Large Macular Holes Research Articles

Internal limiting membrane inverted flap technique: a new paradigm in large macular holes surgery

Purpose: To evaluate the efficacy and safety of the internal limiting membrane (ILM) inverted flap technique (IFT) in large macular hole (MH) surgery. Material and Methods: Retrospective analysis of eyes of patients with large MHs who underwent vitrectomy with ILM IFT between January 2013 and December 2014, with a minimum follow-up of 6 months. Myopic macular holes were excluded. We evaluated best-corrected visual acuity (BCVA), hole closure documented by OCT and complications. We compared preoperative and postoperative values. The Wilcoxon test was used for comparing BCVA (p <0.05). Results: 17 eyes of 17 patients with a mean age of 63.24 years were studied. 76.5% of eyes had primary MHs, 11,8% post-vitrectomy and 11,8% post-traumatic. Mean minimum MH diameter was 578,5 ± 147μm and the mean MH duration was 35,9 months. According to lens status, 47,1% were phakic, 11,8% had cataract and 41,2% were pseudophakic. Concomitant cataract surgery was performed in 47,1% of cases. At the mean follow-up of 7,76 months, closure rate was 100%, with BCVA improving from 1,20 ± 0,48 to 0,68 ± 0,36 logMar units. All patients improved BCVA, with 64,7% gaining two or more Snellen lines of BCVA. Complication rate was 5.6%. Conclusions: ILM IFT is an effective and safe technique in MH surgery. In this study, with large MH, the anatomic success rate was 100% and BCVA improvement was significant.

PIMS (Positioning In Macular hole Surgery) trial – a multicentre interventional comparative randomised controlled clinical trial comparing face-down positioning, with an inactive face-forward position on the outcome of surgery for large macular holes: study protocol for a randomised controlled trial

BackgroundIdiopathic macular holes are an important cause of blindness. They have an annual incidence of 8 per 100,000 individuals, and prevalence of 0.2 to 3.3 per 1000 individuals with visual impairment. The condition occurs more frequently in adults aged 75 years or older. Macular holes can be repaired by surgery in which the causative tractional forces in the eye are released and a temporary bubble of gas is injected. To promote successful hole closure individuals may be advised to maintain a face-down position for up to 10 days following surgery. The aim of this study is to determine whether advice to position face-down improves the surgical success rate of closure of large (>400 μm) macular holes, and thereby reduces the need for further surgery.Methods/DesignThis will be a multicentre interventional, comparative randomised controlled clinical trial comparing face-down positioning with face-forward positioning.At the conclusion of standardised surgery across all sites, participants still eligible for inclusion will be allocated randomly 1:1 to 1 of the 2 treatment arms stratified by site, using random permuted blocks of size 4 or 6 in equal proportions. We will recruit 192 participants having surgery for large macular holes (>400 μm); 96 in each of the 2 arms of the study. The primary objective is to determine the impact of face-down positioning on the likelihood of closure of large (≥400 μm) full-thickness macular holes following surgery.DiscussionThis will be the first multicentre randomised control trial to investigate the value of face-down positioning following macular hole standardised surgery.Trial registrationUK CRN: 17966 (date of registration 26 November 2014).Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-015-1048-8) contains supplementary material, which is available to authorized users.

The use of intraoperative spectral domain optic coherence tomography in vitreoretinal surgery: The evaluation of efficacy

