Idiopathic Macular Hole Surgery Research Articles

A Case of Postpartum Macular Hole in a Young Woman

Purpose: To describe a case of macular hole (MH) in a 29-year-old non-myopic woman after uncomplicated delivery. Case summary: A 29-year-old woman visited our clinic complaining of decreased visual acuity in her left eye after uncomplicated delivery. Fundoscopy and optical coherence tomography showed a full thickness macular hole in the left eye. However, we found not posterior vitreous detachment or vitreomacular traction in the posterior pole. The patient underwent pars plana vitrectomy, internal limiting membrane peeling, and SF6 gas tamponade. Three months after vitrectomy, the patient’s visual acuity was improved and the macular hole was closed successfully. Conclusions: We experienced and treated a case of postpartum MH developed in a young woman without posterior vitreous detachment or vitreomacular traction in the posterior pole. This suggests another mechanism of MH formation. Postpartum MH was successfully treated by existing idiopathic macular hole surgery. J Korean Ophthalmol Soc 2015;56(3):463-465

Long-term changes of macular retinal thickness after idiopathic macular hole surgery

Long-term changes of macular retinal thickness after idiopathic macular hole surgery

Can perifoveal pseudocyst area be a prognostic factor in macular hole surgery?: A prospective study with quantitative data.

To evaluate the effect of perifoveal pseudocysts on the anatomical outcomes of the idiopathic macular hole surgery as a prognostic factor.Twenty-one eyes of 20 consecutive patients with a Gass stage 3 or 4 idiopathic macular hole were enrolled in this prospective study between March 2012 and May 2013. Demographic data, medical history, and ocular examinations were recorded preoperatively and on postoperative day 1, week 1, and month 1, 3, and 6. Five spectral domain optical coherence tomography (SD-OCT) parameters were analyzed: macular hole (MH) basal diameter, MH minimum diameter, MH height, macular hole index, and a new parameter, the area of macular pseudocysts via the software of SD-OCT device at the widest cross section of the MH formation.The mean preoperative best-corrected visual acuity was 0.86 ± 0.29 logarithm of the minimum angle of resolution (LogMAR) (between 0.4 and 1.3) and improved to 0.64 ± 0.28 LogMAR (between 0.22 and 1.23) postoperatively (P = 0.004). There was a statistical significant difference between both MH basal diameter and MH pseudocyst area with anatomical success, respectively (P = 0.016 for MH basal diameter, P = 0.004 for MH pseudocyst area). The anatomical closure was correlated with MH basal diameter and MH pseudocyst area (P = 0.01 and P = 0.001, respectively). Spearman correlation rank coefficient between with MH basal diameter and MH pseudocyst area was r = 0.493 and statistically significant (P = 0.02).Perifoveal pseudocysts seem to be associated with anatomic failure and may be used as a prognostic factor in MH surgery.

Long-Term Observation of the Vitreomacular Relationship in Normal Fellow Eyes of Patients with Unilateral Idiopathic Macular Holes

Purpose: To describe long-term changes in the vitreomacular relationship in normal fellow eyes of patients with unilateral idiopathic macular holes (MHs). Methods: This is a retrospective, observational case series. The medical records of patients who underwent surgery for idiopathic MHs between May 2000 and December 2010 were reviewed. Patients who had clinically normal fellow eyes and underwent 12 months or more of follow-up were included. The vitreomacular relationship in the fellow eyes was evaluated using optical coherence tomography (OCT) and slit-lamp biomicroscopy. Results: The study included 153 patients with a mean age of 65.5 years and a mean follow-up of 33.5 months (range, 12-121). The incidence of vitreomacular attachments evaluated by OCT was 52% (80 eyes) at initial examination, which decreased to 41, 37 and 23% at 1, 2 and 3 years after the initial examination, respectively. Of the 80 eyes with vitreomacular attachments at initial examination, 40 (50%) still had vitreomacular attachments at the final visit. Of the remaining 40 eyes in which vitreomacular separation occurred during follow-up, 11 (28%) developed an MH, with a mean interval of 45 months. None of the eyes with vitreomacular separation at presentation developed an MH. Conclusion: This largest series of fellow eyes of MHs followed by OCT shows that, at presentation, about half of the patients already have premacular vitreous detachment and therefore no risk of MH, and that second MH develops in about 30% in the process of vitreomacular separation, which evolves over a prolonged period.

