Gass Classification Research Articles

Idiopathic macular hole – literature review.

Full-thickness idiopathic macular hole (MH) is a common cause of visual loss, affecting 3 per 1000 people. It usually affects females in their sixth to eighth decades of life. Best Visual Acuity decreases to less than 0.5. A typical MH’s symptom is the pincushion metamorphopsia, where the shape of an observed object is enrolled inwards and lines are bowed towards the center, in the direction of the fixation point. Over the years many theories of MH formation have been revealed. A recently approved theory states that vitreomacular adhesion with focal contraction of the perifoveal cheloid and pathologic traction can lead to a loss of full-thickness central retina causing a MH. The most valuable diagnostic procedure for MH is optical coherence tomography. Among other useful examinations are fluorescein angiography and angio-OCT. Classification of the stages of development of MH is done with an anatomical Gass classification and the recent The International Vitreomacular Traction Study Group Classification of Vitreomacular Adhesion, Traction, and MH. Natural history of the MH differs in the early and advanced stages. Pharmacological vitreolysis with ocriplasmin is used in the treatment of the disease. The most effective therapy is the posterior pars plana vitrectomy. Dye and peeling of the internal limiting membrane helps to achieve the closure of the MH and the good visual acuity.

Vitreoretinal interface abnormalities in fellow eyes of patients with a macular hole.

This study aimed to determine the incidence of bilateral macular holes (MHs), and to investigate the incidence and characteristics of retinal abnormalities in the fellow eyes, using high-definition optical coherence tomography (OCT). Medical records from 724 consecutive patients diagnosed with full-thickness MHs, who underwent surgery at Fujita Health University Hospital from May 2015 to March 2022, were retrospectively reviewed. Based on the exclusion criteria, 658 patients with idiopathic MHs were included. B-scan OCT images of the fellow eyes were used to identify vitreoretinal interface abnormalities, such as MHs, epiretinal membranes (ERMs), vitreomacular traction syndrome (VMTS) and lamellar macular holes (LMHs). The mean age of the patients was 65.9±9.0 years. There were 292 males (44.4%) and 366 females (55.6%). There were 39 fellow eyes with MHs (5.9%), 77 with ERMs (11.7%), 32 with VMTS (4.9%) and 11 with LMHs (1.7%). Thirty-four fellow eyes (5.2%) could not be classified and 469 fellow eyes were normal (71.3%). Furthermore, the 39 bilateral MHs were divided into four stages according to the Gass classification, as follows: stage 1, 32 eyes (82.1%); stage 2, none (0%); stage 3, 5 eyes (12.8%); and stage 4, 2 eyes (5.1%). Vitreoretinal interface abnormalities, such as MHs, ERMs, VMTS and LMHs, are more common in the fellow eyes of patients with MHs than in the healthy population. The fellow eyes of patients with MHs should be carefully followed using OCT.

