Evaluation of neuroretinal integrity in optical coherence tomography-graded eyes with partial-thickness macular holes.

Idiopathic Macular Hole Preferred Practice Pattern®

To report on epiretinal membrane (ERM) characteristics and photoreceptor layer integrity of lamellar macular holes (LMHs) and macular pseudoholes (MPHs), and to compare with clinical course in operated and untreated eyes. We consecutively reviewed the charts of patients with LMH and MPH between 2003 and 2013. For clinical analysis, we included 87 eyes (48 with LMH, 39 with MPH) with a minimum follow-up of 6 months. Of these, we included 64 eyes (37 with LMH, 27 with MPH) for high-resolution spectral domain optical coherence tomography analysis with examinations fulfilling the required resolution and quality of optical coherence tomography images. Epiretinal membranes were termed "typical tractional ERM" if presenting with contractive properties, or "atypical epiretinal tissue" if presenting as epiretinal material of homogeneous medium reflectivity without contractive properties. Integrity or discontinuity of the inner and outer segment (IS/OS) and the external limiting membrane (ELM) was evaluated by differentiating between "defect present" and "defect absent." In eyes with LMH, atypical epiretinal tissue presented in 29%, typical tractional ERMs were seen in 57%, and a combination of both in 14%. In contrast, eyes with MPH rarely presented atypical epiretinal tissue, and typical tractional ERMs were found in 89%. Comparing cases with LMH, eyes with atypical epiretinal tissue showed significantly more defects of the IS/OS and the ELM than eyes with typical tractional ERM. Both IS/OS and ELM defects correlated with a significant lower best-corrected visual acuity. Defects of the IS/OS were seen in 41% of LMH and 11% of MPH. Defects of the ELM revealed in 27% of LMH and in 11% of MPH. Operated eyes with disrupted IS/OS but intact ELM had significant better best-corrected visual acuity than eyes with defects in both layers. Atypical epiretinal tissue is related to the presence of photoreceptor layer defects and to poor visual acuity. It seems that integrity of the ELM is most important for functional recovery after surgery in both LMH and MPH. The presence of atypical epiretinal tissue in eyes with LMH may represent differences in the pathogenesis compared with MPH, and might have therapeutic implications for the proceeding with macular surgery in selected cases.

Purpose: To characterize the change in visual acuity (VA) in eyes treated with vitrectomy using the 2020 international consensus-based optical coherence tomography (OCT) definition of lamellar macular hole (LMH), macular pseudohole (MPH), and epiretinal membrane with foveoschisis (ERMF). Methods: A retrospective chart review was performed from 2000 to 2022 of patients who had vitrectomy for symptomatic decreased VA from LMH, MPH, or ERMF performed by the same surgeon at a community hospital. Preoperative spectral domain (SD-OCT) was reviewed to classify patients using the consensus guidelines. Primary outcomes were the mean change in best-corrected VA at 3 months, 1 year, and the final postoperative examination. Results: Fifty-one patients were included, 30 with LMH, 14 with MPH, and 7 with ERMF. The VA was 20/63 at baseline, 20/62 (P = .79) 3 months postoperatively, 20/40 (P = .003) at 1 year, and 20/52 (P = .10) at the final examination for LMH; 20/64, 20/50 (P = .16), 20/40 (P = .040), and 20/40 (P = .02), respectively, for MPH; and 20/53, 20/50 (P = .42), 20/30 (P = .03), and 20/38 (P = .04), respectively, for ERMF. Subgroup analysis showed that eyes with LMH without ellipsoid zone (EZ) disruption on SD-OCT improved from 20/57 at baseline to 20/39 (P = .01) at the final examination. Conclusions: There was no significant improvement in VA at the final postvitrectomy examination in eyes with LMH, while there was significant improvement in eyes with MPH and ERMF. This supports surgery in selected eyes with MPH and ERMF but possibly not in eyes with LMH, unless OCT shows no EZ disruption.

Aim:To assess fundus autofluorescence (AF) for differential diagnosis of macular pseudoholes (MPH) and lamellar macular holes (LMH) evaluated by optical coherence tomography (OCT) as the “gold standard”.Methods:The files on 50...