PurposeTo evaluate the feasibility of intraoperative spectral domain optic coherence tomography (iSD‐OCT) in challenging cases during pars plana vitrectomy (PPV).MethodsIntraoperative imaging was performed using the first commercially available iSD‐OCT system Rescan 700, fully integrated into the surgical microscope OPMI Lumera 700 (Zeiss, Oberkochen, Germany). The feasibility of iSD‐OCT was assessed during three 23‐gauge PPV cases: large macular hole (MH) with inverted internal limiting membrane (ILM) flap technique (Case #1), vitrectomy for asteroid hyalosis with age‐related macular degeneration (Case #2), vitrectomy for morning glory syndrome with retinoschisis and exudative retinal detachment (Case #3).ResultsCase #1. The use of iSD‐OCT facilitated to safely initiate ILM flap, to form inverted flap, to invert the flap into the MH, to control position of the forceps concerning retinal layers, and to confirm the MH covering with the ILM remnants at the end of the surgery. Case #2. Standard OCT was not available before the surgery due to opaque vitreous. Intraoperative SD‐OCT imaging assisted to reveal epiretinal membrane (ERM), retinal pigment epithelium detachment, intraretinal fluid and drusen. These findings required additional surgical steps: ERM removal and injection of anti‐VEGF at the end of the surgery. Case #3. In the case of morning glory syndrome iSD‐OCT facilitated to remove the strongly adherent posterior hyaloid, to control ILM flap initiation, to perform the peeling over the detached retina, to aspirate residual fluid after fluid/air exchange.ConclusionsThe use of iSD‐OCT facilitates real‐time simultaneous to surgical workflow visualisation of tissue behaviour and surgical manoeuvres during pars plans vitrectomy. The obtained information can improve surgical technique and influence the decision making in difficult cases.

The use of intraoperative spectral domain optic coherence tomography in vitreoretinal surgery: The evaluation of efficacy

PurposeTo evaluate the feasibility of intraoperative spectral domain optic coherence tomography (iSD‐OCT) in challenging cases during pars plana vitrectomy (PPV).MethodsIntraoperative imaging was performed using the first commercially available iSD‐OCT system Rescan 700, fully integrated into the surgical microscope OPMI Lumera 700 (Zeiss, Oberkochen, Germany). The feasibility of iSD‐OCT was assessed during three 23‐gauge PPV cases: large macular hole (MH) with inverted internal limiting membrane (ILM) flap technique (Case #1), vitrectomy for asteroid hyalosis with age‐related macular degeneration (Case #2), vitrectomy for morning glory syndrome with retinoschisis and exudative retinal detachment (Case #3).ResultsCase #1. The use of iSD‐OCT facilitated to safely initiate ILM flap, to form inverted flap, to invert the flap into the MH, to control position of the forceps concerning retinal layers, and to confirm the MH covering with the ILM remnants at the end of the surgery. Case #2. Standard OCT was not available before the surgery due to opaque vitreous. Intraoperative SD‐OCT imaging assisted to reveal epiretinal membrane (ERM), retinal pigment epithelium detachment, intraretinal fluid and drusen. These findings required additional surgical steps: ERM removal and injection of anti‐VEGF at the end of the surgery. Case #3. In the case of morning glory syndrome iSD‐OCT facilitated to remove the strongly adherent posterior hyaloid, to control ILM flap initiation, to perform the peeling over the detached retina, to aspirate residual fluid after fluid/air exchange.ConclusionsThe use of iSD‐OCT facilitates real‐time simultaneous to surgical workflow visualisation of tissue behaviour and surgical manoeuvres during pars plans vitrectomy. The obtained information can improve surgical technique and influence the decision making in difficult cases.

Face-down posturing after idiopathic macular hole surgery: a meta-analysis

Objective To evaluate the full thickness idiopathic macular hole (IMH) closure rates in patients positioning non-supine (NSP) compared with patients positioning face-down (FDP). Methods A computerized search was conducted in the PubMed, Chinese Biomedical Database, China National Knowledge Infrastructure, and VIP database. All the included studies were divided into NSP and FDP group. A total of 9 papers were included in this meta analysis, including 285 eyes (145 eyes with small hole ≤400 μm, 104 eyes with large hole >400 μm) in NSP group and 303 eyes (141 eyes with small hole and 124 eyes with large hole ). RevMan 4.2 software was applied for investigating heterogeneity and meta-analysis, and the risk of publication bias was evaluated. Results Meta analysis indicated that there was statistical significance on closure rates betwen NSP and FDP group [odds ratio (OR)=0.47, 95% confidence interval (CI) 0.26 - 0.84, P=0.01]. The difference of closure rates in small macular hole eyes between NSP and FDP group was statistically significant (OR=0.45, 95%CI 0.13 - 1.51; P=0.20). The difference of closure rates in large macular hole eyes between NSP and FDP group was statistically significant (OR=0.35, 95%CI 0.17 - 0.75; P=0.006). Conclusion NSP is equally effective as strict FDP in the repair of small macular hole. Post-operative FDP may improve the macular hole closure rates for holes larger than 400 μm. Key words: Diabetic retinopathy/surgery; Prone position; Meta-analysis