TWO YEARS DESCRIPTIVE STUDY OF MACULAR HOLE PATIENTS OPERATED IN DR. KARIADI GENERAL HOSPITAL, SEMARANG

Introduction & ObjectivesMacular hole (MH) is a vitreomacular interface disorder that could cause visual impairment. Clinicalcharacteristics of MH are important for predicting MH treatment outcomes. This study purpose wasto describe MH patients’ characteristics and postoperative outcomes in Dr. Kariadi Hospital.
 MethodsA retrospective study held on January 2021–December 2022 utilizing patients’ medical records.Preoperative data: sex, age, symptoms, duration of symptoms, origin, preoperative visual acuity(VA), modified Gass classification stage, macular hole index (MHI), and hole forming factor (HFF)were obtained. Postoperative outcomes data: postoperative VA and anatomical closure were alsocollected.
 Results20(20 eyes) patients were obtained, with 14(70%) female, 12(60%) aged >60 years old, 13(65%)metamorphopsia, 12(60%) central visual loss, 10(50%) preoperative VA 6/24-6/60, 10(50%) durationof symptoms <3 months, and 16(80%) idiopathic origin. OCT (Ocular Coherence Tomography)findings revealed base diameter mean was 780,7 um(+ SD 312). 13 patients (65%) stage 3 of MH,12(60%) MHI <0,5, 12(60%) HFF > 0,9. All patients underwent MH surgery procedures.Postoperative examination showed 10 patients(50%) with VA 6/6-6/20. 11(100%) with preoperativeVA>6/60, 10(100%) with duration of symptoms <3 months, 8(100%) with MHI > 0,5, and 11(100%)with HFF > 0,9 had improved visual acuity and anatomical closure. It also revealed 17(85%) hadanatomical closure.
 ConclusionThe most common characteristics found in MH patients were female sex, age >60 years old, anddisorder of idiopathic origin. Preoperative VA, duration of symptoms <3 months before surgery, MHI> 0,5, and HFF > 0,9 were positive prognostic factors for better postoperative functional andanatomical outcomes.

TWO YEARS DESCRIPTIVE STUDY OF MACULAR HOLE PATIENTS OPERATED IN DR. KARIADI GENERAL HOSPITAL, SEMARANG

Introduction and Objective: Macular hole (MH) is vitreomacular interface disorder that could cause visual impairment. Clinical characteristics of MH are important for predicting MH treatment outcomes. This study purpose was to describe MH patients’ characteristics and postoperative outcomes in Dr. Kariadi Hospital. Method: A retrospective study held on January 2021–December 2022 utilizing patients’ medical records. Preoperative data: sex, age, symptoms, duration of symptoms, origin, preoperative visual acuity (VA), modified Gass classification stage, macular hole index (MHI), and hole forming factor (HFF) were obtained. Postoperative outcomes data: postoperative VA and anatomical closure were also collected. Result: 20(20 eyes) patients were obtained, with 14(70%) female, 12(60%) aged >60 years old, 13(65%) metamorphopsia, 12(60%) central visual loss, 10(50%) preoperative VA 6/24-6/60, 10(50%) duration of symptoms <3 months, and 16(80%) idiopathic origin. OCT (Optical Coherence Tomography) findings revealed base diameter mean was 780,7 um(+ SD 312). 13 patients (65%) stage 3 of MH, 12(60%) MHI <0,5, 12(60%) HFF > 0,9. All patients underwent MH surgery procedures. Postoperative examination showed 10 patients(50%) with VA 6/6-6/20. 11(100%;p<0,001) with preoperative VA>6/60, 10(100%;p<0,001) with duration of symptoms <3 months, 8(100%;p=0,012) with MHI > 0,5, and 11(100%;p<0,001) with HFF > 0,9 (p<0,001) had improved visual acuity and anatomical closure. It also revealed 17(85%) had anatomical closure. Conclusion: The most common characteristics found in MH patients were female sex, age >60 years old, and disorder of idiopathic origin. Preoperative VA, duration of symptoms <3 months before surgery, MHI > 0,5, and HFF > 0,9 were positive prognostic factors for better postoperative functional and anatomical outcomes.

Двухпортовая витрэктомия в лечении пациентов с макулярными разрывами

Purpose. Analysis of the first clinical and functional results of treatment of patients with macular holes using the two-port vitrectomy. Material and methods. An analysis of treatment of 15 patients with a diagnosis of macular hole, operated by the method of two-port vitrectomy, was carried out. According to the Gass classification, 7 patients were diagnosed with stage 3 macular hole, and 8 patients with stage 4. All patients underwent microinvasive vitrectomy according to the developed technique. At the beginning of the operation, two ports were installed – one for the infusion cannula with a built-in illuminator (chandelier), the second for the vitreotome. Next, the epiretinal membrane (ERM) (if any) and the internal limiting membrane (ILM) were removed, and plateletrich plasma (PRP) was used at the end of the operation. Intra- and postoperative complications were not registered. Results. The maximum period of observation of patients after treatment was 3 months. In all cases, an anatomical result was achieved – complete closure of the macular hole according to optical coherence tomography (OCT). Mean BCVA results 3 months after treatment were 0.32±0.08. In all cases, improvement in visual functions was achieved (p=0.035). Conclusion. The method of two-port vitrectomy in the treatment of macular holes allows to achieve a good anatomical result, improve visual functions, while minimizing surgical trauma. Key words: macular hole, platelet-rich plasma, two-port vitrectomy.

