Macular Hole Size Research Articles

Sparing versus Removal of Epiretinal Proliferation in the Surgical Repair of Full-thickness Macular Holes.

To evaluate the efficacy of vitrectomy with epiretinal proliferation (EP) sparing for full-thickness macular hole (FTMH) accompanied by EP. A multicenter, retrospective study. Eyes were divided into two groups: the sparing group (Group S) included eyes in which the EP around the hole was peeled and preserved, whereas the removal group (Group R) included eyes in which the EP was partially or completely removed. The internal limiting membrane was peeling in all eyes. Forty-six eyes were included. Twenty-five eyes were in Group S, and 21 eyes were in Group R, with no difference in preoperative best-corrected visual acuity (BCVA) (P = 0.96). After primary surgery, MHs were closed in all eyes, and there were no complications in either group. Postoperative 12-month BCVA significantly improved in both groups (both P < 0.01), while Group S had better 12-month BCVA than Group R (P = 0.016). In the multivariable analysis, EP sparing was associated with better BCVA at 12 months (P = 0.006) after accounting for the minimal macular hole size and preoperative BCVA. EP sparing and removal were both safe and effective techniques, while EP sparing may provide a favorable outcome for eyes with FTMH and EP.

Topographic analysis of retinal and choroidal vascular displacements after macular hole surgery

It has been reported that the retinal vessel and macular region of the retina are displaced after macular hole (MH) surgery. However, there is no detailed information for correlations between retinal and choroidal displacements. We obtained optical coherence tomography angiography (OCTA) and en-face optical coherence tomography (OCT) images from 24 eyes to measure the retinal and choroidal vascular displacement before and after surgery. These images were merged into infrared images using blood vessel patterns. The same vascular bifurcation points were automatically selected for each follow-up image, and the displacements of the bifurcation points were analyzed as a vector unit for prespecified grid regions in a semi-automated fashion. The results showed displacements of the choroidal intermediate vessels and retinal vessels following MH surgery (p = 0.002, p < 0.001). The topographic changes showed inferior, nasal, and centripetal displacement of the retina and inferiorly displaced choroid. The ILM peeling size and basal MH size were significantly associated with the retinal displacement (p < 0.001 and p = 0.010). Additionally, changes in the amount of the choroidal displacement were significantly correlated with that of the retinal displacements (p = 0.002). Clinicians should keep in mind that there might be topographic discrepancies of the displacement between retina and choroid when analyzing them following surgery.

OPTICAL COHERENCE TOMOGRAPHY FEATURES ASSOCIATED WITH VITREOMACULAR TRACTION RELEASE AND MACULAR HOLE SIZE PROGRESSION FOLLOWING TREATMENT WITH OCRIPLASMIN.

To evaluate OCT features for vitreomacular traction (VMT) release and change in macular hole (MH) size after treatment with ocriplasmin. Patients who had undergone treatment with ocriplasmin for VMT with or without MH ≤400 µm were included. The main outcomes were VMT release and changes in minimum linear diameter MH size at 4 weeks in MHs that persisted. OCT features evaluated were central retinal thickness, vitreomacular adhesion length, posterior vitreous cortex (PVC) insertion angles 500 µm from the insertion points, and minimum linear diameter size. Sixty patients were included: 37 had isolated VMT and 23 VMT with a MH. Four weeks after ocriplasmin injection, the overall VMT release rate was 66.7% (40/60); 64.9% (24/37) in eyes with isolated VMT and 69.6% (16/23) in eyes with MH. VMT release was associated with younger age (P = 0.02). Macular hole closure was achieved in 26.1% (6/23) and was associated with a smaller ratio of the temporal to the nasal PVC angle (P < 0.01). Of the 17 persistent MHs, 76.5% (13/17) increased in minimum linear diameter size from baseline 186 (±78) to 358 (±133) µm (P < 0.001). Progression in minimum linear diameter size showed a negative linear association with the size of the nasal PVC angle (R2 = 0.39, P = 0.002) and a positive linear association with the ratio of the temporal to nasal PVC angle (R2 = 0.39, P = 0.002). In patients with VMT-associated MHs, the risk of MH enlargement following ocriplasmin is negatively correlated with the nasal PVC angle size and is increased if the ratio of the temporal to nasal angle is >1.

