Macular Hole Research Articles

Effects of Autologous Platelet Concentrate Injection on Persistent Macular Hole

Purpose: To evaluate the effects of secondary pars plana vitrectomy (PPV) with autologous platelet concentrate (APC) injection in patients with a persistent macular hole that failed to close after the primary surgery.Methods: This study included 10 eyes of 10 patients who required secondary PPV and APC injection due to unsuccessful hole closure following primary macular hole surgery between February 2021 and July 2023. We measured the minimum and base diameters of the holes before primary and secondary PPV, respectively. Furthermore, we evaluated the anatomical closure of the holes and changes in best corrected visual acuity (BCVA) for 6 months following secondary PPV.Results: The mean age of the 10 patients was 61.6 ± 9.5 years. Prior to the primary PPV, the mean BCVA (LogMAR) was 1.6 ± 0.7, the mean minimum diameter of the hole was 654.4 ± 98.9 μm, and the mean base diameter of the hole was 1,135.4 ± 276.5 μm. Prior to the secondary PPV with APC injection, the mean BCVA (LogMAR) was 1.3 ± 0.7, the mean minimum diameter of the hole was 666.8 ± 270.2 μm and the mean base diameter of the hole was 845.4 ± 292.4 μm. Following secondary surgery, all holes were successfully closed, the mean BCVA (LogMAR) was 0.9 ± 0.6 and the BCVA was significantly improved (<i>p</i> = 0.007).Conclusions: PPV with APC injection can be an effective therapeutic option for persistent macular hole that failed to close following primary surgery both in terms of anatomical and functional outcomes.

REMOTE FUNCTIONAL RESULTS PATIENTS WITH MACULAR HOLE AND RHEGMATOGENOUS RETINAL DETACHMENT SURGICAL TREATMENT WITH DIFFERENT VOLUMES OF PRESERVATION OF THE INTERNAL LIMITING MEMBRANE ACCORDING TO MICROPERIMETRY DATA

Rationale: Macular hole is a defect of the retina in the foveolar zone. In combination with rhegmatogenous retinal detachment, this disease can lead to irreversible deterioration of visual functions and requires immediate surgical treatment. One of the trends in modern ophthalmic surgery is to increase the area of preservation of the internal limiting membrane during the macular hole blocking. Despite this, microperimetry data indicate the appearance of microscotomas at the point of peeling initiation and a general decrease in the photosensitivity of the retinal tissue in the membrane removal zone.Objective: to analyze the dynamics of changes in the retinal functional parameters of patients with macular hole and rhegmatogenous retinal detachment according to microperimetry data after surgical treatment in the late postoperative period.Methods: Data from 40 patients (40 eyes) diagnosed with macular hole and rhegmatogenous retinal detachment were prospectively studied. Patients in group 1 (20 patients, 20 eyes) underwent surgical treatment, including three-port 25G vitrectomy, perfluoroorganic compound, vitreous body sanitation at the periphery, and silicone tamponade. Membrane peeling was performed during the second operation to remove silicone. Patients in group 2 underwent vitrectomy, membrane staining under the perfluorine layer, membrane peeling with closure of the macular hole with an inverted flap, vitreous body sanitation during the first intervention. The operation was also completed with silicone tamponade. During the second intervention, silicone oil was removed from the vitreous cavity.Results: When comparing the light sensitivity index of the retinal tissue in the foveolar zone between the groups, a reliable difference in the indices by 1.2 times continued to persist up to one and a half years after the final stage of surgical treatment, there was a predominance of values in patients of the 1st group with a completely preserved membrane (p = 0.043 in comparison with the data of patients of the 2nd group). In three peripheral zones of the macula, during the long-term observation period up to one and a half years after surgery, the indices of patients of the 1st group prevailed by 1.5 times (p = 0.041 in comparison with the data of patients of the 2nd group).Conclusion: based on the analysis of the dynamics of the functional indices of the retina of patients after surgical treatment of macular hole in combination with rhegmatogenous retinal detachment, the refusal to perform membrane peeling on the detached retina during the first stage of surgical intervention allows to avoid aggressive mechanical trauma to the retinal tissue.