Anatomical and functional results of vitrectomy and gas tamponade in macular hole treatment

AbstractBackground: Idiopathic macular holes (IMH) of large sizes are still challenging for vitreoretinal surgeons. Predict factors of the treatment effectiveness are little‐known.Purpose: To evaluate the effectiveness of large idiopathic macular holes surgery with 18% perfluoropropane (C3F8) gas tamponade.Methods: The retrospective study, which includes 68 eyes of 68 patients diagnosed with IMH stage 3 or stage 4 (Gass classification) between January 2015 and January 2020. Among them, there were 16 men (23.5%) and 52 women (76.5%). The mean age of patients was 66.7 ± 4.3. Morphologic parameters of the macular hole (base diameter, minimum diameter) were measured and then hole form factor (HFF) was calculated. All eyes underwent 25 gauge pars plana vitrectomy, internal limiting membrane peeling, 18% C3F8 gas tamponade and postoperative face‐down positioning for two weeks. The minimum follow‐up period was 3 months and the mean follow‐up period was 19.6 ± 11.4 months. The main outcome measures were IMH closure confirmed by spectral domain optical coherence tomography at 1 month postoperatively and visual acuity at 3 months postoperatively.Results: No intra‐ and postoperative complications were observed. The IMH were closed in 61 out of 68 eyes at one month after surgery. The anatomic closure rate was 89.7%. The mean base diameter of IMH was 1022.82 ± 292.36 μm (range: 682–2019 μm). The mean minimum diameter of IMH was 471.71 ± 138.73 (range: 258–766 μm). The mean preoperative BCDVA was 0.72 ± 0.29 logMAR and mean postoperative BCDVA at 3 months after surgery was 0.5 ± 0.33 logMAR (p = 0.063, t‐test). In 47 patients (69.1%) BCDVA improved after surgery. Mean gain in visual acuity at 3 months after operation was 0.20 ± 0.27 (ΔBCDVA, logMAR). Visual acuity worsened or remained unchanged after surgery in 21 patients (30.9%) due to postoperative vitreoretinal interface disorders (foveal thinning, retinal pigment epithelium defects, and foveal cysts). The mean HFF value was 0.77 ± 0.09. There was a statistically significant moderate positive correlation between HFF and postoperative BCDVA (r = 0.56, p = 0.03, Spearman's Rho).Conclusion: Macular hole surgery with 18% C3F8 tamponade is effective technique and is associated with high rates of IMH closure and postoperative BCVA improvement. HFF was significantly correlated with postoperative visual outcomes in cases of large IMH.

Динамика диаметра макулярного разрыва после пилинга внутренней пограничной мембраны по данным интраоперационной оптической когерентной томографии

Purpose. To evaluate the dynamics of changes in the diameter of the macular hole after removal of the ILM in patients with large-diameter macular holes. Material and methods. Under observation were 16 patients aged 53 to 73 years with idiopathic macular holes (IMH) III–IV stage according to J. Gass classification. Corrected visual acuity averaged 0.1 ± 0.04. The surgical technique was a standard 25G vitrectomy followed by ILM peeling, maculoplasty, and air tamponade of the vitreal cavity. Structural changes in the fovea during surgery were assessed on intraoperative spectral optical coherence tomography (SOCT) (Leica EnFocus Ultra-HD). The measurement of the IMH diameter was assessed strictly before the ILM pilling and immediately after it. Results. After measurements of the fracture diameter before and after ILM peeling, the following results were obtained: the tear diameter before ILM pilling was 610 ± 115µm, after membrane pilling the tear diameter decreased to 448 ± 61µm. The difference in the IMH diameter before and after ILM peeling was 131 ± 32µm. Conclusions. Pilling of the inner limiting membrane during surgery for large diameter macular holes with tangential traction at the edge of the tear, which leads to an intraoperative reduction in the diameter of the macular hole by 131 ± 32µm. This shows the detection and identification of the ILM on surgical viewing of the IMH. Keywords: idiopathic macular hole, internal limiting membrane, intraoperative OCT.