ILM peeling technique influences the degree of a dissociated optic nerve fibre layer appearance after macular hole surgery.

We sought to assess the effect of two different internal limiting membrane [ILM] peeling techniques carried out during surgery for idiopathic macular holes on the postoperative extent of a dissociated optic nerve fibre layer appearance [DONFL]. We collected prospective data of surgical records, videos, and pre- and postoperative imaging of a consecutive series of patients undergoing surgery for idiopathic macular hole with one of two surgeons. One surgeon used a forceps pinch-peel technique to peel the ILM, whereas the other surgeon used a diamond dusted membrane scraper. The extent of any DONFL was measured using spectral domain optical coherence tomography and blue reflectance imaging at three months postoperatively. A proportion of the ILMs removed were examined with transmission electron microscopy. Fifty-seven patients were studied, with 41 in the forceps group and 16 in the scraper group. The groups were well matched, with no significant difference in any preoperative parameters. Some degree of DONFL was observed on the 3-month blue reflectance images in 88 % of the forceps group and 100 % of the scraper group [p = 0.14]. There was a significant difference in the total number of depressions in the nerve fibre layer typical of DONFL on OCT between the two groups [p = 0.001], and general regression analysis showed that the peeling technique used had the only significant association with the degree of DONFL observed. Electron microscopy showed large patches of cellular debris on the retinal side of the peeled ILM in 3 out of 4 cases in the scraper group and 1 out of 12 cases in the forceps group. ILM peeling technique and possibly other surgeon-specific factors appear to influence the extent of DONFL observed after ILM peeling macular hole surgery.

A study on determinants of utilization in health and welfare services among the elderly who were recognized non-grade for long-term care insurance

Purpose: To compare the outcomes of indocyanine green (ICG) and triamcinolone (TA) assisted internal limiting membrane (ILM) peeling during idiopathic macular hole surgery. Methods: Fifty-four eyes of 54 patients with idiopathic macular hole underwent pars plana vitrectomy including peeling of the posterior cortical hyaloid and peeling of the internal limiting membrane. For enhanced visualization of ILM, ICG was used in 25 eyes and TA in the remaining 29 eyes. Postoperative visual acuity was measured and OCT was performed. Results: Anatomical closure was achieved in 25 eyes (100%) in ICG group and 28 eyes (97%) in TA group, Best corrected visual acuity improvement by ?2 lines was in 15 eyes (60%) in ICG group and 18 eyes (62%) in TA group. Postoperative visual improvement rates by ?20/50 were 10 eyes (40%) in ICG group and 9 eyes (31%) in TA group. Conclusions: Peeling of the internal limiting membrane using triamcinolone and indocyanine green was safe and effective for anatomic and functional success in idiopathic macular hole surgery. Further studies of the toxicity of TA, ICG and the result of internal limiting membrane peeling is needed.

Evaluation of secondary surgery to enlarge the peeling of the internal limiting membrane following the failed surgery of idiopathic macular holes

The aim of the present study was to evaluate the clinical results of pars plana vitrectomy (PPV) combined with the surgical enlargement of internal limiting membrane (ILM) peeling in patients who had previously undergone failed idiopathic macular hole (IMH) surgery. In the study, 134 eyes from 130 IMH patients who had received PPV combined with ILM peeling surgery (2 disk diameters) were analyzed. Within this cohort, 14 eyes had IMHs that were not closed, of which 13 eyes underwent a second surgery involving enlargement of the ILM peeling. The extent of the ILM peeling was increased to the vascular arcades of the posterior fundus in the secondary surgery. Of the 13 eyes that underwent secondary surgery, five were in stage III and nine were in stage IV. The second surgery successfully achieved IMH closure in 61.5% (8/13) of the eyes. The IMH was completely closed following surgery and the logMAR vision increased from 0.98 to 0.84 (P=0.013) in the 8 successfully treated cases. The surgical enlargement of ILM peeling closed the IMHs and improved vision in the majority of patients. In addition, the procedures were safe. Therefore, the results of the present study indicate that enlargement of ILM peeling may be an effective therapy for patients who have previously undergone the failed surgical correction of an IMH.