THE RELATIONSHIP BETWEEN RETINAL PERFUSION AND FUNCTIONAL RECOVERING OF FOVEA IN DIFFERENT TYPES OF SURGICAL CLOSURE OF FULL-THICKNESS MACULAR HOLES

Rationale: The effect of retinal perfusion on functional recovery of the fovea, as well as the value of quantitative perfusion parameters as predictors of functional outcome in the surgical treatment of full-thickness macular holes (FTMH) remains poorly understood.Objective: To study the relationship between changes in retinal perfusion and functional parameters of the fovea in the postoperative period at 1 and 2 types of FTMH closure.Methods: A prospective study including 93 patients (93 eyes) with idiopathic FTMH stage 2-4 according to D. Gass after surgical treatment. In subgroups with type 1 and type 2 of FTMH closure, changes in the foveal avascular zone (FAZ) area and vessel density in the superficial and deep capillary plexuses (SCP and DCP) in the fovea, changes in BCVA, retinal sensitivity (RS) at the fixation point, and P1 amplitude in the fovea were studied. Studies were performed preoperatively, 1 and 6 months after surgery. A significant correlation was found between the changes in BCVA, RS at the fixation point, P1 amplitude in the fovea, and changes in vessel density in the SCP and DCP, which was more pronounced in the period from 1 to 6 months after surgery. The correlation of the changes in the parameters is higher in type 2 of FTMH closure than in type 1 of FTMH closure.Results:. Subgroups with type 1 and type 2 FTMH closure included 67 and 26 eyes, respectively. Type 2 FTMH closure showed lower vascular density in the DCP before (p=0.02) and 6 months after surgery (p=0.03), lower BCVA before surgery (p=0.03), 1 and 6 months after surgery (p <0.001), lower RS at the fixation point before and after surgery (p<0.002).Conclusion. In type 2 macular hole closure, postoperative changes in retinal perfusion have a more pronounced impact on functional recovery of the fovea, especially in the late postoperative period.

Subretinal tissue plasminogen activator without vitrectomy for submacular hemorrhage displacement using Nano-vitreoretinal gateway device: A pilot report

Purpose: To evaluate the surgical outcome of subretinal tissue plasminogen activator (tPA) delivered without vitrectomy for the displacement of submacular hemorrhage (SMH). Method: A retrospective interventional cases series of consecutive patients who underwent subretinal tPA and intravitreal expansile gas without vitrectomy for SMH displacement. Concomitant injection of subretinal air and intravitreal ranibizumab and expansile gas was performed per surgeon’s discretion. Results: Seven eyes from 7 patients were included. 6 eyes (85.7%) had polypoidal choroidal vasculopathy (PCV) and 1 (14.3%) had wet age-related macular degeneration (wAMD). The median baseline visual acuity (VA) was 0.014 (range 0.005-50.1) ETDRS letters, which improved to 35 (range 26.3-65.1), 35 (range 31.0-73.9), 35 (range 35-77.3) and 35 (range 5-80.2) ETDRS letters at 1 week, 1 month, 3 months and 6 months, respectively. Visual gain of ≥5 letters was achieved in majority of patients through 6 months. Successful displacement of blood away from fovea was achieved in 100% of eyes. The rate of postoperative vitreous hemorrhage, retinal pigment epithelium tear and macular hole were 14.3% (1 patient) each. Conclusion: This novel, minimally invasive surgical technique is effective in displacing SMH and preserving vision.

Delayed closure of highly myopic macular holes combined with retinoschisis after inverted internal limiting membrane flap.

To assess functional and anatomical outcomes of internal limiting membrane (ILM) inverted flap in highly myopic macular holes (HMMHs) with outer-retinoschisis (O-RS). Retrospective interventional analysis of 19 eyes with HMMH and O-RS undergoing vitrectomy and ILM inverted flap. At baseline and every follow-up visit (1, 3, 6, 12months and the most recent) we performed best-corrected visual acuity (BCVA, Snellen) and optical coherence tomography (OCT), collecting several parameters: minimum linear diameter (MLD), basal diameter (BD), peri-HMMH nasal and temporal retinal thickness (RTNAS and RTTEM), peri-HMMH nasal and temporal O-RS height (O-RSNAS and O-RSTEM). The ratios O-RSNAS/ RTNAS and O-RSTEM/RTTEM were defined as %O-RSNAS and %O-RSTEM. Postoperatively, we distinguished classic HMMH closure (n = 14) from a newly described "delayed" closure pattern (n = 5). Primary anatomical closure was obtained in 89% of eyes. Mean BCVA improved from 0.23 ± 0.17 to 0.44 ± 0.20 and 0.46 ± 0.25 at 6-months and final follow-up (p = 0.009 and p = 0.001, respectively). At every follow-up, "classic" vs. "delayed closure" did not influence BCVA (all p > 0.05). Baseline O-RSNAS (p = 0.026), O-RSTEM (p = 0.04), %O-RSNAS (p = 0.04) and %O-RSTEM (0.004), were significantly associated with the "flap closure" pattern, differently from MLD and BD. In the "delayed closure" subgroup we reported a 100% closure rate, but 65.8 ± 64.4days after first surgery. Meantime, OCT showed an inverted ILM flap covering an area of persistent tissue loss. O-RSNAS and O-RSTEM progressively reduced until HMMH closure. Inverted flap is useful to close HMMH with O-RS. In case of "delayed closure" pattern, watchful-waiting allows for HMMH self-sealing, without impact on BCVA. What is known Inverted internal limiting membrane (ILM) flap showed favorable anatomic success in cases of highly myopic macular holes (HMMH). What is new HMMHs with outer retinoschisis (class 2c of the staging system) may close following a classic or "delayed closure" pattern. In cases of delayed closure, it took a variable range of 30-179days to seal the HMMH but no further surgery was advisable. Post-operative BCVA improvement was not impacted at any follow-ups when comparing "delayed" and "classic" closure subgroups.