Posterior Pole Detachment Technique for the Management of Full Thickness Macular Hole

Purpose: To investigate the clinical characteristics, visual and anatomical outcomes of a series of large full thickness macular holes treated by vitrectomy, ILM peeling and gas tamponade augmented by retina expansion. Methods: Prospective, non-comparative, interventional case series of seven eyes of seven patients with Gass Stage 3 or above full thickness macular hole presenting to a vitreo-retinal unit of a tertiary eye hospital. All patients underwent 23 gauge pars plana vitrectomy, peeling of the internal limiting membrane, retina expansion through detachment of the posterior pole with injection of balanced salt via a 41-gauge subretinal cannula, and gas tamponade with sulfur hexafluoride gas. The main outcome measures were: anatomical closure of the macular hole and post-operative visual acuity. Results: Six cases were Gass Stage 3, and one Gass Stage 4. Preoperative visual acuity ranged from hand movement to 6/36. Patients were followed post operatively for a minimum of 6 months. Anatomical closure of the full-thickness macular hole was successfully achieved and confirmed on optical coherence tomography in six of the seven cases. All patients in our case-series recorded improved visual acuity by 6 months follow up. Six patients attained a postoperative best corrected Snellen visual acuity of 6/24 or better. Conclusion: The retina expansion technique has demonstrated promising results in improving anatomic and visual outcomes in patients with large, chronic, full thickness macular hole. The proposed mechanism is the undermining of the retina by fluid to facilitate approximation of the hole edge and aid migration of glial cells to close the foveal defect.

Autologous Transplantation of Internal Limiting Membrane for the Treatment of Large Macular Hole

양산부산대학교병원 안과학교실, 양산부산대학교병원 의생명융합연구소, 부산대학교병원 안과학교실, 부산대학교 의학전문대학원 안과학교실 Department of Ophthalmology, Pusan National University Yangsan Hospital, Yangsan, Korea Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan, Korea Department of Ophthalmology, Pusan National University Hospital , Busan, Korea Department of Ophthalmology, Pusan National University School of Medicine, Yangsan, Korea

Inverted internal limiting membrane peeling technique with silicone oil tamponade for repair of recurrent large macular holes in vitrectomized Diabetic patients

Purpose : To present a new approach to treatment of large macular holes in already vitrectomized eyes of patients with proliferative diabetic retinopathy, whose ILM has not been removed during primary surgery. Patients and methods : Two eyes of two different patients with proliferative diabetic retinopathy which had undergone vitrectomy with endolaser 1.5 to 2 years before admittance to our department. No data for ILM peeling during surgery were available. Our OCT examinations showed macular holes with upper diameter of 765 I¼m in the first patient and 1160 I¼m in the second one. In both cases we combined two well-known surgical approaches: first, inverted ILM flap technique; second, long-term silicone oil tamponade for a period of 4 months. Results : The macula of both patients was followed up by photographs and regular OCT-s on day one, month one and three months after silicone oil removal. The macular holes remained closed after removal of the tamponade agent. BCVA was 0.5 three months after the last surgery in both patients. During the final examination, macular contour seemed almost normal. Discussion : Large, long-standing macular holes are less likely to be closed after pars plana vitrectomy. The inverted ILM flap technique has been recently reported to be successful in nearly 99% of patients with macular holes more than 400 I¼m in diameter. The position of the inverted ILM flap is much more controllable under silicone oil than under gas tamponade.