Evaluation of internal limiting membrane peeling for idiopathic full-thickness macular hole by optical coherence tomography and multifocal electroretinography

PurposeThe aim of the study was to evaluate the anatomical and functional success of idiopathic macular hole surgery using optical coherence tomography (OCT) and multifocal electroretinography (mfERG).DesignThe study was designed as a prospective interventional case series.Patients and methodsFourteen eyes with idiopathic full-thickness macular hole were treated with pars plana vitrectomy and internal limiting membrane peeling. OCT and mfERG were performed in all patients preoperatively and during a follow-up period of 6 months to elicit anatomical and functional changes of the macula.ResultsOCT images revealed closure of macular holes in all patients after 3 months of follow-up, whereas mfERG showed improvement of retinal responses. These changes were associated with a significant improvement in visual acuity (P = 0.0001).ConclusionPars plana vitrectomy with internal limiting membrane peeling successfully restored the normal architecture of the fovea, with improvement in retinal function.

Idiopathic macular hole: analysis of visual outcomes and the use of indocyanine green or brilliant blue for internal limiting membrane peel

Our aim was to analyze outcomes of idiopathic macular hole surgeries in relation to staging and the use of indocyanine green (ICG) or brilliant blue (BB) for internal limiting membrane (ILM) peel. Baseline, surgical, and outcome data for 351 consecutive primary macular hole surgeries was prospectively collected using electronic medical record software between 2001 and 2011. The outcomes for these cases were analysed in relation to staging and the use of ICG (0.5mg/ml) or BB for ILM peel. Mean age was 68.9years (range 39-87) with 66.4% females and 54.1% right eyes. Follow-up duration was median 0.55years. Vision was significantly improved from logMAR 0.97 (SD 0.45) (Snellen equivalent 20/185) preoperatively to 0.65 (SD 0.51) (20/90) at final follow-up. One hundred and eighteen patients had stage 2 macular holes, 185 stage 3, and 48 stage 4. Mean duration of symptoms varied with stage of hole: stage 2 0.53years (SD 0.43), stage 3 0.79years (SD 0.68), and stage 4 1.20years (SD 1.26), p = 0.0002. Closure rates of the holes were significantly different, with stage 2 closing in 95.8%, stage 3 in 73.0%, and stage 4 in 56.3%, p < 0.0001. At final follow-up, mean visual acuity (VA) was 0.42 (SD 0.33) (20/50) for stage 2, 0.75 (SD 0.53) (20/110) for stage 3, and 0.87 (SD 0.60) (20/145) for stage 4 holes, p < 0.0001. Postoperative VA was 0.71 (SD 0.53) (20/100) for patients in whom ICG was used, and 0.52 (SD 0.43) (20/70) for BB, p = 0.003. The proportion of patients who achieved a closed hole was less for ICG (73.2%) than BB (89.9%), p = 0.0005. For those patients with stage 2 hole who achieved hole closure, mean improvement in VA was significantly better for BB (0.47, SD 0.36) than for ICG (0.30, SD 0.31), p = 0.01. Macular hole stage is a useful measure to help predict the chance of postoperative hole closure and visual outcome. The relationship between duration of symptoms and increasing stage suggests macula hole patients require prompt referral for consideration of early surgery. Better visual outcomes were achieved with BB for ILM peel than with ICG.

Transient increase of retinal nerve fiber layer thickness after macular hole surgery

We studied the changes in the thickness of the retinal nerve fiber layer (RNFL) after surgery for idiopathic macular hole (MH) using spectral-domain optical coherence tomography (SD-OCT). Twenty eyes of 20 consecutive patients who underwent vitrectomy to close a MH were studied. The peripapillary RNFL thickness was measured by SD-OCT before and at 1, 3, and 6 months after surgery. The mean overall thickness, the thickness of the four quadrants, and the thickness of each of the 12 clock hours of the RNFL were analyzed. The mean overall RNFL thickness before surgery was 93.3 ± 9.6 lm,and it increased significantly to 98.7 ± 7.4 lm at 1 month after surgery (P\0.05). The mean overall thickness then returned to the pre-surgery level at three and 6 months. The transient increase of RNFL thickness at 1 month after surgery was statistically significant in the superior, nasal, and inferior quadrants. The increase in the thickness of the nasal quadrants was maintained for up to 6 months. When the thickness of the individual 12 clock hours were analyzed, the transient increase of RNFL thickness at 1 month after surgery was significant at each of the 0–5 o’clock positions. The transient increase in the RNFL thickness after MH surgery may be caused by mild edema of the inner retinal layers caused by the MH surgery.