Two macular holes due to choroidal neovascularization after pars plana vitrectomy with internal limiting membrane peeling

Introduction: To present a case of two macular holes (MHs) with myopic choroidal neovascularization (CNV) lesion. Case Presentation: A single case was evaluated. A 72-year-old woman presented with two small MHs in her left eye. One year ago, she had undergone vitrectomy for myopic foveal schisis, and a significant reduction of the schisis and a CNV lesion was observed after surgery. On examination, OCT (optical coherence tomography) showed the atrophic CNV and two MHs were located upper and lower close to the edge of the CNV. A PPV (pars plana vitrectomy) with two free ILM (internal limiting membrane) flaps implant was performed in her left eye. At 3 months after surgery, the two macular holes were both closed and the BCVA (best corrected visual acuity) was improved. Conclusions: Two MHs secondary to the regression of CNV after primary PPV combined with complete ILM peeling in eyes with macular schisis.

Autologous neurosensory retinal flap transplantation in a porcine model of retinal hole

PurposeAutologous retinal transplantation (ART) has been successfully employed in the treatment of large and myopic macular holes that are refractory to standard surgical treatments. Patients transplanted with a peripheral neurosensory retinal graft have shown unexpected improvements in visual acuity. The study aims to investigate if neural integration of the graft takes place in a porcine model of retinal hole. DesignExperimental animal study. SubjectsLeft eyes of ten Danish landrace pigs. MethodsThe pigs underwent vitrectomy under general anesthesia, and a subretinal bleb was created within the visual streak on both sites of the optic disc. A retinal hole, approximately 1900-4000 microns in size, was cut temporally using a vitrector. A graft of matching size was harvested from the nasal retina. The graft was gently moved toward the retinal hole under perfluoro-n-octane and placed within it. Endolaser was applied around the donor site, and either air or oil tamponade was used. Optical Coherence Tomography (OCT) and Color Fundus Photography were performed two and six weeks after surgery. At the end of follow-up, the eyes were enucleated for histological examination, including immunohistochemical analysis with antibodies against retinal glial cells, photoreceptors, and inner retinal neurons. ResultsRetinal hole closure was achieved in 9 out of 10 cases, with the graft remaining in situ in 6 cases. In 4 cases, OCT scans indicated preservation of the outer retinal layers, and in 2 of these cases, there was apparent integration with the adjacent host retina. Corresponding histology confirmed the preservation of the photoreceptor layer in 3 cases, but there was no evidence of graft integration with degeneration of the inner retina in all cases. The distance between the margins of the retinal hole decreased during follow-up, suggesting that the graft contracts and drags the surrounding retina towards the center. ConclusionThe outer retina of a retinal graft can be preserved, while the inner retina degenerates. No evidence of neuroretinal integration of the graft was observed. The retinal graft serves as a scaffold, promoting the centripetal migration of the edges of the hole, resulting in closure of large retinal holes.

Submacular hemorrhage: My personal journey to the goal.