Comparative Efficacy of Posterior Subtenon Kenacort Compared to Standard Surgical Treatment for Macular Hole Closure

Background: Macular holes cause significant vision loss, particularly in older adults. Although standard surgical treatment (SDT) has been successful, there is increasing interest in less invasive treatments that might offer better outcomes, especially in terms of best-corrected visual acuity (BCVA) and macular hole closure. Objective: This study aimed to determine the effectiveness of posterior subtenon Kenacort (SBT) in closing macular holes and to compare its efficacy with standard surgical treatment (SDT). Additionally, the study examined the impact of macular hole classification on treatment outcomes in both groups. Methods: An interventional study was conducted at Al-Shifa Trust Eye Hospital in Rawalpindi, involving 60 subjects aged 45 to 65 years with idiopathic macular holes. Participants were selected using non-probability sampling. Group A (30 eyes) received two SBT injections three months apart, while Group B (30 eyes) underwent SDT, which included pars plana vitrectomy with internal limiting membrane (ILM) peeling and gas tamponade. OCT imaging and logarithm of the minimum angle of resolution (LogMAR) measurements were obtained for all subjects before treatment, with follow-up assessments conducted six months post-treatment. Data analysis was performed using SPSS version 25.0, with quantitative variables expressed as mean ± SD and inferential statistics explored using ANOVA and paired sample t-tests. A p-value ≤ 0.05 was considered statistically significant. Results: Both treatment groups had thirty patients each with similar average macular hole sizes (SBT: 436 ± 126 µm, SDT: 439 ± 127 µm). In the SBT group, average BCVA improved from 1.48 to 0.846, while in the SDT group, it changed from 1.44 to 1.25. Macular hole classification significantly affected post-treatment BCVA scores in both groups (p &lt; 0.001). The SBT group showed significantly greater BCVA improvement compared to the SDT group. Conclusion: Posterior subtenon Kenacort effectively closed macular holes and improved BCVA more than standard surgical treatment. Macular hole classification influenced post-treatment BCVA scores in both treatment groups, highlighting its importance in predicting treatment outcomes.

Duration after Macular Hole Surgery for Stabilisation of Visual Acuity: A Long-term Retrospective Review

The purpose of the study is to determine the median duration for visual recovery to achieve visual stability and visual acuity gain after macular hole surgery in our local population. This was a retrospective study. Patients with full-thickness macular holes (FTMH) from surgical logs were included between January 2009 and December 2019. The patients' medical records were reviewed for pre-, intra-, and post-operative data collection. Patients who fulfilled the inclusion and exclusion criteria were recruited and analysed. Data collected from the medical record pre-operatively, which included baseline best corrected visual acuity (BCVA), interval of symptoms development to surgery, any ocular co-morbidities, optical coherence tomography (OCT) for size and stage of macular hole and central subfield thickness (CST). Intra-operative notes included whether vitrectomy with or without phacoemulsification and with the internal limiting membrane (ILM) peel or ILM flaps, types of dye, and tamponade agent used. Post-operative data included BCVA and CST on each visit, types of macular hole closure, or any complications. Data were analysed using SPSS.Thirty-one patients were diagnosed with FTMH. Sixteen patients who underwent pars plana vitrectomy (PPV) were included and analysed. Fifteen patients (93.75%) achieved successful macular hole closure after the primary operation. The median duration BCVA reached at stability was 19.5 months (IQR 9 – 26.25), and visual acuity gained by 0.44 LogMAR (IQR 0.165 – 0.565). Ten patients (62.5%) underwent combined PPV with phacoemulsification. CST showed improvement from baseline, 444 (IQR 347.5 – 519.75) to 273 (IQR 232 -285.5), 230 (IQR 221.5-255), and 270 (IQR 254-322) at the period interval of 0 to 3 months, 3 to 6 months, and 6 to 12 months respectively. Gas C3F8 and membrane blue were commonly used as tamponade agents and dyes, and PPV with ILM peel was the common surgery performed. Six patients (40%) achieved type 1 macular hole closure within 12 months of follow-up. Despite the small sample size, our study provided practical information regarding patient’s expectations of when their vision can become stable after macula hole surgery in our local population.

