Large Full-thickness Macular Hole Research Articles

Pedicle transposition flap, inverted flap, free flap, and standard peel for large full thickness macular holes: a comparative study.

Purpose: To compare anatomical and functional outcomes of four different techniques for the treatment of large idiopathic full-thickness macular holes (FTMH). Methods: Single-centre retrospective study including 129 eyes of 126 patients with large (>500μm) FTMH between January 2018-October 2022. All patients underwent 23/25G vitrectomy and gas with standard internal limiting membrane (ILM) peel, pedicle transposition, inverted, or free flap technique. Postoperative OCT images were assessed by 2 independent masked graders. Results: Mean age was 73.2 years (SD 8.4) with median F/U of 5 months (IQR 8). Overall anatomical success rate was 81%; significantly lower (59%) for the standard ILM peel (p<0.0001). The pedicle transposition flap showed superior visual recovery compared to the free flap (+27 vs +12 ETDRS letters, p=0.02). At 3 months, restoration of the ELM was significantly better for the pedicle transposition flap compared to free flap and standard ILM peel (p=0.008 and p=0.03), and superior to all the other techniques at 6 months (p=0.02, p=0.04 and p=0.006). Conclusions: Standard ILM peel alone offers inferior outcomes for the management of large FTMH. Of the alternative ILM techniques, despite similar closure rates, foveal microstructural recovery is most complete following the pedicle transposition flap, and least complete following the free flap.

Anatomical and functional results after vitrectomy with conventional ILM peeling versus inverted ILM flap technique in large full-thickness macular holes

BackgroundAim of the study was to compare success rate and functional outcome following pars plana vitrectomy (PPV) with conventional internal limiting membrane (ILM) peeling versus ILM flap technique for full-thickness idiopathic macular holes (FTMH).MethodsRetrospective analysis of consecutive eyes with FTMH having undergone vitrectomy with sulfur hexafluoride (SF6) endotamponade 25% at the University Medical Center Rostock, Germany (2009–2020). Eyes were divided according to applied surgical technique (ILM peeling [group P] versus ILM flap [group F]). Inclusion criteria were macular hole base diameters (MH-BD) ≥ 400 μm plus axial length ≤ 26.0 mm. Each group was divided into two subgroups based on macular hole minimum linear diameter (MH-MLD): ≤ 400 μm and > 400 μm. Exclusion criteria were FTMH with MH-BD < 400 μm, trauma, myopia with axial length > 26.0 mm or macular schisis. Demographic, functional, and anatomical data were obtained pre- and postoperatively. Preoperative MH-BD and MH-MLD were measured using optical coherence tomography (OCT; Spectralis®, Heidelberg Engineering GmbH, Heidelberg, Germany). Main outcome parameter were: primary closure rate, best-corrected visual acuity (BCVA), and re-surgery rate.ResultsOverall 117 eyes of 117 patients with FTMH could be included, thereof 52 eyes underwent conventional ILM peeling (group P) and 65 additional ILM flap (group F) technique. Macular hole closure was achieved in 31 eyes (59.6%) in group P and in 59 eyes (90.8%) in group F (p < 0.001). Secondary PPV was required in 21 eyes (40.4%) in group P and in 6 eyes (9.2%) in group F. Postoperative BCVA at first follow-up in eyes with surgical closure showed no significant difference for both groups (MH-MLD ≤ 400 μm: p = 0.740); MH-MLD > 400 μm: p = 0.241).ConclusionAnatomical results and surgical closure rate following ILM flap technique seems to be superior to conventional ILM peeling for treatment of FTMH.

ILM Insertion for the Treatment of Macular Hole Associated with Phakic Intraocular Lens Implantation

Purpose: To report a case of macular hole closure using an internal limiting membrane (ILM) flap following implantation of a posterior chamber phakic implantable contact lens (ICL).Case summary: An 18-year-old female patient presented with visual loss of the left eye after ICL implantation. She had high myopia of -12.5 diopter (spherical equivalent) and a corrected visual acuity of 2/100. The fundus photograph and optical coherence tomography showed a full-thickness macular hole measuring 688 µm in width and 976 µm in length. The ILM around the hole was detached from the retinal surface, which was greater in size than the macular hole. The initial surgical intervention involved vitrectomy, inverted ILM flap placement, and gas tamponade. The decrease in gas volume was associated with a loss of the ILM flap. For hole closure, the remaining ILM flap in the peripheral macula was harvested and inserted in the hole during the second surgery. The silicone oil was used for tamponade. One month after ILM insertion, complete closure of the hole was observed. The visual acuity improved to 20/40 after silicone oil removal.Conclusions: A large full-thickness macular hole developed after ICL implantation in a patient with high myopia. Macular hole surgery using ILM insertion and prolonged tamponade closed the hole and effectively improved the visual acuity.