Persistent outer retinal fluid following non-posturing surgery for idiopathic macular hole

AimTo present the anatomical and visual outcomes of patients with hypo-reflective cystic defects in outer fovea (outer foveal defect; OFD) in macular holes repaired with non-posturing vitrectomy and short term...

Assessment of Retinal Function Before and After Idiopathic Macular Hole Surgery

To evaluate preoperative and postoperative retinal function in patients who underwent macular surgery for idiopathic macular hole. Prospective, comparative, interventional case series. Thirty eyes of 30 patients with idiopathic macular hole were included in the study. Patients underwent pars plana vitrectomy and peeling of the internal limiting membrane (ILM). ILM visualization was improved in 15 patients by using triamcinolone acetonide and in the remaining 15 patients by using infracyanine green dye. Spectral-domain optical coherence tomography examination was performed to document macular hole closure. Retinal function was assessed preoperatively and postoperatively over a period of 12months by best-corrected visual acuity (BCVA) measurement (ETDRS chart), MP-1 microperimetry, and focal electroretinogram recording (fERG). Focal electroretinograms were recorded in response to a sinusoidally modulated (41Hz), uniform field presented to the macular (18 degrees) and foveal (2.25 degrees) region. Macular hole closure was achieved in all patients in both groups. At 12months, visual acuity improved in both groups (P < .001), and there were no statistically significant differences between groups. Mean macular sensitivity within the central 2 and 8 degrees increased in both groups, and there were no statistically significant differences between groups at any follow-up. In the triamcinolone acetonide group, 12months after surgery the amplitude of the fERG's first harmonic (1F) increased both in the macular region (P < .001) and in the foveal region (P < .05). In the infracyanine green group, at 12months the amplitude of the first harmonic (1F) decreased in both areas. The decrease was significant in the macular region (P < .05) and not significant in the foveal region (P= .095). Vitrectomy and ILM peeling assisted with either triamcinolone acetonide or infracyanine green staining improves visual acuity and mean macular sensitivity at 12months in patients affected by idiopathic macular hole. However, triamcinolone acetonide staining is associated with an increase of fERG's first harmonic amplitude in the foveal and macular region, whereas in the case of infracyanine green staining it seems to decrease after surgery. The reduction of the amplitude of fERG's first harmonic suggests that infracyanine greenmay have a late toxic effect on photoreceptor cells.

Morphological Change of Inner Retinal Layer on Spectral-Domain Optical Coherence Tomography following Macular Hole Surgery

Background/Aims: To investigate the morphological changes of the inner retinal layer by spectral-domain optical coherence tomography (OCT) after idiopathic full-thickness macular hole (MH) surgery. Methods: In a retrospective study, the authors evaluated 52 eyes of 49 patients with MH closed following vitrectomy. All patients were followed postoperatively for more than 6 months. Cross-sectional and retinal surface images were obtained using Cirrus high-definition OCT before and after surgery. In 24 of the 52 eyes, fundus autofluorescence (FAF) was analyzed. Results: The incidence of dissociated optic nerve fiber layer (DONFL) increased gradually over time after surgery. 57.7% had defects of only the retinal nerve fiber layer (RNFL) and 30.8% had defects in the inner plexiform layer at 6 months after surgery. Postoperative best-corrected visual acuity did not differ significantly based on the depth of the DONFL (p = 0.299). There were no changes in FAF in the area with DONFL. Conclusions: DONFL is characterized by progressive defects that are not limited to RNFL thickness. The healing process after vitrectomy for MH is not limited in the RNFL affecting deeper structural changes. Further investigations are required to evaluate the pathophysiological mechanism of inner retinal change after MH surgery.