Outcomes of inverted internal limiting membrane flap surgery for chronic large macular holes in a sub-Saharan African setting

TopicOutcomes of inverted internal limiting membrane (ILM) flap surgery for chronic large macular holes (MH) in a sub-Saharan Africa setting. PurposeTo report the anatomic and visual outcomes of ILM flap surgery without face-down positioning for eyes with chronic large MH at Eye Foundation Hospital, Lagos, Nigeria. DesignRetrospective, observational study. MethodsCase files of patients who underwent inverted ILM flap surgery for large MH in the retina unit of the Eye Foundation Hospital, Lagos, Nigeria, between January 2022 and December 2022 were reviewed. ResultsThe study included 30 eyes of 29 patients. MH size was between 471 μm and 1530 μm. The mean overall preoperative best corrected logMAR visual acuity was 1.27 ± 0.58. A one-line worsening of preoperative logMAR vision was associated with an increase in MH size by 129.5 μm (p = 0.056). MH closure was achieved in 90% of eyes. There was an improvement in mean best corrected postoperative logMAR visual acuity at 6 months to 0.83 ± 0.49 (p < 0.001). Good visual outcomes were seen in 60.7% of eyes. The remodeling of the external limiting membrane seen in 46.7% of eyes was associated with good visual outcomes (p = 0.04). ConclusionThere was a 90% anatomic closure rate for chronic large MHs that underwent inverted internal limiting membrane flap surgery among our series of patients in a sub-Saharan African setting. Good visual outcomes were seen in 60.7% of eyes, with an overall improvement in logMAR visual acuity.

Delayed closure of a full-thickness macular hole following pars plana vitrectomy with ILM flap

Purpose: Our aim is to describe a patient with delayed closure of a stage 3 full thickness macular hole after pars plana vitrectomy. Methods: A retrospective case report. Details of the case were obtained from the electronic patient record system, Medisoft. Results: A 65-year-old male was referred with a left stage 3 full thickness macular hole measuring 720 microns and visual acuity of 6/36. He underwent phaco-vitrectomy, ILM peel with an inverted ILM flap and C3F8 gas tamponade. 7 weeks after surgery, the macular hole was smaller at 196 microns but remained open. The patient was listed for repeat surgery, however another 13 weeks later the full thickness macular hole demonstrated type 2 closure without further intervention. Discussion/conclusion: Delayed macular hole closure after pars plana vitrectomy is rare. In cases where there has been a substantial decrease in the size of a full thickness macular hole after surgery without full closure, a short period of observation to allow for further closure may be appropriate before reconsidering surgery.

Macular hole repair: the effect of size and nonsupine posture on postoperative outcomes.

Postoperative face-down positioning (FDP) for up to 2 weeks is believed to be necessary for successful closure of macular holes. FDP, however, can be disabling and uncomfortable and is a major burden for elderly patients. The aim of this study was to investigate how nonsupine posturing and macular hole size affect anatomical and functional success of macular hole closure. The medical records of patients with idiopathic macular holes who were treated surgically between 2016 and 2019 were reviewed retrospectively. Exclusion criteria included vitreomacular traction, previous retinal detachment, or chronic macular hole. A total of 115 eyes of 115 patients were included. Average age was 69.2 ± 8.2 years; 63 patients (55%) were female. Anatomical success was achieved in 108 patients (94%) with a single operation. In small holes (<400 μm), closure was seen in 98% of cases (95% CI, 94%-100%); in large holes (≥400 μm), 90% of cases (95% CI, 76%-94%). Visual acuity remained stable or improved in 108 patients (92%). Average preoperative best-corrected visual acuity was 1.02 ± 0.45, with an overall improvement of 5 lines postoperatively. Small holes and large holes improved, with an average of 3 versus 7 lines gained, respectively. In this study cohort, favorable anatomical and functional outcomes were achieved without postoperative FDP. These outcomes are comparable to the traditional FDP approach.

Surgical treatment of idiopathic macular holes with a fovea-sparing technique and 20% SF6 gas tamponade