Prognostic factors for visual recovery after successful large macular hole surgery using the inverted flap technique

The goal of our study is to describe the functional results and preoperative factors predicting visual recovery after successful inverted flap technique and closure of large full-thickness macular holes (FTMH) and to evaluate the correlations between microstructural foveal changes and final visual acuity. Retrospective, descriptive, analytical study including 80eyes of 78patients with large FTMH; operated by inverted flap technique with successful closure of the macular hole after surgery. All eyes underwent a full preoperative ophthalmic examination and macular B-scan SD-OCT. We performed the classic inverted flap technique for all patients. Postoperatively, all patients were examined at 7days, 1, 3, 6, 9 and 12months after surgery. SD-OCT was performed for all patients on each follow-up. Preoperatively, best-corrected visual acuity (BCVA), FTMH size and basal hole diameter were the main outcome measures. Postoperatively, BCVA, macular thickness, integrity of the external limiting membrane (ELM) and ellipsoid zone (EZ) were recorded. Mean age was 62±8.42years with female predominance. Mean size of the FTMH was 692.59μm, and mean basal hole diameter was 1436.06μm. Mean BCVA improved from 1.06±0.491 LogMAR preoperatively to 0.52±0.32 at 9months following surgery (P<0.001). At 9months, the ELM was absent, partial or fully restored in 6.67, 10 and 83.33% respectively. The EZ was absent, partial or fully restored in 6.67, 33 and 63.33% respectively. ELM regeneration always preceded EZ regeneration at every point of follow-up. Final BCVA was statistically correlated with initial hole size (P=0.006, OR=1.056; CI [1.016-1.098]) and mean symptom duration prior to surgery (P=0.001. OR=0.987; CI [0.976-0.998]). Analysis of the ROC curve demonstrated that a hole diameter>478.5μm and symptom duration>5weeks were correlated with non-improvement of visual acuity, with 81.3% sensibility and 18.7% specificity. We report tomographic microstructural foveal changes and functional results following successful large idiopathic FTMH surgery using the classic inverted flap technique. Preoperative parameters such as initial FTMH diameter and mean symptom duration prior to surgery are crucial prognostic factors influencing final visual results.

RONA technique: A novel ILM peeling method for treatment of large full-thickness macular holes.

To present a new technique, RONA, for internal limiting membrane (ILM) peeling and show its comparable success rate in closure of large full thickness macular holes (FTMHs). This prospective interventional case series was implemented from January 2018 to November 2019. Consecutive cases with large FTMH with an aperture size of more than 500 µm were included. RONA technique was used to make consecutive flaps; central border of which remained adherent to the FTMH edge. The emphasis is that the central border of all flaps should remain adherent to the FTMH edge, letting the flaps remain there spontaneously. Seventeen eyes of 17 patients (4 males and 13 females; age 62.3 ± 7.8) were included. The mean size of opening and base of FTMH were 651.1 ± 141.1 µm (range: 501 - 950) and 964.6 ± 383.8 µm (range: 527 - 2098), respectively. One week after the surgery, complete closure of all FTMHs occurred with no hole reopening until the end of month 12. Mean BCVA at baseline and twelve months after surgery were 1.57 ± 0.30 logMAR and 0.75 ± .028 logMAR, respectively with statistically significant improvement (P<0.001). The first advantage of this efficacious technique is that there is no need to manipulate FTMH edge or underneath tissues. Another and of course, the most important advantage of this technique over others is that there is no need to care about flap unfolding during the exchange stage.