Оценка клинической эффективности хирургического лечения идиопатических макулярных разрывов большого и среднего диаметра с использованием модифицированной технологии инвертированного лоскута внутренней пограничной мембраны (предварительные результаты)

Purpose. To assess the clinical effectiveness of surgical treatment of medium-and large-diameter idiopathic macular ruptures (IMR) using a modified technology by inversion and fixation of a free flap of the internal limiting membrane (ILM). Methods. A prospective study was conducted in 11 patients (11 eyes), 9 women and 2 men with medium-and large-diameter IMR. Mean age - 67.3 ± 5.38 (55-80) years. Patients with penetrating IMR of 2-4 stages according to the J. Gass classification. All patients underwent optical coherence tomography (OCT) along with traditional ophthalmological methods. The scans were performed in Retina Map, Cross line, Radial line, and Angio Retina modes. The obtained images were used to measure the parameters of the macular rupture (MR) of the retina manually. All patients underwent surgical treatment of IMR according to the proposed method. Results. In all cases, 1 day after the surgery, the closure of the gap was achieved according to ophthalmoscopy. 1 month after the surgery, according to OCT, 3 patients (27.2%) had a defect in the photoreceptor layer, 4 patients (36.3%) had deformity or peripheral non-attachment of the edges of the ILM flap, and 2 patients (18.1%) had a combination of these defects. According to OCT data in the Angio Retina mode, changes in the parameters of retinal blood flow were noted: there was a significant, moderate expansion of the avascular zone, accompanied by a moderate decrease in retinal perfusion. Despite this, there was a significant increase in visual acuity in the postoperative period. Conclusion. Endovitreal intervention for medium-and large-diameter macular ruptures using a modified technology by inversion and fixation of an ILM free flap is highly effective, as well as a low-traumatic treatment method that allows achieving anatomical closure of the macular defect and improving visual functions.

Анализ результатов хирургического лечения макулярных разрывов различной степени сложности

Purpose. To provide an analysis of the results of surgical treatment of macular holes, reflecting our own experience of vitreoretinal operations for this pathology of the macular interface. Material and methods. The work was carried out in a private ophthalmological clinic "EyeDoctor" in Almaty, Kazakhstan. The patients were divided into 3 groups, depending on the stage of macular holes and concomitant eye diseases. Results. 1. The macular hole 2-3 stage it is enough to carry out vitrectomy with careful removal of the ILM and PRP technology (the defect is up to 400 microns). 2. The macular hole 4 stage – removal the ILM with PRP technology with obligatory tamponade with silicon oil. Conclusion. To predict the results, it is necessary to take into account the stage of macular hole, its morphological and functional parameters, the duration of the process and the presence of concomitant ocular pathology. Key words: macular hole, J.D. Gass classification, vitrectomy, PRP method.