There is a wide spectrum of macular conditions that are characterized by an irregular foveal contour caused by a break in the inner fovea. These include full-thickness macular hole (FTMH), foveal pseudocyst, lamellar macular hole (LMH) and macular pseudohole (MPH). Clinical examination of vitreomacular interface disorders is notoriously poor in differentiating these conditions. These conditions were initially described with slit-lamp biomicroscopy, and the main goal was to distinguish an FTMH from the others. The introduction of optical coherence tomography (OCT) has revolutionized our understanding of the foveal microstructural anatomy and has facilitated differentiating these conditions from an FTMH. However, the definitions of the other conditions, particularly LMH, has evolved over the past two decades. Initially the term LMH encompassed a wide spectrum of clinical conditions. As OCT became more widely used and observations became more refined, two different phenotypes of LMH became apparent, raising the question of different pathogenic mechanisms for each phenotype. Tractional and degenerative pathological mechanisms were proposed. Epiretinal membranes (ERMs) associated with each phenotype were identified. Typical ERMs were associated with a tractional mechanism, whereas an epiretinal proliferation was associated with a degenerative mechanism. Epiretinal proliferation represents Müller cell proliferation as a reactive process to retinal injury. These two types of ERM were differentiated by their characteristics on SD-OCT. The latest consensus definitions take into account this phenotypic differentiation and classifies these entities into LMH, MPH and ERM foveoschisis. The initial event in both ERM foveoschisis and LMH is a tractional event that disrupts the Müller cell cone in the foveola or the foveal walls. Depending on the extent of Müller cell disruption, either a LMH or an ERM foveoschisis may develop. Although surgical intervention for LMH remains controversial and no clear guidelines exist for pars plana vitrectomy (PPV), eyes with symptomatic, progressive ERM foveoschisis and LMH may benefit from surgical intervention.

PurposeTo evaluate clinical and optical coherence tomography (OCT) findings and visual outcomes in patients with macular pseudohole (MPH), epiretinal membrane foveoschisis (ERM-FS), and lamellar macular hole (LMH) based on axial length (AL).MethodsWe retrospectively reviewed consecutive patients diagnosed with MPH, ERM-FS, and LMH who underwent vitrectomy and were followed for at least 6 months postoperatively. In each disease group, eyes were categorized into three groups based on AL; normal (< 24 mm), myopic (≥ 24 to < 26 mm), and highly myopic (≥ 26 mm). Analyzed factors included age, AL, preoperative and postoperative best-corrected visual acuity (BCVA), and OCT parameters such as the presence of inner and outer retinal cysts, epiretinal proliferation, and ellipsoid zone disruption.ResultsA total of 171 eyes from 170 patients (79 males and 91 females) were included: 74 eyes with MPH, 59 eyes with ERM-FS, and 38 eyes with LMH. Postoperative BCVA significantly improved in all AL groups across all disease types. In the MPH group, postoperative BCVA was significantly better in the highly myopic group than in the myopic group (p = 0.04). There were no significant differences in the frequency of the OCT findings among the AL groups in any of the diseases. However, the presence of outer cysts at 6 months postoperatively tended to be more frequent in the highly myopic group in LMH (p = 0.065).ConclusionVitrectomy improved visual acuity in all AL groups across MPH, ERM-FS, and LMH. AL did not significantly affect the frequency of abnormal findings for the preoperative and postoperative OCT.

To evaluate the optical coherence tomography (OCT) findings of epiretinal membrane (ERM) and its three associated diseases: macular pseudohole (MPH), ERM-foveoschisis (ERM-FS), and lamellar macular hole (LMH). We retrospectively reviewed all eyes that underwent vitrectomy with a follow-up of at least 6 months. All eyes were classified into four groups, ERM, MPH, ERM-FS, and LMH based on spectral-domain (SD) OCT findings. Factors analyzed included preoperative and postoperative best-corrected visual acuity (BCVA), presence of inner and outer retinal cysts, epiretinal proliferation (EP), and ellipsoid zone (EZ) disruption, central fovea thickness (CFT), central retina thickness (CRT), and macular volume (MV). After enrolling 720 eyes of 664 patients, eyes were classified into four groups: ERM (592 eyes), MPH (76 eyes), ERM-FS (63 eyes), and LMH (42 eyes). BCVA significantly improved in all groups. Although preoperative BCVA was not significantly different among the four groups, postoperative BCVA was significantly worse in LMH versus ERM (p < 0.001). Inner and outer retinal cysts were significantly more prevalent in ERM-FS versus ERM and the other three groups, respectively. EP was significantly more frequently observed in LMH versus the other three groups (p < 0.001). CFT and CRT were significantly higher in ERM versus the other three groups, and MV was significantly larger in ERM than in MPH and LMH (p < 0.05). ERM had a higher CFT and CRT, and a larger MV. The postoperative BCVA was worse in LMH versus ERM, while LMH had a higher frequency of EP.

