Degenerative Lamellar Macular Holes Research Articles

Volumetric Biomarkers of Visual Outcome after Surgical Repair in Lamellar Macular Holes

Background: We investigate novel OCT parameters, based on the volumetric analysis of lamellar macular holes (LMHs), as prognostic indicators for visual outcomes after surgery. Methods: LMHs were divided into degenerative LMHs (D-LMHs) and ERM-foveoschisis (ERM-FS). Pre-operative clinical, OCT linear and volumetric parameters were collected. Volumes were obtained using the OCT automatic segmentation, such as central retinal volume (CRV) and outer nuclear layer (ONL) volume, or using a novel method to calculate volumes of specific LMH entities like epiretinal proliferation (ERP), foveal cavity (FC) in D-LMH and schitic volume (SV) in ERM-FS. Univariate and multivariate linear regression analysis evaluated the factors predictive for post-operative best-corrected visual acuity (BCVA). Results: We included 31 eyes of 31 patients (14 D-LMH,17 ERM-FS). A pre-operative BCVA ≤ 0.48 logMAR was a predictor for achieving ≤0.30 logMAR at final follow-up. A lower pre-operative BCVA (p = 0.008) and the presence of ERP (p = 0.002) were associated with worse visual outcomes post-surgery. Moreover, novel pre-operative OCT parameters significantly associated with worse post-operative BCVA, such as increased FC volume (p = 0.032) and lower CRV (p = 0.034) in the D-LMH subtype and lower CRV (p < 0.001) and ERP volume (p < 0.001), higher SV (p < 0.001) and foveal ONL volume (p < 0.001) in the ERM-FS subtype. Conclusions: Novel volumetric OCT parameters can be prognostic indicators of visual outcome following surgery in LMHs.

Phenomenology of spontaneous closure in degenerative and mixed type lamellar macular hole.

To the describe OCT imaging characteristics of a cohort of patients showing spontaneously closing degenerative or mixed type lamellar macular holes (LMH) and to compare them to the ones of a sex and age matched group showing stable lesions. Patients diagnosed with degenerative and mixed type LMHs showing OCT-documented spontaneous anatomical closure were retrospectively selected from 3 specialized retina centres. An equal number of age and sex matching subjects were randomly selected among patients with anatomically stable lesions. Eleven (11) spontaneously closing (SC group) and 11 stable (ST group) degenerative LMH with a mean follow up of 4 years were recruited. Hyperreflective inner border (HIB) and linear hyperreflectivity in the outer plexiform layer (LHOP) at baseline were significantly more prevalent in SC group in processed images (respectively p = 0.007 and p = 0.003). A borderline significance in lamellar hole associated epiretinal proliferation (LHEP) at last follow up was detected (p = 0.085). As for mixed type LMH, 10 patients for SC group and 10 for ST group were recruited. LHOP at baseline in processed images was significantly more prevalent in SC group (p = 0.005). Spontaneously closing LMHs show higher prevalence of HIB and LHOP at the beginning of the closing process, a difference which is enhanced by image processing. These signs might be a signal of microglial and Muller cells coordinated activation.

Lamellar macular defects: are degenerative lamellar macular holes truly degenerative?

To investigate morpho-functional changes after surgical treatment for ERM foveoschisis or lamellar macular hole (LMH), and to evaluate whether the two entities are associated with different healing processes and long-term outcomes. Retrospective interventional case series. A total of 56 eyes, treated for lamellar macular defects and followed up for 24 months, were enrolled. The eyes were divided into two groups: 34 with ERM foveoschisis and 22 with LMH. Changes in the following features were evaluated and compared between the two groups: best-corrected visual acuity (BCVA), external limiting membrane (ELM) and ellipsoid zone (EZ) defects, central foveal thickness (CFT), and autofluorescence (FAF) diameter and area. After surgery, progressive BCVA improvement was observed with no significant difference between the two groups (p-value: 0.06). An increased number of eyes with intact outer-retinal layers was found both in the ERM foveoschisis and LMH groups. FAF diameter and area decreased significantly throughout the FU with no significant difference between the two groups (p-value: 0.2). In the present study, significant functional and microstructural improvements were observed after surgery for both ERM foveoschisis and LMH, demonstrating considerable repair potential in both types of lamellar defects. These findings question the true "degenerative" nature of LMH.

Primary vitrectomy for degenerative and tractional lamellar macular holes: A systematic review and meta-analysis.