Surgical classification for large macular hole: based on different surgical techniques results: the CLOSE study group

BackgroundThe CLOSE study group proposes an updated surgical classification for large macular holes based on a systematic review of new treatments. Recently, many new techniques have been introduced to treat large full-thickness macular holes (FTMH); although the indications are not clear. An updated surgical classification is needed to help surgical decision-making.MethodsWe gathered published series by the CLOSE Study Group members and from literature search until June 2021. Techniques included: internal limiting membrane peeling (ILM peeling), ILM flaps, macular hydrodissection (macular hydro), human amniotic membrane graft (hAM), and autologous retinal transplantation (ART). Within each technique, chi-square test assessed association between the minimal linear diameter (MLD) (in µm) and closure rate; the postoperative best-corrected visual acuity (BCVA) gains were compared among groups.ResultsData extraction included 31 published articles: total of 1135 eyes. Eyes were divided into the following groups: ILM peel (n: 683), ILM Flap (n: 233), macular hydrodissection (n: 64), hAM (n: 59), and ART (n: 96). The initial BCVA and size were heterogenous between the groups. ILM peel showed the best results in large FTMH ≤ 535 µm (closure rate 96.8%); adjusted mean BCVA: 0.49 (LogMAR) with a statistical difference among groups. Large FTMH between 535 and 799 µm: ILM flap technique showed better results (closure rate 99.0%); adjusted mean BCVA: 0.67(LogMAR); also with a statistical difference. For large FTMH ≥ 800 µm more invasive techniques are required. Use of hAM, macular hydrodissection and ART showed higher closure rates for this category (100%, 83.3% and 90.5% respectively), and adjusted mean BCVA varied from 0.76 to 0.89. Although there was no statistical difference between those techniques for this group due to the smaller number of cases.ConclusionsThe CLOSE study group demonstrated the potential usefulness of a new surgical classification for large FTMHs and propose OCT biomarkers for use in clinical practice and future research. This new classification demonstrated that Large (400–550 µm) and X-Large (550–800 µm) holes can be treated highly successfully with ILM peel and ILM flap techniques, respectively. Further studies are necessary for the larger FTMHs (XX-Large and Giant), using the CLOSE classification, in order to determine which technique is better suited for each hole size and characteristics.

Comparative study of conventional internal limiting membrane peeling versus temporal inverted internal limiting membrane flap for large macular hole treatment.

To compare the anatomical, morphological, and functional outcomes of the conventional internal limiting membrane (ILM) peeling versus temporal inverted ILM flap technique for large full-thickness macular holes (FTMHs). Sixty eyes of 60 patients with a minimum base diameter >600 μm were included in this retrospective interventional study. Patients were divided into conventional ILM peeling (Group 1) and temporal inverted ILM flap (Group 2) groups. The hole closure rate, best-corrected visual acuity (BCVA), ellipsoid zone (EZ), and external limiting membrane (ELM) defects were analyzed at baseline and 6 months after surgery. Hole closure was achieved in 24/32 (75.0%) cases of Group 1 and 27/28 (96.4%) cases of Group 2 (P = 0.029). The mean BCVA (logMAR) changed from 1.23 ± 0.47 to 0.70 ± 0.29 logMAR in Group 1 and from 1.03 ± 0.36 to 0.49 ± 0.24 logMAR in Group 2 at 6 months (P < 0.001 in both cases). U-shaped closure was observed in 5 (15.6%) eyes in Group 1 and 19 (67.9%) eyes in Group 2 (P < 0.001). The total restoration rates of ELM and EZ were significantly higher in the temporal inverted ILM flap group (P = 0.002, P = 0.001, respectively). The study results suggested that the FTMH closure rate, recovery of the outer retinal layers, and, consequently, the post-operative BCVA were better with the temporal inverted ILM flap technique than with the conventional ILM peeling for larger than 600 μm macular holes.