Lamellar Macular Holes: Tomographic Features and Surgical Outcome

Background/Objectives: To investigate and compare the clinical characteristics of epiretinal membrane (ERM) and associated diseases: macular pseudohole (MPH), ERM foveoschisis (ERM-FS), and lamellar macular hole (LMH). Methods: We retrospectively reviewed of all patients who underwent vitrectomy with at least 6 months follow-up, all eyes were classified into four groups: ERM, MPH, ERM-FS, and LMH. Age, gender, presence of glaucoma, preoperative spherical equivalent, axial length (AL), preoperative and postoperative best-corrected visual acuity (BCVA), metamorphopsia using M-CHARTS®, and frequency of overlapping associated diseases were investigated. The association between pre- and postoperative BCVA and these clinical factors was analyzed. Results: After enrolling 718 eyes of 662 patients, eyes were classified as ERM (592 eyes), MPH (76 eyes), ERM-FS (63 eyes), and LMH (42 eyes). Overlapping cases included MPH+ERM-FS (17 eyes), ERM-FS+LMH (14 eyes), MPH+LMH (18 eyes), and MPH+ERM-FS+LMH (3 eyes). The AL was significantly longer (p < 0.05) in MPH, ERM-FS, and LMH versus ERM. In all groups, BCVA significantly improved after vitrectomy. Although preoperative BCVA was not significantly different among the four groups, postoperative BCVA was significantly worse for LMH versus ERM (p < 0.001). Preoperative metamorphopsia was significantly more severe in ERM (0.52 ± 0.51) versus MPH (0.34 ± 0.29) (p < 0.05). Postoperative BCVA correlated with preoperative BCVA and age in all groups except LMH. Conclusions: Associated diseases often overlap and were more myopic than ERM. Postoperative BCVA was worse in LMH, while preoperative metamorphopsia was severe in ERM. These results highlight the importance of both clinical and functional evaluations in determining surgical indications and predicting visual outcomes.

Introduction: The aim of this study was to describe differences in the vitreomacular interface (VMI) in idiopathic epiretinal membrane (ERM) foveoschisis compared to macular pseudohole (MPH) and lamellar macular hole (LMH). Methods: We analysed surgically excised epiretinal material and internal limiting membrane (ILM) specimens obtained from 16 eyes of 16 patients with ERM foveoschisis (6 eyes), MPH (5 eyes), and LMH (5 eyes) during standard pars plana vitrectomy (PPV) with membrane peeling. The three entities were classified according to the newly introduced optical coherence tomography (OCT) terminology. Transmission electron microscopy (TEM) was used to describe the ultrastructural features. Results: We found fibrocellular epiretinal tissues in all samples analysed. However, the cell and collagen composition of the VMI differed between groups. Eyes with ERM foveoschisis were characterized by a higher number of cells, multilayered membranes, and thick strands of vitreous collagen embedding the major cell types of myofibroblasts compared to MPH. Eyes with MPH also showed a predominance of myofibroblasts, but these were located directly on the ILM with no collagen between the cells and the ILM. Eyes with LMH showed a thick, multilayered epiretinal proliferation consisting mainly of non-tractional glial cells, corresponding to hypodense epiretinal proliferation on OCT. Eyes with ERM foveoschisis and MPH were more likely to have incomplete PVD compared to LMH in terms of posterior hyaloid status. Discussion/Conclusion: Tractional ERMs in eyes with ERM foveoschisis and MPH differ in their ultrastructure. The main difference is in the amount and topographical distribution of vitreous collagen. However, the epiretinal cell types are predominantly myofibroblasts in both entities. This highlights the importance of distinguishing ERM foveoschisis from both MPH and LMH in terms of pathogenesis and surgical peeling procedures.

