Early outcomes of macular hole surgery on visual acuity, retinal anatomy and vision-related quality of life.

Abstract

Macular hole (MH) is a defect in the central neurosensory retina affecting the fovea. Generally, MHs are idiopathic, but infrequently, MHs can be seen in highly myopic eyes, or post-traumatically. Idiopathic MH (IMH) is a common disorder with an estimated annual incidence of 8/100 000 individuals (Allen et al. 1998; Giansanti et al. 2011; Xu et al. 2013). Over 70% of IMHs occur in women and more than half in patients 65–74 years old (Giansanti et al. 2011). We evaluated the outcome of pars plana vitrectomy in IMH treatment. Postoperative best corrected visual acuity (BCVA), macular closure, retinal thickness, need for additional surgery, intra-operative and postoperative complications, vision-related quality of life (VR-QoL) and the patients' opinion of surgical outcomes were assessed. In this prospective, interventional case study, 20 consecutive patients underwent 23-gauge transconjunctival pars plana vitrectomy with internal limiting membrane (ILM) peeling and gas tamponade to treat IMH. To minimize the bias by the surgeon or surgical technique, two experienced vitreoretinal surgeons performed the operations with similar technique including postoperative 1-week face-down positioning. Comprehensive ophthalmic examinations were preformed postoperatively and at one and three months. Cross-sectional images of the MH by optical coherence tomography (OCT), measurements of minimum diameter, base diameter and hole height were analysed (Fig. 1). The macular hole index (MHI) is calculated as the ratio of hole height to base diameter (Kusuhara et al. 2004). VR-QoL was evaluated by the VF-14-questionnaire. The patients' experiences of the surgical outcome were determined using another questionnaire. The study protocol was explained to each patient and informed consent obtained. The participants had the right to withdraw from the study under the Helsinki Declaration. The average age of the patients at the time of surgery was 68 (68 ± 7, range 56–83 years). 70% (14/20) of the patients were women. All patients had unilateral IMHs. One patient had stage 1, 3 stage 2, 10 stage 3 and 6 stage 4 MHs. Preoperative BCVA was 0.2 on average (Snellen E-chart) (0.2 ± 0.1, range 0.04–0.5), whereas mean postoperative BCVA was 0.3 (0.3 ± 0.2, range 0.02–0.8). Initial anatomical closure of the IMH was achieved in 75% (15/20) of patients. Retinal thickness decreased from 450 μm (450 ± 85) to 380 μm (380 ± 88) postoperatively (p = 0.025, t-test). Decrease in retinal thickness correlated with postoperative BCVA (p = 0.045, Pearson analysis), and postoperative BCVA in the MHI >0.5 group was better than in the MHI <0.5 group (p = 0.048, t-test). The patients with stage 3 MHs achieved the best postoperative visual outcomes and experienced most advantages (63%) from surgery compared to those with stage 2 or 4 MHs. 59% of patients experienced surgical intervention benefit. Postoperative VF score was 85 on average (85 ± 23, range 16–100), which correlated significantly with postoperative BCVA (p = 0.045, Pearson analysis). Five patients developed postoperative cataract and one patient needed further surgery to reduce intra-ocular pressure. Five patients needed revitrectomy with silicone oil tamponade due to failure of MH closure. The final closure rate after reoperation was 85% (17/20). Most patients' experience of IMH vitrectomy was favourable, although VA may not have improved significantly. Even patients with advanced MHs seemed to benefit from surgery. Improvement of VR-QoL is related to increased postoperative BCVA, which correlates significantly with decreased macular thickness. Poorer preoperative VA may result in better postoperative VR-QoL in cases of anatomical closure of the MH due to prevention of further visual impairment. Better visual outcomes in patients with small MHs may not produce better VR-QoL because preoperative visual disturbances were less marked. In agreement with previous studies, MHI or preoperative VA may serve as a prognostic tool for MH surgery (Kusuhara et al. 2004; Hirneiss et al. 2007). Larger population studies are needed to establish MH surgery optimal timing. It seems obvious, however, that vitrectomy improves VR-QoL in patients with MH.