Multi-layer internal limiting membrane plug technique for management of large full-thickness macular holes

BackgroundTo evaluate the efficacy of the multi-layer internal limiting membrane plug (MIP) technique in promoting the closure of large full-thickness macular holes (FTMH) and improvement of visual function.MethodsA prospective interventional non-comparative consecutive case series including patients with surgically naïve large FTMH whether primary or secondary. All macular holes were > 400 µm. All patients had 23-gauge pars plana vitrectomy (PPV), MIP technique, and sulfur hexafluoride (SF6) 20% gas tamponade. The main outcome measures were the closure of the hole, improvement of best-corrected visual acuity (BCVA), and detection of complications that might develop due to surgery.ResultsThe study included 15 eyes of 15 patients. The mean age was 44 years (range 10–68; SD 21.5). Primary FTMH constituted 53% of cases. The mean pre-operative minimum linear diameter (MLD) was 702 µm (range 401–1068 µm; SD 154). The mean duration of the macular hole was 6 months (range 1–24; SD 6). The mean pre-operative BCVA was 0.06 decimal units (range 0.01–0.1; SD 0.03). Post-operatively, the macular hole was closed in all patients. U- and V- type closure developed in 93% and 7% of patients, respectively. None of the patients developed W-type closure. Post-operatively, the mean post-operative BCVA was 0.2 decimal units (range 0.05–0.5; SD 0.1). The mean improvement was 5 lines of vision. The mean postoperative follow-up period was 4 months (range 1–10; SD 2.5). None of the patients developed complications attributed to the surgical technique described.ConclusionMIP technique is effective in promoting macular hole closure and improvement of visual function in large FTMH.

Visual improvement and regeneration of retinal layers in eyes with small, medium, and large idiopathic full-thickness macular holes treated with the inverted internal limiting membrane flap technique over a period of 12 months

PurposeThis study aims to compare the improvement of best-corrected visual acuity (BCVA) and the reduction in defect length of external limiting membrane (ELM) and ellipsoid zone (EZ) in small (< 250 μm), medium (ge 250 μm), and large (ge 400 μm) full-thickness macular holes (FTMH) treated with inverted internal limiting membrane (I-ILM) flap technique over a follow-up period of 12 months.MethodsNinety-one eyes of 87 patients were enrolled in this retrospective study. BCVA and spectral-domain optical coherence tomography (SD-OCT) were conducted preoperatively as well as after 1, 3, 6, 9, and 12 months postoperatively. The defect length of the ELM and the EZ was measured using the caliper tool at each follow-up time point.ResultsBCVA improved significantly in the group of small, medium, and large FTMH over the time of 12 months, whereby the improvement did not depend on FTMH size over 9 months. Only after 12 months, large FTMH showed significantly higher BCVA improvement compared to small and medium FTMH. The closure rate was 100% (91/91). The defect length of ELM and EZ reduced continuously over the period of 12 months. There was a significant correlation between defect length of ELM and EZ with postoperative BCVA.ConclusionThe I-ILM flap technique has very good morphological and functional outcomes in small, medium, and large FTMH over a long-time period, indicating that it can be considered as a treatment option in small and medium FTMH. The defect length of ELM and EZ is directly connected to postoperative BCVA.

Combined epiretinal and internal limiting membrane retracting door flaps for large macular holes associated with epiretinal membranes.

To assess the closure rate of large full-thickness macular holes (FTMH) associated with epiretinal membrane (ERM) with a combined epiretinal and internal limiting membrane retracting door flap. Retrospective chart review of patients treated at a single tertiary retina practice between January 2017 and November 2019. Individuals with FTMH larger than 400μm and co-diagnosis of ERM who underwent surgical repair with an ERM flap were included. Patients underwent pars plana vitrectomy with peeling of ERM that was positioned as a retracting door flap to cover the FTMH. Primary outcome was closure rate at 6months following surgery. Final surgical success rate and visual acuity were secondary outcomes. Among 7 eyes of 7 patients, 6 eyes achieved primary surgical success and final surgical success rate was achieved in all 7 eyes with a large FTMH repaired with ERM flap. The mean minimum linear diameter of the FTMH was 681μm ± 295. All patients had follow-up greater than 6months, with a mean duration of 17months (range 14-23months). Visual acuity improved from a mean of 0.9 ± 0.3 logMar (20/160) before surgery to 0.3 ± 0.5 logMar (Snellen 20/40), postoperatively. Large FTMH with concurrent ERM that are managed with an ERM flap have high single-surgery success rate.