Autologous Transplantation of the Internal Limiting Membrane for Refractory Macular Holes

To determine the effectiveness of autologous transplantation of the internal limiting membrane (ILM) for refractory macular holes. Prospective, interventional case series. Ten eyes of 10 consecutive patients who underwent autologous transplantation of the ILM for the treatment of refractory macular holes were studied. The primary diseases in these patients were large idiopathic macular holes that had existed for more than 1 year (4 eyes), a traumatic macular hole (1 eye), myopic foveoschisis (2 eyes), foveoschisis resulting from pit-macular syndrome (2 eyes), and proliferative diabetic retinopathy (1 eye). Apart from the 5 eyes with idiopathic or traumatic macular holes, macular holes developed in the other 5 eyes after initial vitrectomies with ILM removal. In all eyes, regular macular hole surgery failed to achieve closure. The main outcome measures used in this study were macular hole closure and best-corrected visual acuity (BCVA). Macular holes were closed successfully in 9 eyes (90%) after autologous transplantation of the ILM. The postoperative BCVAs were significantly better than the preoperative BCVAs (P = .007, paired t test). Postoperative BCVAs improved by more than 0.2 logarithm of the minimal angle of resolution units in 8 eyes (80%) and were unchanged in 2 eyes (20%). Although this is a pilot study, the results suggest that autologous transplantation of the ILM may contribute to improved anatomic and visual outcomes in the treatment of refractory macular holes and may warrant further investigation.

Novel Surgical Technique for Closure of Large Full-Thickness Macular Holes

Novel Surgical Technique for Closure of Large Full-Thickness Macular Holes

Surgical outcomes of inverted internal limiting membrane flap technique for large macular hole

We are presenting the initial results of inverted internal limiting membrane (ILM) flap technique for large macular hole. Five eyes of five patients with large diameter macular hole (>700 μm) were selected. All patients underwent inverted ILM flap technique for macular hole. Anatomical closure and functional success were achieved in all patients. There was no loss of best-corrected visual acuity in any of the patients. Inverted ILM flap technique in macular hole surgery seems to have a better hole closure rates, especially in large diameter macular holes. Larger case series is required to assess the efficacy and safety of this technique.

Tapping of Macular Hole Edges: The Outcomes of a Novel Technique for Large Macular Holes.

To describe the novel technique of tapping macular hole edges for holes with low macular hole index (MHI) and assess its outcomes. A prospective interventional study. Twenty-eight consecutive eyes with idiopathic large macular holes (MHI < 0.5) were enrolled. A standardized surgical protocol was performed using vitrectomy with brilliant blue G dye-assisted large internal limiting membrane peeling, intraocular gas tamponade with 18% C3F8, and strict postoperative prone positioning for 5 days. Tapping of macular hole edges was performed on all sides using 23-gauge GreenTip soft tip cannula. Hole closure was examined postoperatively using optical coherence tomography. There were 16 females and 12 males aged 63 ± 14.38 years. The mean MHI was 0.32. Hole closure was seen in 25 eyes (89.29%). MHI was less than 0.25 in the 3 eyes with failed macular hole surgery. Epiretinal membrance (ERM) was present in 22 eyes (78.57%). The presence of ERM did not correlate with hole closure (P = 1.00). Continuity of external limiting membrane was a better predictor of functional success than inner segment/outer segment continuity (P < 0.05). Type I hole closure was seen in 20 (80%) of 25 eyes while the remaining 5 eyes (20%) had type II hole closure on optical coherence tomography. Corrected distance visual acuity improved significantly from 0.86 ± 0.2 logMAR preoperatively 0.43 ± 0.22 logMAR postoperatively (P < 0.0001). Newer technique of tapping macular hole edges provides acceptable anatomical and functional success rates even in large macular holes (MHI< 0.5).

Arcuate Retinotomy for the Repair of Large Macular Holes

To present a case series to elucidate a novel technique that involves the creation of an arcuate retinotomy in the treatment of large macular holes after failed primary repair. retrospective chart review. Six eyes (six patients) with large macular holes, all of which had failed primary repair, underwent 25 gauge pars plana vitrectomy revision coupled with full thickness arcuate retinotomy temporal to the macular hole and fluid-gas exchange. The main outcome measure was anatomic macular hole closure based on optical coherence tomography (OCT), with visual acuity and visual field evaluation as secondary outcome measures. Five of the six patients (83%) had successful hole closure with three of the six patients (50%) exhibiting improvement in visual acuity. Arcuate retinotomy is a new approach that may aide in the repair of large macular holes not otherwise amenable to closure with traditional techniques.