PurposeTo assess the efficacy of vitrectomy in degenerative and tractional lamellar macular holes (LMHs) by meta-analysis of published studies.MethodsPubMed, Medline and Embase databases were searched up to May 2020. Included cohorts were divided into three groups: degenerative LMH group, lamellar hole associated epiretinal proliferation (LHEP) group and tractional LMH group. LHEP is likely to be associated with degenerative LMHs, but less commonly could be associated with mixed LMHs. To reduce risk of possible misclassification bias, eyes with LHEP which could not have been precisely classified by the authors, were included into the LHEP group. The primary outcome was to investigate the visual change following primary vitrectomy in the degenerative LMH and LHEP group versus the tractional LMH group. A sensitivity analysis excluding the LHEP group was also performed on the primary outcome. Mean difference (MD) in best corrected visual acuity between baseline and post-treatment was calculated, along with 95% confidence interval (CI). Rate of incidence of post-operative full-thickness macular hole (FTMH) was assessed as secondary outcome.ResultsThirteen studies were included. Pooled analyses including all groups showed a significant visual improvement following vitrectomy (pre-post MD = -0.17;95%CI = -0.22,-0.12;p<0.001), with no difference in visual improvement between the degenerative LMH and LHEP group and the tractional LMH group. The sensitivity analysis excluding LHEP group confirmed no difference in visual change between the degenerative LMH group (pre-post MD = -0.18;95%CI = -0.24,-0.12;p<0.001) and the tractional LMH group (MD = -0.16;95%CI = -0.26,-0.07;p<0.001). The incidence rate of post-operative FTMH was higher in the degenerative LMH and LHEP group than in the tractional LMH group (p = 0.002).ConclusionPrimary vitrectomy for LMH ensured a favorable visual outcome, with no difference in visual gain between degenerative and tractional LMHs. However, a higher incidence of post-operative FTMHs was found in eyes with the degenerative LMH subtype.

Degenerative lamellar macular holes: tractional development and morphological alterations

PurposeThe 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.MethodsA retrospective case series of 44 eyes of 44 patients is described.ResultsThe 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.ConclusionsTractional 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.

Nodular Epiretinal Gliosis in the Fovea

Abstract To describe a peculiar hyperreflective optical coherence tomography finding of nodular epiretinal gliosis at the fovea that may be a manifestation of Muller response to retinal injury. The central fovea is stabilized by the Muller cell cone but is at risk of foveal dehiscence due to various insults including vitreomacular traction which can lead to lamellar or full thickness macular hole formation. 1 Degenerative lamellar macular holes can be associated with epiretinal proliferation which has been attributed to activated Muller cells. 2 In this report, we describe a very unusual optical coherence tomography (OCT) finding of nodular epiretinal gliosis which may be the result of Muller cell activation and expansion.

Optical coherence tomography angiographic findings of lamellar macular hole: comparisons between tractional and degenerative subtypes

We investigated the microvascular changes in eyes with lamellar macular holes (LMHs) using optical coherence tomography angiography (OCTA), compare them between two subtypes of LMH. Tractional and degenerative LMH were differentiated based on the morphological characteristics of OCT. In OCTA images, foveal and parafoveal vessel density (VD) in the superficial and deep capillary plexus (SCP, DCP) and foveal avascular zone (FAZ) area were measured. Eyes that underwent vitrectomy for LMH were included in subgroup analysis. We analysed 63 LMH (42 tractional and 21 degenerative) eyes and 63 control eyes. Compared with degenerative LMH, tractional LMH had better BCVA (p = 0.010), smaller FAZ area (p = 0.001), and higher foveal VD in the SCP (p = 0.130) and DCP (p = 0.002). In degenerative LMH, better BCVA was associated with greater foveal VD in the SCP (p = 0.040) and DCP (p = 0.005), and parafoveal VD in the SCP (p = 0.006). In subgroup analysis, only the tractional LMH group showed significant increases in foveal and parafoveal VDs in the SCP after vitrectomy (p = 0.001 and p = 0.026, respectively). Significant differences in microvascular changes were noted between tractional and degenerative LMH, suggesting that two subtypes are distinct pathogenetic entities.

Surgical interventions for degenerative lamellar macular holes

Objectives This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effect of surgical interventions on postoperative visual and anatomical outcomes in people with a confirmed degenerative lamellar macular hole.