MANAGEMENT OF LARGE IDIOPATHIC MACULAR HOLE WITH PARS PLANA VITRECTOMY AND MODIFIED MINIMAL ILM PEELING WITH SUPERIOR ILM FLAP

Introduction: Idiopathic macular hole is an anatomic discontinuity of the neurosensory retina in the center of the macula or fovea resulted from tractional forces on the foveola at the vitreoretinal interface not associated with other causes. Diagnosis and management of this condition requires expertise, skills, and specialized examination to detect changes in the retina which is important for deciding the appropriate management.&#x0D; Case Report: We report a case of 66-year-old man with idiopathic macular hole (IMH) in the right eye with initial best corrected visual acuity (BCVA) 20/1200. Fundus examination and optical coherence tomography (OCT) confirmed the presence of large full thickness macular hole with mean linear diameter 673 µm and posterior hyaloid still attached to the optic nerve. The patient was managed with pars plana vitrectomy (PPV) surgery using modified minimal internal limiting membrane (ILM) peeling with superior ILM flap and SF6 gas tamponade. Two weeks after surgery OCT showed closure of the macular hole. BCVA at two and four weeks after surgery improved to 20/240 and 20/200 respectively.&#x0D; Discussion: PPV with ILM peeling is one of the standardized procedures in IMH surgery. Failure of the vitrectomy surgery to close the macular hole or late reopening of initially successfully closed holes may occur without removal of the ILM due to ILM role as a scaffold for cellular proliferation or attachment of contractile tissue that may cause persistent vitreomacular traction. Variations of ILM peeling such as inverted ILM peeling has been used to improve closure rate for large IMH and has showed favorable results both anatomically and functionally. Nowadays, to avoid or minimize the damage of retinal microstructure by ILM peeling, some surgeons introduced new techniques aiming to preserve the ILM for IMH. Minimal ILM peeling with superior ILM flap technique in this case was done to obtain MH closure with less microstructural retinal abnormalities and better visual outcomes.&#x0D; Conclusion The management of large IMH with PPV and modified minimal ILM peeling with superior ILM flap in this case showed good results in terms of anatomic and functional outcomes.

Modern approaches to the surgical treatment of large full-thickness macular holes

Vitreoretinal surgery is an actively developing area of modern ophthalmic surgery. Intravitreal interventions in the central retina with large full-thickness macular holes deserve special attention. This article provides an overview of the scientific literature published in journals recommended by the Higher Attestation Commission, also presented in the scientific databases Scopus, PubMed, dedicated to modern techniques to the surgical treatment of large full-thickness macular holes. The main methods for closing defects in the macular area today are the use of various modifications of the inverted internal limiting membrane flap technique and the application of autologous platelet rich plasma in a macular hole. These techniques provide high anatomical and functional outcomes. Modifications of the inverted internal limiting membrane flap technique demonstrated effectiveness in such complex clinical situations as recurrent macular holes, concomitant high myopia, retinal detachment. Over the past 10 years, data on the use of autologous platelet-rich plasma for this group of patients appeared in the scientific literature. More accurate surgical procedures are required for the use of this technique compared with the standard methods, but this technique is applicable in all patients, does not require additional manipulations (blood sampling and centrifugation), additional equipment. Vitreoretinal interventions with the use of platelet-rich plasma are characterized by relative simplicity and ease of carrying out surgical procedures. However, it is important to consider the possibility of pseudouveitis development, the need for additional equipment. Since both of these methods demonstrate good anatomical results, the problem of choosing a technique in a particular clinical case remains. It was clear that the method of surgical intervention should be chosen, taking into account possible disadvantages and limitations to the method, as well as the skills of an ophthalmic surgeon. The lack of a unified approach to macular hole surgery encourages researchers to improve surgical techniques, develop and implement new modifications of surgical approaches.

Commentary: To evaluate the functional and anatomical outcomes for autologous retinal autograft with Finesse™ Flex Loop for failed macular holes.

Commentary: To evaluate the functional and anatomical outcomes for autologous retinal autograft with Finesse™ Flex Loop for failed macular holes.

Combination of Inverted ILM Flap Technique and Subretinal Fluid Application Technique for Treatment of Chronic, Persistent and Large Macular Holes.