The method of closing macular holes with partial preservation of the internal limiting membrane

To suggest a new technique and to evaluate the dynamics of anatomical and functional parameters after surgery for macular hole with preservation of ILM. The study examined the results of treatment of 52 patients (52 eyes) with end-to-end macular holes of stages 2 to 4 according to the Gass classification. Patients of the 1st group underwent standard surgical treatment: vitrectomy and then circular maculorhexis. Patients of group 2 were operated according to the original method with partial preservation of ILM in the foveolar zone. All patients underwent standard ophthalmological examination before and after the surgery. The morphometric data was evaluated using optical coherence tomography (OCT). Statistical processing of the results was carried out using IBM SPSS Statistics 23 software. Morphofunctional parameters of the retina did not differ between patients of the two groups before treatment. According to the results of surgical treatment, on day 7 after the operation, higher indices of functional parameters of the retina were observed in patients of the 2nd group. On day 30, patients of group 2 were observed to have an increase in best-corrected visual acuity (BCVA) in comparison with these indicators on day 7, and a significant increase in comparison with the data before surgery. In patients of group 1, no improvement of vision was observed. It was also revealed that holes with permanent cystic cavities have the worst prognoses in terms of increasing visual functions and restoring the foveolar profile. The described procedure allows partial preservation of ILM, which reduces the risk of intraoperative damage to the retinal layers; the observed functional results were higher.

Clinical and morphological comparisons of idiopathic macular holes between stage 3 and stage 4.

To compare clinical and morphological differences in idiopathic macular holes (IMHs) between stage 3 and stage 4. In this retrospective cross-sectional observational study, patients with stage 3 and stage 4 IMHs based on Gass's classification in 1988 were enrolled. Horizontally and vertically, optical coherence tomography (OCT)-based parameters including minimum linear diameter (MLD), basal diameter (BD), and macular hole height (H) were measured; fluid cuff (FC), diameter hole index (DHI), macular hole index (MHI), traction hole index (THI), and hole form factor (HFF) were calculated. Afterwards, stage 3 IMHs smaller than 400μm were excluded according to Gass's classification in 1995. Clinical features, such as age, duration of symptoms, and baseline best-corrected visual acuity (BCVA), and OCT parameters were compared respectively between two stages based on both classifications. Given classification of 1988, stage 3 IMHs had significantly shorter duration of symptoms (P = 0.020) and smaller horizontal BD (P = 0.041). Horizontally and vertically, MLD (P = 0.001, 0.004 respectively), DHI (P = 0.032, 0.021 respectively), and HFF (P = 0.032, 0.017 respectively) were significantly smaller and THI (P = 0.011, 0.020 respectively) was significantly larger in stage 3 holes. Clinical features like age and baseline BCVA showed no significant differences. When staged by classification of 1995, IMHs of the two stages shared similar features. Stage 3 IMHs, instead of owning shorter duration of symptoms and smaller diameters, share similar clinical and morphological features with stage 4 IMHs according to Gass's classification in 1995, which excludes IMHs smaller than 400μm from stage 3 compared to his 1988 version.

MICROPERIMETRY IN BEST VITELLIFORM MACULAR DYSTROPHY.

To investigate retinal sensitivity in eyes with all the clinical stages of Best vitelliform macular dystrophy (VMD). Thirty-two patients affected by VMD in subclinical, vitelliform, pseudohypopyon, vitelliruptive, and atrophic stages were enrolled in this prospective cross-sectional study. Patients underwent a complete ophthalmologic examination, including determination of best-corrected visual acuity (BCVA), staging of the disease (Gass's classification), and microperimetry by means of the macular integrity assessment microperimeter. The primary outcome measure was to describe the alterations in the retinal sensitivity of eyes affected by VMD in different stages. Secondary outcome measures included correlations between retinal sensitivity and best-corrected visual acuity and the correlation between the VMD stage and the specific microperimetry pattern. Mean retinal sensitivity was reduced in all the VMD stages. Nevertheless, vitelliform, pseudohypopyon, and vitelliruptive stages turned out to be very similar, especially within 10°. Fixation was classified as stable in 27 eyes (44.2%), relatively unstable in 16 eyes (26.2%), and unstable in 18 eyes (29.5%). Fixation stability correlated both with the disease stage and best-corrected visual acuity. VMD is characterized by complex microperimetric abnormalities, involving the whole macular area. Microperimetry may contribute to the global clinical assessment of patients affected by VMD and could be used in future therapeutic approaches.