Purpose: To assess the macular hole (MH) closure rate and final visual acuity after idiopathic MH treatment with a modified fovea-sparing technique and 20% SF6 gas tamponade. Material and Methods: Fifteen patients (16 eyes; 12 women and 3 men; mean age (standard deviation or SD), 65.5 (5.90 years)) with Gass stage 2 to stage 4 MHs were involved in the study. Before surgery, mean best-corrected visual acuity (BCVA) (SD) was 0.15 (0.09), and mean MH diameter (SD), 437.2 (164.7) µm. Patients underwent surgical treatment with the modified fovea-sparing technique and 20% SF6 gas tamponade of two-week duration and were instructed to maintain a face-down position for a week after surgery. Results: At 1 month after the first surgery, MHs were closed in 11/16 eyes (68.75%). In addition, mean BCVA (SD) in eyes with closed MHs improved significantly from 0.15 (0.09) to 0.48 (0.16) (р = 0.000000). Of the five eyes in which the MH had failed to close after primary fovea-sparing surgery, two received a gas fluid exchange gas tamponade with 15% С3F8, and these patients were advised to maintain a face down position for 3 more weeks. In addition, in another two eyes, the vitreous cavity was revised, and the internal limiting membrane (ILM) was removed by a conventional technique with 15% С3F8 gas tamponade. Moreover, one patient rejected repeat intervention. In the four eyes in which the MH had failed to close after primary fovea-sparing surgery, after a repeat intervention, the MH was closed, and mean BCVA (SD) improved to 0.35 (0.04). There was no significant difference between the eyes in which the MH failed to close and the eyes in which the MH did close after primary surgery in terms of mean MH size (SD) (455 (203) µm versus 415 (155) µm, р = 0.66) or MH duration. Conclusion: A long gas tamponade (longer than 1 week) is required to improve the closure rate with the fovea-sparing ILM peeling technique for idiopathic MHs.

Swept Source-Optical Coherence Tomography-Guided Facedown Posturing to Minimize Treatment Burden and Maximize Outcome after Macular Hole Surgery.

We evaluated the closure of full-thickness macular holes (MHs) the day after surgery in minimizing the burden and maximizing patient outcomes. Herein, 25-gauge pars plana vitrectomy, internal limiting membrane peeling, and fluid-gas (20% sulfur hexafluoride) were performed for the treatment. Patients were instructed to remain in the facedown position until the confirmation of MH closure, and the position was discontinued in cases where the closure was confirmed. In total, 43 eyes of 43 patients, whose average age was 69.7 ± 8.6 years, were enrolled in this study. We used swept source (SS)-optical coherence tomography (OCT) for the confirmation of MH closure for gas-filled eyes and used spectral domain (SD)-OCT for the reconfirmation of MH closure after the gas volume was reduced to less than half of the vitreous cavity. MH closure was confirmed in 40 eyes (93%, the closure group) on the next day after surgery. The time from surgery to SS-OCT imaging was 24.7 h. Although facedown positioning was terminated in cases where MH closure was confirmed, there were no cases in which the MH was re-opened afterward. The basal and minimum MH size was significantly larger in the non-closure group than that in the closure group (p = 0.027, p = 0.043, respectively). Therefore, checking with SS-OCT the day after surgery and terminating facedown positioning in cases where MH closure was confirmed would be a useful method, removing a great burden for the elderly without sacrificing the MH closure rate.

Vitrectomy with sulfur hexafluoride versus air tamponade for idiopathic macular hole: a retrospective study

BackgroundTo evaluate the effect of room air and sulfur hexafluoride (SF6) gas in idiopathic macular hole(MH)surgery.MethodsRetrospective, interventional, and comparative study. 238 eyes with the idiopathic macular hole that underwent pars plana vitrectomy, internal limiting membrane peeling, fluid-air exchange, and 20% SF6 (SF6 group:125 eyes) or room air tamponade (air group: 113 eyes) were reviewed. The primary outcome measure was the closure rate of primary surgery.ResultsThe baseline characteristics of the SF6 group and air group were comparable except for the hole size (479.90 ± 204.48 vs. 429.38 ± 174.63 μm, P = 0.043). The anatomical closure rate was 92.8% (116 / 125) with the SF6 group and 76.1% (86 / 113) with the air group (P < 0.001). A cut-off value of MH size to predict primary anatomical closure was 520 μm, which is based on the lower limit of 95% confidential interval of the MH size among the unclosed patients in the air group. There was no significant difference in anatomical closure rates between SF6 and air group (98.7% vs. 91.9%, P = 0.051) for MH ≤ 520 μm, whereas a significantly lower anatomical closure rate was shown in the air group than SF6 group (46.2% vs. 84.0%, P < 0.001) for MH > 520 μm.ConclusionSF6 exhibited more effectiveness than air to achieve a good anatomical outcome for its longer tamponade when MH > 520 μm.

Impact of inverted internal limiting membrane-flap technique on functional outcome and structural restoration of small and medium size macular holes.