IntroductionThe choice of surgical treatment for chronic, persistent and large full-thickness macular holes (FTMH) continues to be undefined and challenging, as some of these cases remain refractory to the treatment. We report the efficacy of combination of inverted internal limiting membrane flap technique (IILMFT) and subretinal application of the fluid (SR fluid application) technique for treatment of refractory FTMHs.MethodsNine patients (nine eyes) were enrolled into this retrospective non-randomized exploratory consecutive case series study. All patients were diagnosed with chronic, persistent or large FTMH and were treated with a combination of IILMFT and SR fluid application technique. The following outcome parameters were analysed during 1- and 6-month follow-up visits: anatomical FTMH closure rate on spectral domain optical coherence tomography (SD-OCT), best-corrected visual acuity (BCVA), degree of postoperative retinal displacement.ResultsThe mean preoperative diameter of FTMH was 542.0 μm (range 154–1930 μm). Final closure of FTMH was achieved in nine of nine cases (100%). In one case a second operation was required because of postoperative rhegmatogenous retinal detachment. The mean BCVA after the FTMH closure increased from 1.0 logMAR (0.7–1.3) to 0.4 logMAR (0.2–0.8 logMAR) (W = 2.67; p = 0.008). A positive correlation was revealed between preoperative BCVA and axial length (ρ = 0.67, p = 0.048), between preoperative BCVA and duration of the symptoms (ρ = 0.818, p = 0.007), as well as between postoperative BCVA at 1-month follow-up and BCVA at 6-month follow-up (ρ = 0.821, p = 0.007).ConclusionCombination of IILMFT with SR fluid application technique for refractory FTMH surgery appears to be effective and safe. Improvement of anatomical and visual outcomes after the single surgery benefits from and is ensured by the advantages of both novel surgical approaches.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40123-021-00361-2.

Inverted ILM Flap Technique in Idiopathic Full-Thickness Macular Hole Surgery: Functional Outcomes and Their Correlation with Morphologic Findings.

Objectives The inverted internal limiting membrane (ILM) flap technique has been shown to increase the success rate in large full-thickness macular holes (FTMHs) and in FTMHs associated with high myopia. The aim of our study was to confirm the efficacy and safety of inverted ILM flap technique in idiopathic FTMHs independent of their dimensions and to assess functional outcomes and their correlation to morphologic findings. Methods Sixteen consecutive patients affected by idiopathic FTMH were enrolled in this prospective study. The preoperative mean (±SD) diameter of the FTMH was 422 (±106) µm. All patients underwent vitrectomy and ILM peeling with inverted ILM flap. At 1-, 3-, and 6-month postoperative visits, visual acuity measurement, indirect ophthalmoscopy, and microperimetry were performed, and the foveal contour and the integrity of the ellipsoid zone (EZ) and external limiting membrane (ELM) were investigated using spectral domain optical coherence tomography (SD-OCT). Results At six months postoperatively, 15 out of 16 (93.75%) patients obtained FTMH closure. The mean best corrected visual acuity (BCVA) improved from 1.1 LogMAR to 0.3 LogMAR, and the mean retinal sensitivity (MS) improved from 7.2 to 23.4 dB. ELM defects were evident in 1 out of 16 (6.25%) eyes, and EZ defects were detected in 2 out of 16 (12,50%) eyes. A statistically significant relationship was observed between BCVA, MS, and EZ reconstitution at each follow-up visit. Conclusions Results confirm that the inverted ILM flap technique is a safe and effective option for FTMH treatment and show a strong correlation between higher BCVAs and MSs and EZ reconstitution after surgery.

Efficacy of Pars Plana Vitrectomy with Internal Limiting Membrane Peeling for Treatment of Large Idiopathic Full-Thickness Macular Holes.