Long-term anatomical and functional outcomes of idiopathic macular hole surgery. The yield of spectral-domain OCT combined with microperimetry

To evaluate the correlations between anatomical and functional changes studied with microperimetry (MPM) and spectral-domain OCT (SD-OCT) in patients after successful repair of idiopathic macular hole (MH). Monocentric, retrospective, interventional study in 23 eyes of 23 patients who underwent successful surgery for MH defined as closure of the hole, at least 1 year before. Reported data were pre- and postoperative best-corrected visual acuity (BCVA), retinal sensitivity values on MPM, macular and foveal thicknesses, and retinal anatomic lesions on SD-OCT. Macular sensitivity (MS) and foveal sensitivity (FS) were lower and the number of lesions of the outer retinal layers was higher in patients with a poorer postoperative VA (P = 0.029, P = 0.011 and P = 0.003 respectively). Preoperative MH size was lower and MS and FS were better in patients with a preserved junction line between the inner and outer segments of photoreceptors (IS/OS) (P = 0.045, P = 0.001, and P = 0.001 respectively). Better postoperative VA was correlated with better preoperative VA (P = 0.012, r = 0.513). Postoperative VA was correlated with MS and FS (P = 0.032, r = 0.449, and P = 0.019, r = 0.483 respectively). Greater foveal thickness was associated with better postoperative VA (P = 0.020, r = 0.482). Postoperative outer retinal layer integrity is associated with better final retinal sensitivity. Further studies are warranted to assess the role of SD-OCT and microperimetry in the pre- and postoperative evaluation of idiopathic macular holes.

Comparison of triamcinolone and VisCoat in indocyanine-green-assisted internal-limiting-membrane peeling in macular hole surgery

BackgroundThe objective of our study was to compare the clinical outcomes of idiopathic full-thickness macular hole surgery using either triamcinolone (TA) or VisCoat treatment of the macular hole before indocyanine-green (ICG)-assisted internal-limiting-membrane (ILM) peeling. MethodsDuring macular hole surgery, the hole and adjacent areas were treated with TA (Group 1, n = 15 eyes) or VisCoat (Group 2, n = 22 eyes) to minimize ICG-induced toxicity during ILM peeling. Changes in visual acuity and anatomical success rates were compared between the two groups. ResultsAt 6 months following surgery, the hole closure rate was 80% (12/15 eyes) in Group 1 and 100% (22/22 eyes) in Group 2. The mean ± standard deviation logarithm of the minimum angle of resolution decreased from 1.40 ± 0.41 to 1.08 ± 0.38 in Group 1 (p = 0.04) and from 1.25 ± 0.41 to 0.75 ± 0.44 in Group 2 (p < 0.001), indicating that a greater increase in the average best corrected visual acuity had occurred in Group 2 than in Group 1 (p = 0.02). At 1 month following surgery, small outer-retinal blebs were noted in 42% of the closures in Group 1 and 9% of the closures in Group 2. The blebs persisted in four Group-1 participants for >1 year, but no long-standing outer retinal bleb occurred in Group 2. ConclusionParticipants who received the VisCoat treatment displayed a higher hole closure rate and a better final visual acuity than those who received the TA treatment. Participants who received the TA treatment also had more outer retinal blebs at 1 month and 1 year or more following the surgery.

The Effect of Autologous Serum on Vitrectomy with Internal Limiting Membrane Peeling for Idiopathic Macular Hole

We sought to evaluate the effects of intraoperative adjunctive autologous serum in idiopathic full-thickness macular hole surgeries, and to compare the surgical outcomes with a no-serum control group. In this retrospective, case-control study, 38 consecutive eyes received vitrectomy with internal limiting membrane removal for idiopathic full-thickness macular holes. Two groups were created according to the use of autologous serum. Outcome measures were visual acuity (VA), closure of the macular hole confirmed by optical coherence tomography, and surgical complications. Anatomical closure of the macular hole was achieved in 18 of 19 eyes (94.7%) in the vitrectomy with the autologous serum group, and in 18 of 19 eyes (94.7%) in the control group. The closure rates did not differ significantly between 2 groups (P=1.000; the Fisher's exact test). At the final follow-up, the mean logMAR VA improved significantly in both groups (SD, standard deviation) [from 1.08 (0.21) to 0.47 (0.21) in vitrectomy with the serum group and from 1.01 (0.32) to 0.44 (0.30) in the control group (both P<0.001; 2 tailed, paired t test)]. There was no significant difference between these 2 groups in terms of visual outcomes (P=0.738; 2-tailed t test). There were no surgical complications, such as retinal detachment and endophthalmitis. The outcome of macular hole surgery did not differ both anatomically and functionally regardless of the use of adjuvant autologous serum. There seemed to be no additive effect with autologous serum.

