eyes and to detail novel surgical techniques and technological advancements in its surgical management.

Clinical Efficacy of Platelet-Rich Plasma in the Treatment of Neurotrophic Corneal Ulcer

Purpose

Platelet-rich plasma (PRP) is an autologous blood product without preservatives and rich in proteins and growth factors which make it possible for cells to differentiate, proliferate, and migrate, thus stimulating healing and regeneration of tissues. The aim of this study was to evaluate the efficiency of autologous platelet-rich plasma in the treatment of neurotrophic keratopathy.

Methods

The study group consists of 25 patients with nonhealing corneal ulcers due to herpes simplex or herpes zoster infection and facial nerve or trigeminal nerve paralysis as a result of a neurosurgical operation caused by a tumour or stroke. The patients were given autologous platelet-rich plasma drops five times a day and additionally preservative-free artificial tears and a vitamin A ointment at night for maximum 3 months. The following were evaluated: best corrected visual acuity (BCVA), healing of corneal surface, subjective symptoms, and changes in corneal thickness with the use of anterior segment optical coherent tomography (AS-OCT).

Results

BCVA before the treatment was 0.10 ± 0.14, and after the treatment it was –0.3 ± 0.27 (p=0.001). Improved visual acuity and less subjective symptoms were observed in all patients. Complete healing of the ulceration was observed in 20 patients (80%). Four patients (16%) experienced considerable improvement of their clinical condition (reduced size and depth of the ulceration and inflammatory state: smaller conjunctival injection and swelling, improved visual acuity, and less subjective symptoms). In one of the patients, an amniotic membrane was transplanted due to the lack of improvement of his local condition. In all patients, the progression of corneal thinning was stopped. An average corneal thickness in its thinnest point was 322.3 ± 125.8 µm before the treatment, and 404.5 ± 118.7 µm (p < 0.05) after the treatment. None of the patients reported general or local side effects of the treatment.

Conclusions

Autologous platelet-rich plasma is a blood-based product which seems efficient in the treatment of neurotrophic keratopathy.

Vitrectomy in high myopia: a narrative review

Pathologic myopia is associated with degenerative changes of the globe, especially at the posterior pole. Eyes affected by pathologic myopia have higher odds to undergo posterior segment surgery and, in those eyes, vitreoretinal surgery is challenging. Many practical tips and tricks can make the surgical procedures simpler, significantly preventing sight-threatening intra- and post-operative complications. Moreover, novel surgical techniques and technological advancements (i.e. ad-hoc instrumentation, minimally invasive vitreoretinal surgery, filters, dye staining, intraoperative optical coherence tomography and 3-dimensional surgery) may play role in highly myopic eyes. The aim of the present work is to review practical tips and tricks, novel surgical techniques and technological advancements.