Acute submacular hemorrhage (SMH) can be caused by various diseases including age-related macular degeneration (AMD), polypoidal choroidal vasculopathy (PCV), and retinal arterial microaneurysm (RAM). The natural course of submacular hemorrhage is generally poor. Animal studies have suggested that the removal of subretinal hemorrhage may effectively reduce retinal damage caused by hemorrhage in humans and removal of submacular hemorrhage have been performed with limited visual outcomes. Pneumatic displacement involving intravitreal expansile gas with or without adjunctive intravitreal injection of tissue plasminogen activator (tPA) has demonstrated effective displacement of SMH and improvement in visual acuity in the majority of cases. Although tPA may not be indispensable, its use may facilitate displacement. Combining pneumatic displacement with vitrectomy and subretinal injection of tPA may achieve superior displacement of SMH compared to pneumatic displacement of SMH, implying that pneumatic displacement of SMH with vitrectomy and subretinal injection may offer enhanced effectiveness in SMH displacement,while noobvious different was found in visual outcomes between the two treatments.Complications associated with these procedures encompass breakthrough hemorrhage, retinal detachment and macular hole formation. Breakthrough hemorrhage is more commonly observed following pneumatic displacement whereas retinal detachment appears to be more prevalent following vitrectomy. Macular hole formation subsequent to vitrectomy represents a significant complication, particularly in eyes with SMH attributed to ruptured retinal arterial microaneurysm. Both pneumatic displacement and vitrectomy present advantages and disadvantages, and the superiority between the two remains undetermined. Sequential strategy for the treatment of submacular hemorrhage is another option. As the initial step, pneumatic displacement of SMH should be attempted, and if displacement is insufficient, pneumatic displacement following vitrectomy with subretinal injection of tPA may be pursued. Further investigations are warranted to ascertain optimal management strategies for SMH leading to improved outcomes. KEY MESSAGES: What is known • Pneumatic displacement with/without intravitreal tPA injection, and vitrectomy with subretinal tPA injection and gas are the two major treatments for submacular hemorrhage. What is new • No obvious different was found in visual outcomes between vitrectomy, subretinal tPA injection and gas, and intravitreal tPA injection and gas while vitrectomy with subretinal tPA injection and gas may achieve better displacement of submacular hemorrhage. • Macular hole formation is a specific complication for submacular hemorrhage due to ruptured retinal arterial macroaneurysm.

Macular Alterations in a Cohort of Caucasian Patients Affected by Retinitis Pigmentosa.

Our objective was to investigate the prevalence of macular complications detected by spectral-domain optical coherence tomography (SD-OCT) in a large Caucasian cohort of RP patients, highlight the major alterations in chorioretinal structure, and compare the macular structural changes in eyes affected by retinal dystrophies with those in healthy controls. This was an observational, retrospective, and cross-sectional study. Three hundred and seven patients with RP were consecutively enrolled and underwent clinical assessment. In particular, SD-OCT images were used to ascertain the morphology of the posterior pole of patients with RP by evaluating the residual ellipsoid zone (EZ), the volume and thickness of the outer nuclear layer (ONLT), and subfoveal choroid thickness (SCT). At the same time, the pathological finding that the patients' vision was reduced under treatment was analyzed. A total of 436 eyes of 218 patients with RP were studied. Considering all of the eyes studied, 103 had cystoid macular edema (CME) (23.62%), 123 (28.21%) had vitreomacular traction (VMT), and 199 (45.75%) had epiretinal membranes (ERMs). There were also 12 (2.75%) cases of lamellar macular holes (LMHs), of which 3 (1.38% of all patients) cases were bilateral. Only 137 eyes (31.42%) did not have the above-mentioned alterations. SCT was significantly reduced compared to that of the control group (193.03 µm ± 67.90 SD vs. 295 µm ± 69.04 SD), while the foveal central macular thickness (FCMT) was greater (270.91 μm ± 74.04 SD vs. 221 µm ± 37.25 SD). This research highlights the high incidence of macular complications. The results of our study indicate the importance of regular monitoring of RP patients and early intervention to avoid further complications in this group of subjects with severe visual field impairment to avoid further central vision loss.