Surgery for macular holes associated with unusual concomitant pathologies

Macular hole (MH) is uncommonly seen in association with retinitis pigmentosa (RP), optic disc pit or choroidal coloboma. The visual disability in eyes with RP, optic disc pit or choroidal coloboma can range from mild to severe. However, the macula may not be involved in the primary pathology and hence, the central vision may be preserved in these eyes. If a MH develops in such eyes the central vision is lost, making the patient severely vision disabled. A perceived poor prognosis in such patients may lead to no intervention. However, an attempt should be made to repair and restore the macula in these situations in order to conserve the vision and limit disability. These eyes can however pose unique surgical challenges. We report our experiences of operating on cases of MH associated with unusual concomitant pathologies such as RP, choroidal coloboma, and optic pit. The outcomes and the surgical challenges differed greatly from the conventional idiopathic MH surgery.

Comparison of Prone and Seated Position after Vitrectomy for Idiopathic Macular Hole Surgery

Comparison of Prone and Seated Position after Vitrectomy for Idiopathic Macular Hole Surgery

Intraoperative SD-OCT in Macular Surgery

Intraoperative use of spectral-domain optical coherence tomography (SD-OCT) using an OCT-mounted surgical microscope could provide additional information to predict visual outcomes of macular surgery and identify intraoperative changes in the macular anatomy that affect visual recovery. This interventional retrospective case study included 5 eyes of 5 consecutive patients with various macular pathologies. All patients underwent the standard surgery for idiopathic macular holes and epiretinal membranes (ERMs) using the same 25-gauge three-port pars plana technique. If present, the ERM was removed. The dye procedure was then repeated to stain and remove the internal limiting membrane (ILM). OCT images were obtained with the retinal map or cross-section program preincision, post-hyaloid elevation (if applicable), post-residual ERM peel (if applicable), and post-ILM peel. In 3 of 5 patients, the intraoperative scan revealed an increased area of subretinal hyporeflectivity corresponding with a clinically visible "cuff" of retinal detachment. In 2 patients, the SD-OCT scan taken immediately after ERM removal helped find a cleavage plane for the subsequent ILM peeling, which could be further confirmed by a scan taken immediately after it. In 2 cases, the scans identified intraoperative complications that otherwise would not have been noted and allowed the surgeon to modify the next procedures during surgery. Use of this technology in an operative setting can provide greater insight into the changes in retinal anatomy created during macular surgery.

Comparison of Efficacy and Safety between Transconjunctival 23-Gauge and Conventional 20-Gauge Vitrectomy Systems in Macular Surgery

PurposeTo compare the efficacy and safety of 23-gauge transconjunctival vitrectomy with the conventional 20-gauge method in idiopathic epiretinal membrane and macular hole surgery.MethodsSixty-one consecutive patients undergoing vitrectomy for idiopathic epiretinal membrane and macular hole were recruited to either 20- or 23-gauge vitrectomy groups and prospectively evaluated. Surgical success rates, operating time, surgery-related complications, long-term visual outcomes, and postoperative ocular surface problems are compared in the two groups.ResultsThere were 31 eyes in the 20-gauge group and 33 eyes in the 23-gauge group. The macular hole closure rate after the first surgery was 83% and 90.9% in the 20-gauge and 23-gauge groups, respectively, with no significant difference between groups (p = 0.59). The success rate for idiopathic epiretinal membranes cases was 100% in both groups. There was no statistically significant difference between overall surgical times (p = 0.90). None of the patients in either group experienced postoperative complications of severe postoperative hypotony, vitreous hemorrhage or endophthalmitis, except one eye in the 20-gauge group, which was found to have retinal detachment. In both groups, statistically significant improvement in visual acuity was achieved 1-month postoperatively (p = 0.002) and thereafter at all postoperative visits (p < 0.05). The mean ocular surface scores were significantly lower in the 23-gauge group at all postoperative visits compared with the 20-gauge group scores (p = 0.001).ConclusionsTransconjunctival 23-gauge vitrectomy appears to be as effective and safe as conventional 20-gauge vitrectomy in idiopathic epiretinal membrane and macular hole surgeries.