To evaluate the impact of the inverted internal limiting membrane (ILM)-flap technique on the visual outcome and anatomical recovery for small (<250 μ), medium (<400 μ), and large (>400 μ) macular holes (MHs). Retrospective study included consecutive idiopathic MH cases operated on using the inverted ILM-flap technique. Clinical data were retrieved from electronic medical records (EMRs), surgical videos, and optical coherence tomography (OCT) machines. Eyes with axial length >25 mm, coexisting macular diseases, and follow-up <6 weeks were excluded. Data included the presence or absence of ILM flap and restoration of External Limiting Membrane (ELM), Ellipsoid Zone (EZ) lines. Mean visual improvement and structural recovery were compared between eyes showing ILM flap and those showing no flap in three MH size groups. Forty eyes of 38 patients with a mean age of 62.7 ± 10.1 years and a mean MH diameter of 348 ± 152 μm were included. The mean follow-up was 527 ± 478 days with anatomical closure observed in all eyes. Mean best-corrected visual acuity (BCVA) improved significantly from 0.87 ± 0.38 to 0.35 ± 0.26. ILM flap was visible in 29 (72.5%) all MHs, 7 (53.8%) small MHs (n = 13), 8 (61.5%) medium MHs (n = 13), and 14 (100%) large MHs (n = 14). The mean BCVA change was 0.47 ± 0.34, 0.53 ± 0.48, and 0.56 ± 0.20 in large, medium, and small MHs, respectively, and the difference between eyes showing ILM flap versus no flap in each MH size group was not statistically significant (P > 0.05). However, for medium MHs, it was higher in the ILM flap (0.66 ± 0.52) group compared to the no flap (0.32 ± 0.37) group. One eye with small MH developed significant gliosis resulting in reduced BCVA. ELM was restored in all eyes with small and medium MHs. We observed that the ILM flap did not adversely affect anatomical and visual outcomes for MHs <400 μm. Restoration of ELM suggests minimal interference in structural recovery by an ILM flap.

Direct Macular Hole Manipulation Results in High Success Rate in Secondary Macular Hole Repair.

To investigate closure rates and functional outcomes of surgery for refractory and recurrent macular holes (MH) in a real-world setting. Retrospective review of secondary MH surgeries. A total of 72 eyes from 72 patients were included. Eyes had a mean of 1.51 surgeries before inclusion into the study with a mean MH size of 762 µm and a mean baseline logMAR BCVA of 1.11(∼20/260 Snellen). Closure rates were 89.3 % for tissue transplantation, 77.3 % for ILM flaps, 92.9 % for MH manipulation, and 12.5 % for repeat ILM peeling (p<0.05). BCVA changes in logMAR from baseline to postoperative month 6 were +0.29 for ILM peeling alone (15 ETDRS letters worse), -0.39 for macular hole manipulation (20 ETDRS letters improved), -0.23 for tissue transplantation (13 ETDRS letters improved), and -0.2 for ILM flaps (10 ETDRS letters improved; p<0.05). Secondary MH closure is possible using various surgical techniques with acceptable anatomical closure rates. Repeat ILM peeling is associated with the lowest closure rates and poorest functional results. To distinguish between techniques would require a large sample size of about 750 eyes.

Клинический анализ эффективности анатомического восстановления фовеолярной сетчатки в витреоретинальной хирургии сквозных макулярных разрывов

Purpose. To compare the anatomical and functional results of various techniques macular hole (MH) closure. Material and methods. 24 patients (age from 67 to 81 years; 6 men and 18 women): stage III MH, complete detachment of the posterior hyaloid membrane. MH sizes were from 427x202 to 1392x758 µm. Initial best-corrected visual acuity (BCVA) were from 0.03 to 0.2. Endovitreal intervention 27G with removal of the posterior hyaloid membrane, complete membrane peel was performed. In 18 patients, tamponade was performed with silicone oil, in the remaining 6 patients – with air. 2 groups were formed, comparable in age, sex, MH diameter. In the 1st group (12 patients) vacuum massage was performed, in the 2nd group (12 patients) – partial membrane peel with inverted internal limiting membrane flap technique. Results. All surgery perfomed without complications. In 18 eyes with silicone oil tamponade, all MH were completely closed, BCVA was from 0.15 to 0.5. In 2 of 3 eyes of the 1st group with combination of vacuum massage and pneumotamponade, incomplete closure of the edges of the MH with residual defects 112 µm and 84 µm, respectively, was noted. BCVA ranged from 0.1 to 0.2. In the third case of combination of vacuum massage with pneumotamponade, the MH completely closed, the BCVA increased from 0.2 to 0.6. In all 3 eyes, using the inverted flap technique and pneumotamponade, the MH were completely closed, the BCVA ranged from 0.45 to 0.55. After 1 month after ended of silicone oil tamponade in all 18 patients, the MH were closure, BCVA values increased from 0.25 to 0.5. Conclusion. After a month of follow-up, better anatomical results of complete MH closure were shown by the inverted flap technique in combination with air or silicone oil tamponade. After silicone removal, complete MH closure occurred in 10 eyes of the 1st group and 12 eyes of the 2nd group. In the future, the terms of dynamic observation of these patients will be continued for more objective assessment of the long-term effectiveness of both methods. Keywords: macular hole, vacuum massage, vitreous tamponade