Frequency, Causes and Medico-Legal Aspects of Grievous Injury to the Eye after Physical Assault

Aims: A medicolegal report is prepared by the medicolegal officer in conjunction with an ophthalmologist in cases of physical assault claiming vision loss. The objective was to report the frequency and cause of grievous injury to the eye after a physical assault. Methods: This was a descriptive cross-sectional study, conducted in the Department of Ophthalmology of a tertiary care hospital in Pakistan from October 2019 to August 2022. A total of 378 medicolegal cases were reported in the ophthalmology outpatient. Among them, 285 patients of physical assault were included with consecutive sampling technique. Results: The mean age of the patients was 33.93±12.96 years. The mean reporting time to an ophthalmologist was 4.1±8.2 days. Simple and grievous injuries were found in 278 (97.5%) and 7 (2.4%) cases, respectively. Among the grievous injuries, 4 (57.2%) were close globe injuries and 3 (42.8%) were open globe injuries. Thirteen (4.5%) were malingers. Domestic violence was observed in 82 (28.8%) study subjects. Conclusion: The frequency of grievous injury to the eye is very low (2.4%) in patients with physical assault. The patients of assault-related grievous injury were mostly males, young age, low level of education, and doing manual jobs. Vitrolage with corneal melting, and firearm injury caused the grievous injury in open globe patterns. Vitreous hemorrhage, retinal detachment, macular hole, and secondary glaucoma were seen among close globe patterns. J Bangladesh Coll Phys Surg 2024; 42: 336-341

Ultrastructural investigation of the posterior hyaloid membrane in posterior vitreous detachment.

Separation of the posterior hyaloid membrane (PHM) from the retina in posterior vitreous detachment (PVD) is a fundamental, but poorly understood, process underlying vitreoretinal disorders including retinal detachment and macular hole. We performed electron microscopy studies of the PHM after PVD to investigate its ultrastructure, associated cellular structures and relationship to the internal limiting membrane (ILM). Post-mortem human eyes were collected from recently deceased patients over 70 years of age. A posterior scleral button was trephined to identify PVD status, and the PHM and vitreous prepared for analysis with transmission and scanning electron microscopy. Twelve eyes from six patients were collected. Seven eyes had PVD; five eyes had attached vitreous. PHM was isolated from seven of seven eyes with PVD. The PHM in eyes with PVD is a laminar lacy sheet, distinct from the disorganised fibres of vitreous gel. Eyes without PVD had vitreous encased in internal limiting membrane which had separated en bloc from the retina. Cells embedded in the PHM (laminocytes) were identified in five of seven eyes with PVD, with strands stretching into the membrane. PHM isolated from eyes with PVD is distinct from artefactual separation of the ILM from the retina during dissection. PHM is ultrastructurally distinct from vitreous gel and is a separate entity. The en face appearance of PHM is similar to that of ILM, suggesting that in PVD, PHM forms from separation of an inner layer of ILM. Laminocytes may play a role in the pathogenesis of vitreoretinal disease.

PLASMA RICH IN GROWTH FACTORS MEMBRANE IN THE TREATMENT OF MACULAR HOLES ASSOCIATED WITH MACTEL TYPE 2.

To demonstrate the regenerative effects of Plasma membrane rich in growth factors (PRGFm) as an adjuvant in the surgical treatment of Full-thickness macular holes (FTMH) associated with MacTel type 2 (MacTel). Observational study of a consecutive case series. Type 2 MacTel patients with FTMH. Best-corrected visual acuity, optical coherence tomography (OCT) data, anatomic closure rates, and duration of follow-up were documented. 3 patients who met the inclusion criteria were enrolled, 2 are naïve and one is already operated with silicon oil in situ. Median follow-up was 6 months (range 6-18 months), anatomic closure rate was 100%, and median visual acuity change was 20/60 (range 20/40 - 20/100). No complications related to PRGFm were found. PRGFm is a valuable option for the treatment of FTMH associated with MacTel type 2. Its application promotes tissue regeneration and facilitates anatomical closure. The technique is reproducible and does not require manipulation of the internal limiting membrane.

Epiretinal membrane: an overview and update.

Epiretinal membrane (ERM) is a frequently diagnosed macular disease associated with aging, characterized by a fibrous membrane forming on the internal limiting membrane (ILM) and leading to visual dysfunctions such as metamorphopsia. Various hypotheses regarding the pathology of metamorphopsia have been proposed; however, the complete pathophysiologic mechanism underlying ERM remains unclear. Optical coherence tomography (OCT) provides detailed images enabling precise diagnosis and characterization of ERM, with several recent studies using the latest OCT imaging techniques. Surgical removal of ERM is the only treatment option; however, criteria for surgical intervention are not established, complicating the decision-making processes. Furthermore, the debate on whether simultaneous peeling of the ILM during ERM surgery enhances outcomes or poses unnecessary risks is ongoing, with no definite conclusion having yet been reached. This review also focuses on epiretinal proliferation, which is different from ERM and is characteristic of lamellar macular hole (LMH). Recently, diagnostic criteria for LMH and related diseases were proposed. Reports on effective surgical procedures for LMH exist, although more research is needed to confirm the long-term outcomes. Thus, this review article aims to provide an overview and updated knowledge of ERM, LMH, and related diseases.