CHOROIDAL THICKNESS IN BEST VITELLIFORM MACULAR DYSTROPHY.

To assess the changes in choroidal thickness in different stages of Best vitelliform macular dystrophy (VMD). Thirty-four patients affected by VMD were prospectively enrolled and underwent a complete ophthalmologic examination, including best-corrected visual acuity measurement, biomicroscopic examination, and spectral domain optical coherence tomography. The Gass classification was used in defining the stages of VMD. Twenty healthy subjects served as the control group. Main outcome measures were the identification of choroidal changes in different stages of VMD and detection of a correlation between choroidal thickness and best-corrected visual acuity. No significant difference was found in the subfoveal choroidal thickness (SFCT) between eyes displaying Stage 1 and the control group (P = 0.181). Stages 2 and 3 showed an increased SFCT (320.4 and 319.1 μm, respectively) compared with that of control patients (P < 0.001 and P = 0.004, respectively). Stage 4 had a significantly inferior SFCT compared with Stages 2 and 3 (P = 0.007 and P = 0.025, respectively) but no significant difference was found between Stage 4 and control patients (P = 0.733). The Stage 5 group displayed a significant decrease in SFCT compared with that of the control group (181.3 μm and 238.4 μm, respectively, P = 0.002). Analyzing the association between SFCT and best-corrected visual acuity in patients affected by clinical VMD (Stages 2-5), the authors found that the best-corrected visual acuity decreased as the choroid thinned (P = 0.004). Choroidal thickness varies according to the stage of VMD, being higher in the vitelliform stage and thinner in the atrophic/cicatricial stage. Long-term studies are warranted to provide a more precise evaluation of the morphofunctional alterations in the different stages of VMD.

Vitrectomy for idiopathic macular hole: outcomes and complications

Purpose The aim of this study was to determine the anatomical closure rate together with the rate of functional success of idiopathic macular holes following vitreous surgery in different optical coherence tomography (OCT) stages. Patients and methods This was a prospective, case series, interventional study. Twenty-two eyes were enrolled in this study conducted at Mansoura University Ophthalmic Center during the period between June 2012 and December 2014 with at least 3 months of follow-up. Eyes with stage 2, 3, and 4 idiopathic macular hole according to the Gass classification were included. All eyes were subjected to 23-G pars plana vitrectomy, inner limiting membrane peeling, fluid-gas exchange, and postoperative positioning. Results Idiopathic macular hole closure was achievable in 18 of 22 cases, with overall 81.4% anatomical success. Type 1 closure (U-shaped closure) was achieved in 13 cases (59.1%), type 2 closure (V-shaped closure) in three cases (13.6%), type 3 closure (irregular closure) in one case (4.5%), and type 4 closure was reported in one case (4.5%). The median postoperative log MAR visual acuity at 3 months was 1.0 (0.9445-1.2073). The overall postoperative visual acuity improvement was strongly statistically significant ( P = 0.000). The visual acuity improvement at 3 months compared with the preoperative visual acuity was statistically significant ( P = 0.000). The delta change in log MAR visual acuity at 3 months was 0.5 (−0.7782 to −0.4331), with greater improvement in log MAR visual acuity in group I (stage 2 OCT) compared with group III (stage 3 and 4 OCT at 3 months; P = 0.05). Retinal breaks were observed intraoperatively in three cases. Retinal detachment was reported in one case 4 months postoperatively. Conclusion Macular hole closure rate and visual acuity markedly improved following vitreous surgery for idiopathic macular holes.