Влияние различных факторов на прогнозирование функционального результата при хирургии больших сквозных идиопатических макулярных разрывов

Purpose.To evaluate the effect of various factors on the prognosis of functional outcome after surgical treatment of large macular holes. Materials and methods. The results of surgical treatment of idiopathic macular holes (over 400 µm) in 47 patients (47 eyes) were analyzed. Endovitreal intervention of 25 or 27 G was performed with removal of epiretinal membrane and air tamponade. Results. Mean values of the best corrected visual acuity (BCVA) and retinal photosensitivity have been significant improved postoperatively: BCVA – from 0,12 ± 0,1 to 0,24 ± 0,18 (p&lt;0,01), photosensitivity – from 20,07 ± 3,85 dB to 21,43 ± 3,44 dB (p&lt;0,05). The mean value of the predicted BCVA according to the maximum hole diameter was 0.21 ± 0.0898. There was no dependence of BCVA on patients' age, duration of macular hole (more than 6 months) and anterior-posterior eyeball size (p&lt;0.05). Conclusion. Prediction of visual acuity after surgery is dependent by the initial retinal photosensitivity in the macular zone as well as the maximal diameter of the macular hole. Key words: idiopathic macular hole, microperimetry, vitrectomy, optical coherence tomography

Commentary: Retinal changes after internal limiting membrane peeling.

The internal limiting membrane (ILM) is the innermost of the 10 retinal layers. It is a transparent membrane measuring nearly 10 microns and is formed by the basement membrane of the Müller cells. It is peeled as a standard treatment of full-thickness macular hole (FTMH). However, many reports have shown that peeling the ILM may actually damage the retina. Wollensak et al.[1] showed that ILM removal reduces the mean strength of the central retina by almost half. Histological studies performed on human and primate eyes have shown that ILM peeling causes damage to the processes and end feet of the Müller cells. A selective delay has been noted in the B-wave recovery of focal macular electroretinogram in eyes that have undergone ILM peeling. Several anatomical changes have been described after ILM peeling.[2] Swelling of the arcuate nerve fiber layer (SANFL): It was first described by Clark et al.[3] as an early postoperative change. It is seen as hypoautofluorescent arcuate striae in the macular region on fundus autofluorescence (FAF) and infrared (IR) imaging; however, it cannot be detected on either biomicroscopic fundus examination or color photograph. It is seen as a hyperreflectant swelling on spectral domain optical coherence tomography (SD-OCT). It usually disappears gradually over a period of 2–3 months. It does not seem to affect the best-corrected visual acuity (BCVA) or retinal sensitivity. Dissociated optic nerve fiber layer (DONFL): It was first described by Tadayoni et al.[4] in 2001. It is also known as “concentric macular dark spots (CMDS)” or “inner retinal dimpling”.[2] It gives the macula a ‘‘moth-eaten’’ appearance due to the presence of small depressions on the retinal contour situated along the course of retinal nerve fibers on the en face scan. SD-OCT scans show that the depth of these dimples is limited to the RNFL only. Liu et al. found three distribution patterns, namely, papillomacular bundle-dominated, scattered, and temporal raphe-spared patters.[5] Ye et al.[6] showed that DONFL appeared within two months of surgery. The number progressed during the next four months and then slowed down. The number did not change after 12 months since the surgery. It has not been found to have association with either BCVA or retinal sensitivity. Steel et al.[7] showed that the use of a diamond-dusted membrane scraper to initiate the peel is a risk factor for the formation of DONFL. The extent of DONFL has been seen to be positively associated with the amount of cellular debris on the retinal side of the peeled ILM.[8] The perioperative optical coherence tomography (OCT) for ophthalmic surgery (PIONEER) study showed that the immediate increase in the inner retinal layer thickness on intraoperative OCT following ILM peeling was associated with the development of DONFL, while the technique used for peeling did not.[9] Foveal displacement: Several authors have reported a nasal shift of the fovea, that is, shortening of the foveopapillary distance (FPD). Ishida et al.[10] reported that the displacement was greater in the temporal retina compared to the nasal retina. They further reported that the degree of the retinal displacement significantly correlated with the maximum base diameter of the FTMH. However, Nair et al.[11] reported that a temporal foveal shift may be seen in around 25% of the eyes, especially those with a longer temporal segment. Ohta et al. reported that the steepness of the foveal slope increased after ILM peeling in an asymmetrical pattern as the nasal side became significantly steeper than the temporal one.[12] None of these findings seem to affect the BCVA or retinal sensitivity. Retinal thinning: Several studies have shown that the macular volume, especially that of the temporal macula, shows a progressive reduction.[2] It has been proposed that hemi-temporal ILM peeling is as effective as conventional 360-degree peeling for the treatment of FTMH. Additionally, it is associated with less retinal displacement, lesser DONFL formation, lower rates of subjective metamorphopsia, faster visual rehabilitation, and greater safety.[13–15] We congratulate the authors for their study showing that the outcomes of papillomacular bundle sparing ILM peeling is comparable to conventional ILM peeling in terms of hole closure rates and visual gain, with the advantage of less retinal damage for the treatment of idiopathic FTMH ≤400 microns.[16] Studies with larger sample size and larger macular hole size will help validate the surgical technique.