Macular pseudohole is characterized by a specific appearance of epiretinal membranes (ERM) that spares the foveal center resembling a macular hole in the ophthalmoscopic examination. The foveal center is displaced by the contraction of ERM. The differential diagnosis of pseudoholes from full-thickness and lamellar macular holes may not be easy. The natural history of macular pseudoholes is good but vision may decrease if the distortion in foveal center increases. The outcome of early surgical treatment of full-thickness macular holes is good and several methods and tests have been used for the differential diagnosis of full-thickness macular holes and pseudoholes. The diagnosis, determination of pathogenetic mechanisms, and subgroups of macular pseudoholes have become relatively easy after the availability of optical coherence tomography in ophthalmological practice. The macular pseudoholes may be classified as a subgroup of ERM’s and the treatment is either observation or vitreoretinal surgery with a good outcome in cases with decreased visual acuity.

To evaluate clinical features and visual outcomes in macular pseudohole (MPH) and to investigate associations between visual acuity and optical coherence tomography (OCT) parameters in patients with MPH. We retrospectively reviewed consecutive patients with MPH who underwent vitrectomy and were followed for at least 6 months after surgery. MPH was diagnosed based on spectral-domain OCT findings. Analysed factors included axial length, spherical equivalent, overlapping cases of epiretinal membrane foveoschisis (ERM-FS) and lamellar macular hole (LMH), presence of glaucoma, preoperative and postoperative best-corrected visual acuity (BCVA), presence of inner and outer retinal cysts, epiretinal proliferation (EP) and ellipsoid zone (EZ) disruption. This study enrolled 76 eyes of 75 patients, with overlapping cases that included MPH+ERM FS (17 eyes), MPH+LMH (18 eyes) and MPH+ERM FS + LMH (3 eyes). BCVA significantly improved from 0.29±0.25 preoperatively to 0.06±0.17 postoperatively (p<0.001). Preoperative BCVA and the presence of EP exhibited significant associations with worse postoperative BCVA (p<0.0005 and p<0.05, respectively). Presence of EZ disruption at 3 and 6 months postoperatively was associated with worse postoperative BCVA (p<0.001 and p<0.01, respectively). There was significant improvement in patients with MPH after undergoing surgery. Current results suggest preoperative poor visual acuity, preoperative presence of EP and postoperative EZ disruption are negative prognostic factors for visual outcomes.

Macular Pseudoholes With Lamellar Cleavage of Their Edge Remain Pseudoholes

Purpose Macular hole surgery has been long‐established practice in vitreoretinal surgery and yet there is still controversy over its management especially around the value of postoperative face‐down posturing on its outcome. Surgical indications for lamellar macular holes (LMH) are far more controversial. OCT has become the standard assessment tool for success evaluation and may even yield prognostic value.Methods Review of current published literature regarding posturing vs. non‐posturing for full‐thickness macular holes (FTMH), surgery vs. observation in lamellar macular holes (LMH).Results 21 studies investigating the effect of face‐down posturing on the outcome of macular hole surgery were identified. 11 studies included a comparison group and were deemed suitable for inclusion in the meta‐analysis. Of three RCTs, two suggested a benefit in larger holes but none demonstrated evidence of benefit in smaller holes. The lamellar macular hole group is much more heterogenous with some authors distinguishing between lamellar macular holes (LMH) and macular pseudoholes (MPH). Some morphological OCT changes, such as oedema, cystic spaces and lamellar holes were commonly seen in patients with epiretinal membrane (ERM). The presence or absence of an intact IS/OS layer may correlate with visual outcome.Conclusion The field surgery is constantly changing even for what is considered standard surgery in macular holes. The trend towards postoperative posturing seems to recur, especially for macular holes larger than 400μm. CONSORT‐adherent RCTs would be required to provide future guidance. Lamellar macular holes are still a poorly defined group with proponents and detractors in balance. The presence of concurrent ERM on OCT may tip the balance towards surgery.

To report the surgical outcome of pars plana vitrectomy (PPV) without internal limiting membrane (ILM) peeling in three highly myopic patients with macular retinoschisis and associated posterior staphyloma. We report three highly myopic patients with macular retinoschisis and foveal detachment who underwent simple PPV without ILM peeling, with long-acting gas tamponade. Main outcome evaluations included best corrected visual acuity, biomicroscopic appearance and optical coherence tomography findings. Pars plana vitrectomy without ILM peeling resulted in anatomic and functional improvement in all three operated eyes for follow-up periods of > or = 12 months. Pars plana vitrectomy without ILM peeling is effective for treating macular retinoschisis and foveal detachment in highly myopic eyes with posterior staphyloma. Visual and anatomic outcomes are comparable with those in previous studies in which ILM removal was performed.