Fundus Autofluorescence Patterns in Best Vitelliform Macular Dystrophy

To provide a systematic classification of fundus autofluorescence (FAF) patterns in patients affected by Best vitelliform macular dystrophy. Cross-sectional prospective study. Patients affected by Best vitelliform macular dystrophy at different stages of the disease were prospectively enrolled from January 2012 to July 2013. Eighty eyes of 40 patients were included in the study. All patients underwent a complete ophthalmologic examination, including genetic characterization, short-wavelength FAF, and near-infrared FAF. Main outcome measures were the recognition of the FAF patterns in the different stages and the identification of a relationship between FAF patterns and best-corrected visual acuity (BCVA). Six FAF patterns for both short-wavelength and near-infrared FAF were identified, including normal, hyper-autofluorescent, hypo-autofluorescent, patchy, multifocal, and spoke-like patterns. Applying Gass's classification for defining consecutive stages of Best vitelliform macular dystrophy (namely vitelliform, pseudohypopyon, vitelliruptive, atrophic, and cicatricial) identified no pattern as stage-specific. Patchy patterns had the highest prevalence. A statistically significant difference (Kruskal-Wallis ANOVA) was found among hyper-autofluorescent, patchy, and hypo-autofluorescent patterns, both in short-wavelength (P = .001) and near-infrared FAF (P = .001). Hyper-autofluorescent and hypo-autofluorescent patterns were associated with better and worse BCVA, respectively. Six main patterns on both short-wavelength and near-infrared FAF were identified in Best vitelliform macular dystrophy. No FAF pattern can be considered stage-specific. Although a difference in the BCVA among the FAF patterns was registered, only a longitudinal study designed to evaluate the clinical and FAF modifications over the follow-up will help clarify the prognostic implications of each FAF pattern.

RISK ASSESSMENT OF IDIOPATHIC MACULAR HOLES UNDERGOING VITRECTOMY WITH DYE-ASSISTED INTERNAL LIMITING MEMBRANE PEELING

The purpose of this study was to investigate and identify predictors for idiopathic macular hole persistence after pars plana vitrectomy with dye-assisted internal limiting membrane peeling. In a retrospective case series, 160 eyes underwent identical vitreoretinal procedures performed by the same surgeon. Baseline characteristics and preoperative optical coherence tomography were evaluated regarding the postoperative anatomical outcome. n overall closure rate of 86.3% (138/160) was achieved. According to the Gass classification system, the closure rates were 100.0% (11/11) in Stage 2, 95.0% (57/60) in Stage 3, and 78.7% (70/89) in Stage 4. Thereby, a significant influence of preoperative best-corrected visual acuity and basal hole diameter was observed. Especially, idiopathic macular hole with a basal hole diameter of ≥800 μm and a best-corrected visual acuity of ≤20/100 had a 4 and 6 times higher risk to persist, respectively. On the other hand, age, gender, bilateral occurrence, symptom duration, and lens status did not have an effect on the surgical outcome. Furthermore, perifoveal pseudocysts were associated with a higher closure rate in Stage 4 idiopathic macular hole. Simple clinical parameters such as best-corrected visual acuity, basal diameter, and perifoveal pseudocysts are efficient predictors and might be used to expand the validity of the Gass classification.

Stage 1 macular holes of Gass classification illustrated by Optical Coherence Tomography scans: a review of 4 cases

AbstractPurpose Gaudric classification, stage 1 corresponds to intraretinal pseudocyst in the inner part of the foveola. The prolongation of the cyst laterally results in a split between the inner retina and the photoreceptor layer and a disruption of the outer retinal layers.Methods Four patients presented with a history of blurred vision and metamorphopsia. OCT examination showed a foveolar serous detachment between pigment epithelium and photoreceptor layer. Six months later, two patients presented lamellar holes and two patients evolved into stage 3 macular holes. In all cases we reported a complete resolution of the foveolar serous detachment . A surgical treatment was performed for three patients.Results OCT scans performed one month after surgery showed a total closure of the macular holes, an increase of visual acuity and a disappearance of the metamorphopsia. The main physiopathological theory formulated about macular holes formation concerns vitreo retinal tractions. As the posterior hyaloid remained attached to the center of the foveola and to the optic disc, displaying a convexity that may indicate the exertion of anteroposterior traction on its vitreous side, Gaudric admits that stage 1a macular hole is the result of antero posterior vitreo retinal tractions. Stage 1 as described by Gass is characterized by a serous foveolar detachment and is a consequence of tangential tractions of the pre foveolar vitreous cortex.Conclusion Our cases seem to be the tomographic illustration of the anatomic description of the stage 1 macular hole proposed by Gass and not mentioned in the tomographic classification proposed by Gaudric suggesting the implicationof tangential traction in macular holes formation.