PREDICTION OF MACULAR HOLE SIZE PROGRESSION BASED ON BASELINE OPTICAL COHERENCE TOMOGRAPHY FINDINGS.

To quantify the rate of idiopathic macular hole progression from presentation and identify factors that may influence stratification and urgency for surgical listing based on the initial optical coherence tomography scans. The minimal linear diameter (MLD), base diameter (BD), and hole height on nasal and temporal sides of idiopathic macular hole were measured on spectral domain optical coherence tomographies, on initial presentation and just before surgery. Mean hole height, hole height asymmetry (absolute difference between nasal and temporal height), MLD/BD, and MLD change per day (MLD/day) were calculated for each patient. Multivariable linear regression analysis with MLD/day as the dependent variable was performed to identify significant risk factors for MLD progression. Minimal linear diameter was grouped to quintiles: 1: ≤290 µ m, 2: >290 µ m and ≤385 µ m, 3: >385 µ m and ≤490 µ m, 4: >490 µ m and ≤623 µ m, and 5: >623 µ m. In 161 eyes (157 patients), we report significant associations with MLD/day: 1) MLD/BD ( P = 0.039) (i.e., wide BD relative to MLD lead to faster progression of MLD), 2) hole height asymmetry ( P = 0.006) (larger absolute difference between nasal and temporal hole height lead to faster progression), and 3) days between scans ( P < 0.001) (longer duration between scans had reduced MLD/day, indicating more rapid increase initially then plateaux), and relative to MLD Quintile 1, MLD Quintile 3 ( P = 0.002) and MLD Quintile 4 ( P = 0,008), and MLD Quintile 5 ( P < 0.001) all lead to a reduced MLD/day rate on multivariable regression. In addition to finding that the previously reported initial smaller MLD is a risk factor for rapid MLD progression, we report two novel findings, large hole height asymmetry and a low MLD/BD (wide base relative to MLD), that represent significant risk factors. These factors should be taken into consideration on presentation to stratify timing of surgery.

THREE-DIMENSIONAL QUANTIFICATION OF INTRARETINAL CYSTOID SPACES ASSOCIATED WITH FULL-THICKNESS MACULAR HOLE.