PurposeTo evaluate anatomical and visual outcomes of pars plana vitrectomy (PPV) with internal limiting membrane peeling (ILMP) in large idiopathic full-thickness macular holes (FTMH). Predictive factors also formed part of the study.Patients and MethodsA retrospective review of medical charts and optical coherence tomography images of patients with large idiopathic FTMH (≥400 µm) was conducted.ResultsOne hundred and fifty-eight eyes of 155 patients with a mean age of 62.94±7.50 years were included in the study. Mean preoperative visual acuity (VA) was 1.26±0.36 logMAR. Mean preoperative minimum linear diameter (MLD) and basal linear diameter (BLD) were 644.89±136.85 µm and 1208.11±307.14 µm, respectively. At 12 weeks postoperative follow-up, FTMH closure rate was 61.39% and mean postoperative BCVA was 0.92±0.36 logMAR. Multivariate logistic regression analyses showed the anatomical outcome was significantly associated with BLD ≤1200 µm, preoperative vitreomacular interface (VMI) disorder and extended ILMP (a radius of 2 disc diameters), whereas only postoperative ellipsoid loss ≤500 µm was significantly associated with visual outcome. In subgroup analyses, the large FTMH group (400–600 µm) had significantly better results in closure rate (70.97% vs 55.21%, P = 0.047) and visual results (P = 0.031) than the extra-large FTMH group (>600 µm).ConclusionPPV with conventional ILMP provided relatively low closure rate in large FTMH. Surgical success was significantly associated with BLD ≤1200 µm, no preoperative VMI abnormality, extended ILMP and postoperative ellipsoid defect ≤500 µm. Therefore, we suggest the extended ILMP if conventional ILMP technique is used. The large FTMH group had significantly better surgical outcomes than the extra-large group, so there is a need for reclassification of large FTMH.

A novel video overlay guided enlargement of area of ILM peeled versus inverted flap technique: A long-term study in large macular holes.

To compare the intra-operative video overlay guided enlargement of Area of ILM peeled (AIP) more than three Disc Diameter (DD) versus the inverted flap technique in large (>400 µm ) Full Thickness Macular Holes (FTMH). Retrospectively, 127 cases of large FTMHs divided into two groups (i) Group A (n = 62)-intra-operative video-overlay guided enlargement of AIP > 3DD performed and (ii) Group B (n = 65)-Inverted flap technique was done. Mean Best Corrected Visual Acuity (BCVA), hole closure rate and postoperative foveal anatomy were noted on Optical Coherence Tomography (OCT). Mean Minimal Diameter of Macular Hole (MDMH) were 632.05 ± 146.62 µm (A) and 677.24 ± 152.08 µm (B). Hole closure rate were 93.55% (A) and 96.92% (B). Mean preoperative BCVA was 1.07 ± 0.37 Log MAR (A) and 0.94 ± 0.23 Log MAR (B). Mean postoperative BCVA at 3 months were 0.73 ± 0.22 Log MAR (A) and 0.83 ± 0.24 Log MAR (B). One-way ANOVA test showed statistically better visual improvement in Group A at 3 months (p = 0.02), 6 months (p = 0.045), 12 months (p = 0.002), and 24 months (p = 0.011). Chi square test revealed Type I pattern of hole closure was statistically more in Group B (p < 0.001). Delayed Recovery of Outer Retinal Layers was more in group B (Pearson Chi square test, p = 0.039). Anatomically, macular hole closure rate as well as closure pattern was better in Group B. But functional improvement was better in Group A.

Comparative study of 1 DD and 2 DD radius conventional internal limiting membrane peeling in large idiopathic full-thickness macular holes: a randomized controlled trial.

To compare the surgical outcomes of 1-disc diameter (DD) and 2-DD conventional internal limiting membrane peeling (C-ILMP) in large full-thickness macular holes (FTMHs). A prospective randomized controlled trial. One hundred patients with large idiopathic full-thickness macular hole (FTMH) were randomized into C-ILMP and extended C-ILMP (EC-ILMP) groups. The primary outcome was closure rate at 6 months after surgery. Secondary outcomes were visual acuity (VA), closure type, consequence of ILMP and complications. The mean symptom duration was 12.19 ± 9.64 months. Mean preoperative VA was 1.25 ± 0.37 logMAR. The average minimum linear diameter was 633.05 ± 129.82 µm and basal linear dimension was 1158.49 ± 249.07 µm. The two groups did not differ in term of demographic data. Closure rate was significantly higher in the EC-ILMP group (76.47% vs. 51.02%, 95% CI 7.24-43.66; p = 0.008). There were also no significant differences in closure type, central foveal thickness, dissociated optic nerve fibre layer detection, or change in fovea-to-disc distance. There were also no significant differences in postoperative VA (p = 0.069) or visual improvement (mean 0.39 ± 0.43 logMAR; p = 0.286). According to subgroup analysis, EC-ILMP resulted in a higher closure rate in patients with chronic FTMH for >6 months, (p = 0.008). Furthermore, EC-ILMP resulted in better anatomical closure and visual result in patients with FTMH with macular hole closure index ≤0.5, p = 0.003 and p = 0.010, respectively. Extended C-ILMP yielded a significantly higher closure rate in large FTMHs, but visual outcome did not differ significantly. According to subgroup analysis, extended C-ILMP was more effective in chronic large FTMH with MHCI ≤ 0.5.