Natural course of lamellar macular holes

To study natural course of LMH and to develop criteria of their progression. The study analyses retrospective data of patients with LMH observed in S. Fyodorov Eye Microsurgery Federal State Institution from 2013 to 2018 who were examined by optical coherence tomography (OCT) at least 2 times with an interval between the initial and last examinations of at least 6 months. The examinations were carried out to evaluate the types of LMH and epiretinal membrane, the ellipsoid zone of photoreceptors and vitreoretinal interface, as well as calculate the changes in the quantitative parameters of the LMH. One hundred and three patients with LMH were identified; data of 65 patients (65 eyes) was studied in detail. The follow-up lasted 20.5±12.9 months on average. Statistically substantiated criteria for the progression of tractional and degenerative LMH were developed, taking into account the OCT changes most significant for each type of LMH. According to the proposed criteria, signs of marked progression were found in 2 (5.3%) of 38 patients with tractional and 4 (14.8%) of 27 patients with degenerative LMH. Moderate progression was detected in 2 (5.3%) patients with tractional and 2 (7.4%) patients with degenerative LMH. In two patients who were not included in the groups for calculating the criteria for progression, the formation of a full-thickness macular hole has occurred. One of the variants of the natural course of LMH can be its progression up to transition into a full-thickness macular hole. The proposed statistically substantiated criteria allows identifying dangerous progression of LMH, which should be taken into account when determining the treatment tactics.

Comparison of Surgical Outcomes Between Two Types of Lamellar Macular Holes.

PurposeThe classification of lamellar macular holes (LMHs) into two subtypes has recently been proposed. However, the effectiveness of vitrectomy for treatment of each type of LMH is not well established. The goal of this study was to compare functional and anatomic changes after vitrectomy between eyes with degenerative LMH and those with tractional LMH.Patients and methodsThis was a retrospective analysis of the medical records of patients with LMH who underwent vitrectomy. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) were measured preoperatively (baseline), as well as at 1, 3 and 12 months postoperatively. BCVA and CMT were compared between eyes with degenerative LMH and those with tractional LMH.ResultsThirty-two eyes met the inclusion criteria. Thirteen eyes were diagnosed with degenerative LMH and 19 eyes were diagnosed with tractional LMH. Compared with baseline BCVA, postoperative BCVA improved significantly at 12 months postoperatively: from 0.33 to 0.12 logarithm of the minimum angle of resolution (logMAR) in eyes with degenerative LMH and from 0.30 to 0.12 logMAR in eyes with tractional LMH (p < 0.05 for both comparisons). BCVA at 12 months postoperatively did not significantly differ between the two groups. CMT decreased significantly from 419.4 µm at baseline to 364.2 µm at 12 months postoperatively in eyes with tractional LMH (p < 0.05); conversely, there was no significant difference in eyes with degenerative LMH (315.5 µm baseline to 314.9 µm at 12 months postoperatively; p > 0.05).ConclusionVitrectomy improved BCVA in eyes with degenerative LMH as well as in eyes with tractional LMH. BCVA at 12 months postoperatively did not differ between the two groups.

STRUCTURAL AND FUNCTIONAL CHARACTERISTICS OF LAMELLAR MACULAR HOLES.

Lamellar macular holes (LMHs) can been subdivided into tractional and degenerative subtypes. This cross-sectional cohort study compared structural and functional characteristics in these subtypes hypothesizing that tractional LMH has a higher prevalence of vitreopapillary adhesion and tangential traction (macular pucker), whereas degenerative LMH has more ellipsoid zone disruption and worse vision, measured three different ways. Tractional LMH (n = 22) and degenerative LMH (n = 15) were distinguished by optical coherence tomography criteria. Separate spectral domain optical coherence tomography scanning of the macula and optic disk was performed. Visual acuity, contrast sensitivity function (Weber Index, %W), and the degree of visual distortions (3-dimensional threshold Amsler grid; % volume lost [%VL]) were quantified. Vitreopapillary adhesion was present in 14/22 (64%) tractional, but in only 3/15 (20%) degenerative LMH (P = 0.006). Macular pucker was present in 19/22 (86%) tractional, but in only 8/15 (53%) degenerative LMH (P = 0.011). Ellipsoid zone disruption was present in 13/15 (87%) degenerative, but in only 2/22 (9%) tractional LMH (P = 0.0001). Visual acuity was better in tractional than degenerative LMH (P = 0.006), as was contrast sensitivity function (tractional = 3.44 ± 1.07 %W, degenerative = 4.66 ± 1.73 %W; P = 0.015). Visual distortions were less in tractional (0.33 ± 0.61 %VL) than in degenerative (0.85 ± 0.68 %VL) LMH (P = 0.014). Structure and visual function differ significantly in subtypes of LMH. Tractional LMH has 3-fold higher prevalence of vitreopapillary adhesion and 2-fold higher prevalence of macular pucker. Degenerative LMH has 9-fold more ellipsoid zone disruption, worse visual acuity and contrast sensitivity function, and 3-fold more distortions. Thus, outer retinal integrity seems more closely correlated with vision than anterior structural abnormalities in LMH.

LAMELLAR MACULAR HOLES IN THE PRESENCE OF AGE-RELATED MACULAR DEGENERATION.