To evaluate intraretinal cystoid spaces in patients with idiopathic macular hole (MH). Retrospective cohort study included consecutive patients with full-thickness MH who underwent successful MH surgery and 12 months of follow-up. Custom software was applied to preoperative optical coherence tomography scans to generate fluid volume. Inner fluid volume was defined as cystoid spaces in the inner nuclear layer, and outer fluid volume was defined as cystoid spaces in Henle fiber layer of the outer nuclear layer. Thirty-nine eyes from 39 participants were included. Postoperative 12-month visual acuity correlated with both inner fluid volume and minimum MH size (both P < 0.05) but not outer fluid volume. Inner fluid volume positively correlated with minimum MH size ( P = 0.0003). After accounting for minimum MH size with multivariable analysis, inner fluid volume effect on VA remained significant ( P = 0.025). After dividing inner fluid volume into tertiles, mean baseline visual acuity was 20/50 in eyes with small inner fluid volume, and was 20/125 in eyes with large inner fluid volume ( P = 0.0039). Mean postoperative 12-month visual acuity was 20/20 in eyes with small inner fluid volume compared with 20/32 in eyes with large inner fluid volume ( P = 0.019). Increased inner fluid volume was associated with worse postoperative VA.

Intravitreal gas injection for early persistent macular hole after primary pars plana vitrectomy

PurposeTo report the clinical presentations and outcome of early intravitreal injection (IVI) of octafluoropropane (C3F8) for persistent macular holes (MH) after primary pars plana vitrectomy with the internal limiting membrane (ILM) peeling technique.MethodsNineteen eyes of 18 patients with persistent MH after vitrectomy underwent intravitreal injection of C3F8 between 11 and 21 days after the initial surgery (intravitreal gas injection group). Another nine eyes with a persistent MH without additional IVI C3F8 were included (non-intravitreal gas injection group).Best-corrected visual acuity (BCVA), optical coherence tomography (OCT) features including size and configuration of MH, and time duration between the 2 surgeries were compared between the MH closure and open groups. The closure rate of persistent MHs was compared between the intravitreal gas injection group and non-intravitreal gas injection group.ResultsTwelve of 19 eyes (63%) achieved MH closure after 1 to 3 times IVI C3F8. The final BCVA after vitrectomy and IVI gas was significantly better in the MH closure group (P = .005). Nine of 12 patients (75%) in the MH closure group had a visual acuity improvement of more than 2 lines. Original MHs with smaller minimal diameter, higher macular hole index (MHI) and higher tractional hole index (THI); and persistent MHs with smaller minimal diameter, higher THI, and lower diameter hole index (DHI) showed higher MH closure rate. None of the persistent MHs closed in the non-intravitreal gas injection group (0/9 eyes).ConclusionEarly intravitreal injection of C3F8 can be a cost-effective first-line treatment for early persistent MHs after primary surgery, especially in eyes with favorable OCT features.

Effect of Facedown vs Non-Facedown Position on Macular Hole Closure after Surgery

Background: Internal Limiting Membrane (ILM) peeling with Gas tamponade after Pars Plana vitrectomy is routinely done in macular hole surgery. After the procedure, a face-down position (FDP) is advised to the patients to promote macular hole closure by pushing the bubble of Gas against the posterior pole. However, elderly patients and those with medical comorbidities may feel uncomfortable in FDP. A few post-operative complications may also be caused by it. So, the aim of this study is to compare and evaluate the role of postoperative non-face-down position (nFDP) and FDP on the macular hole closure rate after PPV with ILM peeling. Patients and methods: 20 phakic eyes of 20 patients, with idiopathic full-thickness macular holes, underwent vitrectomy, with dye-assisted peeling of the ILM and 14% perfluoro propane gas. Patients were divided randomly into two groups; face down position (FDP, posturing group) or non face down (nFDP, non-posturing group) for 7 days. Main focus was to see anatomical hole closure till 7 days postoperatively. Results: Macular holes closed in 10 of 10 eyes in the posturing (FDP) group and in 9 out of 10 in the non-posturing group (nFDP) seven days after the surgery. Chi-square test was applied to see the association between macular hole closure of patients with / without face down position. It was observed that macular hole closure was less likely to be associated with posturing (X2= 1.2, p-value= 0.549) while it was likely to be associated with size of macular hole (X2= 15.9, p-value= 0.001). In a sub-group analysis according to the size, all the macular holes smaller than 490 µm closed regardless of posturing. While holes larger than 490 µm were not closed in nFDP position. Conclusion: Post-operative face-down position has no statistically significant effect on macular hole closure in comparison to non-face down positioning. Keywords: Macular hole (MH), Face down position (FDP), Posturing, Closure rate, Randomized controlled Trials (RCTs)