Arcuate Retinotomy for the Repair of Large Macular Holes

Arcuate Retinotomy for the Repair of Large Macular Holes

Pars Plana Vitrectomy and Silicone Oil Tamponade as a Primary Treatment for Retinal Detachment Caused by Macular Holes in Highly Myopic Eyes: A Risk-Factor Analysis

Objectives: To determine (i) the efficacy of silicone oil tamponade as a primary treatment for a retinal detachment (RD) resulting from a macular hole (MH) (MHRD) in highly myopic eyes, and (ii) identify variables associated with successful retinal re-attachment.Methods: We retrospectively reviewed 28 eyes of 26 high myopia MHRD patients in one hospital. All eyes had been treated with pars plana vitrectomy (PPV) and silicone oil tamponade (PPV/silicone oil tamponade). Binary logistic regression was used to determine the factor(s) influencing initial anatomical success.Results: The initial anatomical success rate was 75% (21 of 28 eyes); after silicone oil removal, the anatomical success rate was 96.4% (27 of 28 eyes). MH diameter was the only variable associated with initial anatomical success.Conclusion: PPV/silicone oil tamponade is a practical choice for treatment of MHRD in high myopia. While RDs occasionally re-occur after silicone oil treatment, these events are limited and can be managed with simple measures. A large MH is a risk factor for recurrent RD.

ILM peeling in macular surgery: benefits

AbstractInternal limiting membrane (ILM) peeling should be beneficial to improve the anatomic and functional outcomes in macular surgery. In macular hole surgery, it seems to be an additive tool to improve the closing rate especially in large macular hole. In epiretinal membrane surgery, it should be considered either to improve the functional outcome but also to decrease the recurrence of epiretinal membrane on the remaining ILM. However, the characteristics of the peeling (ie area, control with dye) should be given in all clinical trials to obtain more homogeneous surgical criteria.

Traumatic macular hole revealing a retinitis pigmentosa: a case report

AbstractPurpose To report a case of traumatic macular hole revealing a retinitis pigmentosa.Methods A 33‐year old man without past medical history complained of visual loss after direct trauma of his left eye. Visual acuity was 20/50 RE and 20/400 LE. Anterior chamber examination was normal and fundus examination revealed a large macular hole associated with optic atrophy in his left eye. Right eye funduscopy showed a cystoid macular edema and optic nerve palor (RE). Many pigment deposits were present in retinal mid‐periphery of both eyes. Optical coherence tomography showed cystoid macular edema (517 microns) RE and a large macular hole (3100 microns) LE. Typical visual field defects and extinguished electroretinogram responses confirmed the diagnosis of retinitis pigmentosa.Results Macular diseases are well‐known complications of retinitis pigmentosa, especially macular edema. Vitreomacular tractions, epiretinal membranes and macular holes are less frequent. These complications may be explained by pigment epithelium disorders that may compromise ionic drainage of the retina. Causes of macular hole in retinitis pigmentosa remain uncertain. In our patient, development of a macular hole may be explained by occurrence of trauma in an eye with pre‐existent macular edema secondary to the unknown retinitis pigmentosa.Conclusion Despite macular complications of retinitis pigmentosa are relatively common, a traumatic macular hole as a revealing symptom is exceptional.

Short-term postoperative non-supine positioning versus strict face-down positioning in macular hole surgery

The purpose of this study was to compare the efficacy of short-term non-supine positioning (NSP) and strict face-down positioning (FDP) in the repair of macular hole (MH). We retrospectively reviewed all MH repairs over a 27-month period (2008-2010). Inclusion criteria were idiopathic full thickness stage 2-4 MH treated by a single surgeon with 23-gauge pars plana vitrectomy, internal limiting membrane peeling and gas tamponade, followed by postoperative short-term NSP (for 5 days) or strict FDP (for 3-4 days). NSP was achieved by fastening a tennis ball to the back of the nightshirt. Outcome measures were anatomical MH closure verified by optical coherence tomography and postoperative visual acuity. A total of 67 eyes (64 patients) met the inclusion criteria. The median follow-up period was 6.6 months (range, 4.7-19.8 months). The closure rates following a single operation were 30/33 (90.9%) in the FDP group, and 31/34 (91.2%) in the NSP group, respectively (p = 0.97). The FDP group improved 2.9 ETDRS lines, and 23 eyes (69.7%) gained two or more ETDRS lines. The NSP group improved 2.7 ETDRS lines (p = 1.00), and 25 eyes (73.5%) gained two or more ETDRS lines. The closure rates in the MH subgroup with diameters larger than 400 μm were 20/23 (87.0%) and 15/17 (88.2%) in the FDP group and the NSP group, respectively (p = 0.96). The study indicates that short-term NSP is equally effective as strict FDP in the repair of MH. Contrary to previous reports, even large MH did not seem to benefit from FDP.