To investigate whether age-related macular degeneration (AMD) has an influence on the prevalence and anatomical characteristics of lamellar macular holes (LMHs). Clinical records and spectral-domain optical coherence tomography images of 756 eyes of 423 consecutive patients diagnosed with AMD were reviewed and analyzed. Spectral-domain optical coherence tomography was used to identify degenerative or tractional LMH subtypes and assess their morphology. The clinical and optical coherence tomography findings of AMD eyes with LMH were compared with those of a control group of eyes with LMH without AMD from a previously published report. Lamellar macular holes were identified in 25 eyes of 23 patients (3.3%; 25 of 756). Seventeen of 25 eyes (68%) presented with degenerative LMH and underlying late neovascular AMD. Mean best-corrected visual acuity was worse in eyes with AMD and LMH eyes than in those with AMD and no LMH (20/230 vs. 20/98; P = 0.02). The mean outer diameter was greater in the group with degenerative LMH with concomitant AMD than in the control group of degenerative LMH without AMD (1,323.9 ± 999.1 µm vs. 905.9 ± 356.8 µm, respectively; P = 0.01). The incidence of degenerative LMH increased in advanced forms of AMD, whereas the presence of tractional LMH subtype may be unrelated to AMD evolution.

Higher Vascular Density of the Superficial Retinal Capillary Plexus in Degenerative Lamellar Macular Holes.

Optical coherence tomography angiography (OCTA) comparison between vessel density in patients with degenerative-subtype lamellar macular hole (LMH) and healthy individuals. Unaffected fellow eyes were also included in the study. This observational, cross-sectional study examined 32 eyes affected by unilateral degenerative-subtype LMH, as well as the 32 fellow eyes of the enrolled population. Thirty healthy eyes were used as controls. ImageJ software was used to calculate macular vessel density in the three vascular plexuses (superficial capillary plexus [SCP], deep capillary plexus [DCP], choriocapillaris [CC]) in two regions: (1) a fovea-centered 1.5-mm diameter circular area after subtracting the foveal avascular zone (FAZ) area, obtaining a "ring" in the immediate FAZ proximity (peri-FAZ); (2) the area external to (1) included in the scan. In the peri-FAZ, the SCP of both LMH and fellow eyes showed higher vascular density than in controls (P = .004 for LMH; P = .015 for fellow eye), whereas no difference was evident between LMH and fellow eyes (P = .190). No changes were found in the DCP or the CC. No differences in vessel density of the three plexuses in the area outside the peri-FAZ were evident in any of the three groups. The FAZ in the SCP was larger in the LMH (0.39 ± 0.16 mm2) and in the fellow eye (0.39 ± 0.21 mm2) groups compared with controls (0.27 ± 0.07 mm2; P = .021 for LMH; P = .0043 for fellow eye), whereas it was similar between LMH and fellow eyes (P = .967). Degenerative-subtype LMH in the immediate proximity of the FAZ has a larger FAZ and higher vascular density in the SCP compared with healthy eyes. Unaffected fellow eyes also have increased vascular density compared with controls. Microvascular changes are evident in both LMH and unaffected fellow eyes and might play a role in disease pathogenesis. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e112-e117.].

Lamellar Macular Hole: Two Distinct Clinical Entities?

To investigate whether lamellar macular holes can be divided into different subgroups. Retrospective observational case series. In this institutional study, clinical charts and spectral-domain optical coherence tomography (OCT) images of 102 eyes of 90 consecutive patients diagnosed with lamellar macular hole were reviewed. In OCT imaging, the presence of lamellar macular hole was defined according to the following findings: presence of irregular foveal contour, separation of the layers of the neurosensory retina, and the absence of full-thickness macular defect. Mean outcome was the morphologic andfunctional characterization of different subtypes of macular hole. Two different subtypes of lamellar macular hole were identified: tractional and degenerative. The first type, tractional, was diagnosed in 43 eyes, and was characterized by the schitic separation of neurosensory retina between outer plexiform and outer nuclear layers. It often presented with an intact ellipsoid layer and was associated with tractional epiretinal membranes and/or vitreomacular traction. The second type, degenerative, was diagnosed in 48 eyes, and its distinctive traits included the presence of intraretinal cavitation that could affect all retinal layers. It was often associated with nontractional epiretinal proliferation and a retinal "bump." Moreover, it often presented with early ellipsoidal zone defect and its pathogenesis, although chronic and progressive, remains poorly understood. Eleven eyes shared common features with both tractional and degenerative lamellar macular holes and were classified as mixed lesions. Degenerative and tractional lamellar macular holes may be 2 distinct clinical entities. A revision of the current concept of lamellar macular holes is needed.