Surgical management of macular holes-indications and complications

Macular hole surgery is very demand surgery performed due to fullthickness macular rupture characterized by abscence of all retinal layers. Indications for surgery includes stages 3 and 4 regarding to Gass classification. Some authors sugest surgery for stage 2 but results are promissing only in anatomical reconstruction. Complications are evident such as cataract, late macular reopening, retinal tears and detachment, visual field defect etc. With improving surgical techniques, the rate of complications became lower.

Outcomes of 23-gauge pars plana vitrectomy and internal limiting membrane peeling with brilliant blue in macular hole

Purpose:The evaluation of anatomic and visual outcomes in macular hole cases treated with internal limiting membrane (ILM) peeling, brilliant blue (BB), and 23-gauge pars plana vitrectomy (PPV).Materials and methods:Fifty eyes of 48 patients who presented between July 2007 and December 2009 with the diagnosis of stage 2, 3, or 4 macular holes according to Gass Classification who had undergone PPV and ILM peeling were included in this study. Pre- and postoperative macular examinations were assessed with spectral-domain optical coherence tomography. 23 G sutureless PPV and ILM peeling with BB was performed on all patients.Results:The mean age of patients was 63.34 ± 9.6 years. Stage 2 macular hole was determined in 17 eyes (34%), stage 3 in 24 eyes (48%), and stage 4 in 9 eyes (18%). The mean follow-up time was 13.6 ± 1.09 months. Anatomic closure was detected in 46/50 eyes (92%), whereas, in four cases, macular hole persisted and a second operation was not required due to subretinal fluid drainage. At follow-up after 2 months, persistant macular hole was detected in one case and it was closed with reoperation. At 12 months, an increase in visual acuity in 41 eyes was observed, while it remained at the same level in six eyes. In three eyes visual acuity decreased. There was a postoperative statistically significant increase in visual acuity in stage 2 and 3 cases (P < 0.05), however, no increase in visual acuity in stage 4 cases was observed.Conclusion:PPV and ILM peeling in stage 2, 3, and 4 macular hole cases provide successful anatomic outcomes, however, in delayed cases, due to photoreceptor loss, it has no effect on functional recovery. BB, used for clarity of ILM, may be beneficial due to its low retinal toxicity.

Combined phacoemulsification and pars plana vitrectomy for macular hole treatment

To assess the outcome of simultaneous phacoemulsification, pars plana vitrectomy and intraocular lens (IOL) implantation in eyes with macular hole. A retrospective study was conducted in 38 eyes (36 patients) after combined phacoemulsification, insertion of a posterior capsule IOL and pars plana vitrectomy. The macular hole was successfully closed in 32 of the 38 eyes (84%). In six eyes (16%) the hole failed to close and one eye underwent a second operation. Vision improved by two or more Snellen lines in 29 eyes (73%), there was no change in seven eyes (18%), and visual acuity decreased in two eyes (5%). Intraoperative and postoperative complications included retinal tears in nine eyes (24%), posterior capsule rupture in two eyes (5%), transient postoperative increase of intraocular pressure in eight eyes (21%), and posterior capsule opacification in five eyes (13%). Combining phacoemulsification, IOL insertion and pars plana vitrectomy for macular hole repair can reduce the need for cataract surgery in the future, decrease costs, shorten postoperative recovery time and allow for clearer intraoperative visualization, making the procedure safer and more effective.