VITRECTOMY FOR OPTIC DISK PIT WITH MACULAR SCHISIS AND OUTER RETINAL DEHISCENCE

To describe the outcomes of vitrectomy for optic disc pit-related maculopathy with central outer retinal dehiscence. This prospective interventional case series included seven patients with optic disc pit with macular schisis and central outer retinal dehiscence who underwent vitrectomy with internal limiting membrane peeling, barrage laser photocoagulation, and gas tamponade and were followed for at least 6 months. The surgical outcomes in terms of restoration of macular anatomy and visual improvement were recorded at each visit by fundus photography and optical coherence tomography. The mean age of the patients was 21.3 ± 8.6 years (range, 10-35 years), and the mean duration of defective vision was 6.7 ± 8.5 months (range, 1-24 months). Preoperatively, the median best-corrected visual acuity (BCVA) was 20/60 (range, 20/40 to 20/120). Full-thickness macular holes were noticed in 4 patients 1 month postoperatively. Gas tamponade was repeated in two patients with large macular holes. By the final follow-up, macular holes had closed and BCVA improved in all patients except one. Final mean central macular thickness was 176.83 ± 55.74 μ, the range being 109 μ to 256 μ. The median postoperative BCVA was 20/30 (range, 20/20 to 20/80). Six of 7 patients (85.7%) had improvement in BCVA postoperatively (mean, +2 lines; range, 1-4 lines). Five patients (71%) achieved a postoperative BCVA of ≥20/30. Best-corrected visual acuity dropped by one line in the patient with persistent macular hole. Vitrectomy with internal limiting membrane peeling can achieve excellent final surgical outcomes in optic pit maculopathy with outer retinal dehiscence despite the potential for macular hole formation.

Inverted Internal Limiting Membrane Flap Technique for Large Macular Holes

Large macular holes usually have an increased risk of surgical failure. Up to 44% of large macular holes remain open after 1 surgery. Another 19% to 39% of macular holes are flat-open after surgery. Flat-open macular holes are associated with limited visual acuity. This article presents a modification of the standard macular hole surgery to improve functional and anatomic outcomes in patients with large macular holes. A prospective, randomized clinical trial. Patients with macular holes larger than 400 μm were included. In group 1, 51 eyes of 40 patients underwent standard 3-port pars plana vitrectomy with air. In group 2, 50 eyes of 46 patients underwent a modification of the standard technique, called the inverted internal limiting membrane (ILM) flap technique. In the inverted ILM flap technique, instead of completely removing the ILM after trypan blue staining, a remnant attached to the margins of the macular hole was left in place. This ILM remnant was then inverted upside-down to cover the macular hole. Fluid-air exchange was then performed. Spectral optical coherence tomography and clinical examination were performed before surgery and postoperatively at 1 week and 1, 3, 6, and 12 months. Visual acuity and postoperative macular hole closure. Preoperative mean visual acuity was 0.12 in group 1 and 0.078 in group 2. Macular hole closure was observed in 88% of patients in group 1 and in 98% of patients in group 2. A flat-hole roof with bare retinal pigment epithelium (flat-open) was observed in 19% of patients in group 1 and 2% of patients in group 2. Mean (or median) postoperative visual acuity 12 months after surgery was 0.17 (range, 0.1-0.6) in group 1 and 0.28 (range, 0.02-0.8) in group 2 (P = 0.001). The inverted ILM flap technique prevents the postoperative flat-open appearance of a macular hole and improves both the functional and anatomic outcomes of vitrectomy for macular holes with a diameter greater than 400 μm. Spectral optical coherence tomography after vitrectomy with the inverted ILM flap technique suggests improved foveal anatomy compared with the standard surgery.