Large macular hole-Always a poor prognosis?

HintergrundAlter, präoperativer Visus und Makulaforamengröße gelten als prognostische Marker für das postoperative Ergebnis bei Patienten mit durchgreifendem Makulaforamen (MF).Ziel der ArbeitUm den postoperativen Verlauf nach i‑ILM Peeling (inverted-Flap ILM-Peeling) mit konventionellem ILM-Peeling (k-ILM) zu vergleichen, wurde eine retrospektive Beobachtungsstudie durchgeführt. Patienten mit i‑ILM Peeling hatten dabei präoperativ ein statistisch signifikant größeres Makulaforamen.Material und MethodenEs wurden 45 konsekutive Patienten mit durchgreifendem Makulaforamen (MF) in 2 Gruppen (i-ILM vs. k‑ILM) eingeteilt und auf Unterschiede im postoperativen Visus (BCVA) und der Netzhautmorphologie hin untersucht. Die Integrität der äußeren Netzhautschichten, äußere limitierende Membran (ELM), ellipsoide Zone (EZ) und äußere Photorezeptoraußensegmente (OS), wurde postoperativ mittels SD-OCT (Spectral-Domain-OCT) analysiert.ErgebnisseDie präoperative Apertur in der i‑ILM Gruppe war signifikant größer (i-ILM = 408,4 µm, SD = 157,5 µm; k‑ILM = 287,4 µm, SD = 104,9 µm; p = 0,01). Der Ausgangsvisus sowie der postoperative Visus nach 1 Monat waren in der Gruppe mit k‑ILM-Peeling signifikant besser (p = 0,03 und p = 0,001). Der postoperative Visus nach mindestens 6 Monaten zeigte keinen signifikanten Unterschied zwischen den beiden Gruppen (p = 0,24). Die ELM zeigte als erste der äußeren Netzhautschichten eine Re-Integrität in beiden Gruppen.SchlussfolgerungMithilfe der i‑ILM-Peeling-Technik erschien es in dieser konsekutiven Serie möglich zu sein, für Patienten mit großem durchgreifendem MF ein ähnliches postoperatives Visusergebnis zur erreichen wie für mittels k‑ILM-Peeling-Technik operierte Patienten mit kleinerem durchgreifendem MF.

Premacular Cells as Source of Neurotrophic Factors in Idiopathic Macular Holes

ABSTRACT Purpose: To describe the presence of neurotrophic growth factors and histopathologic characteristics of internal limiting membrane (ILM) specimens obtained from large idiopathic full-thickness macular holes (FTMH). Methods: In 24 eyes of 24 patients with FTMH of diameter >400 µm, ILM specimens were harvested directly at the edge surrounding the macular hole during vitrectomy with peeling. We performed interference and phase contrast microscopy of flat mounts followed by immunostaining and transmission electron microscopy. Primary antigens directed against neurotrophic growth factors as well as antigens to glial and ganglion cells were used. Topographic relationship of cells and collagen was demonstrated by serial ultrathin sectioning. Results: Immunofluorescence microscopy demonstrated the presence of glial-derived neurotrophic factor and ciliary neurotrophic factor. Expression of vimentin, glial fibrillary acidic protein (GFAP), neurofilament, calretinin, and melanopsin was seen positive too. Cellular retinaldehyde-binding protein was seen positive in half of the specimens. Co-localisation of anti-GFAP as well as anti-vimentin with neurotrophic factors was found. Electron microscopy revealed cells exclusively on the vitreal side of the ILM. Cell fragments on the retinal side were rarely seen. Conclusion: In large FTMH, ILM specimens present positive immunolabelling of neurotrophic factors. The co-localization with macroglial cell markers suggests a premacular cell composition as a source of the neurotrophic factors. Ultrastructurally, premacular cells were found on the vitreal side of the ILM and not within the collagen network of the ILM itself.