Development and preliminary evaluation of a novel preoperative index for quantitative analysis of photoreceptor loss in full-thickness macular holes.

To identify novel quantitative parameters for evaluating photoreceptor loss in full-thickness macular holes (FTMH), exploring their potential clinical impact on postoperative functional and anatomical recovery. This pilot study enrolled 38 eyes from 38 patients diagnosed with FTMH. Preoperatively, eyes underwent analysis and were subsequently followed for six months post-surgery. Best-corrected visual acuity (BCVA) was recorded, and cross-sectional images of FTMH were obtained using B-scan optical coherence tomography (OCT) and en-face OCT. Quantitative assessment of ellipsoid zone (EZ) and external limiting membrane (ELM) integrity changes was conducted and correlated with postoperative anatomical and functional recovery. The photoreceptor Integrity Index (PIIN), calculated as the ratio of photoreceptor area to lumen hole area measured at customized segmentation, was correlated with the minimum and base diameters of the hole, positive change in BCVA, preoperative EZ defect (EZd), preoperative ELM defect (ELMd), and changes in EZ and ELM over the six-month follow-up period (∆-EZ and ∆-ELM). The main outcome measures focused on evaluating the effectiveness of PIIN in predicting postoperative anatomical and functional changes. A higher PIIN correlated with a greater BCVA change over six months (p < 0.001). Univariate regression analysis using the PIIN as a predictor for positive change in BCVA (|∆-BCVA| [logMAR]) over time yielded significant results (p < 0.001). Additionally, the PIIN significantly correlated with EZd at baseline, ELM at baseline, and ELMd change over the six-month follow-up period. The PIIN shows promise as a tool for evaluating photoreceptor loss in macular holes and estimating postoperative functional and anatomical recovery. What is known Previous studies have extensively used optical coherence tomography (OCT) to investigate various biomarkers for assessing patients with full-thickness macular hole (FTMH), without considering detailed MH ultrastructural features Existing indexes used to predict surgical outcomes for FTMH primarily depend on geometrical parameters and do not integrate detailed ultrastructural characteristics, such as cellular components. What is new A novel concept introduces the quantitative measurement of residual photoreceptors located at the edge of FTMH. The Photoreceptor Integrity Index (PIIN) integrates different ultrastructural components of macular holes, aiming to become a valuable clinical tool to predict both anatomical and functional recovery outcomes following surgical intervention for FTMH.

Surgical outcomes of inverted internal limiting membrane flap technique for primary rhegmatogenous retinal detachment coexisting with a macular hole.

This retrospective study aimed to evaluate the visual outcomes and foveal restoration in eyes with rhegmatogenous retinal detachment (RRD) and macular hole (MH) following surgery using the inverted internal limiting membrane (ILM) flap technique. We collected data on eyes with coexisting RRD and MH that underwent surgery using the inverted ILM flap technique between January 2016 and December 2018. The primary outcome measures were visual acuity (VA) and optical coherence tomography findings. Of 308 eyes with MH originating from various causes, 8 (2.6%) eyes diagnosed with coexisting RRD and MH treated using the inverted ILM flap technique were included. The average patient age and axial length were 65.00 ± 12.01 years and 23.66 ± 0.77 mm, respectively. The mean preoperative best-corrected VA (BCVA) was 1.84 (spherical equivalent [SE], counting finger) ± 0.32 logMAR and the mean final BCVA had improved significantly to 1.05 (SE, 20/223) ± 0.67 logMAR (P = .017). The primary retinal reattachment, MH closure, and secondary retinal attachment rates were 75% (6/8), 87.5% (7/8), and 100% (7/7), respectively. The inverted ILM flap technique led to significant improvements in anatomical and visual outcomes in patients with coexisting RRD and MH.

Human Amniotic Membrane: A Seal for Complex Retinal Detachments.

To evaluate the efficacy of human amniotic membrane (hAM) transplantation for complex retinal detachments (RD). A retrospective analysis of consecutive patients who underwent vitreoretinal surgery with hAM transplantation for complex RD was conducted. The indications included high myopic macular hole (MH)-associated RD (n=5), traumatic large macular tears (n=4), combined RD with MH due to cicatricial retinopathy of prematurity (n=2) and severe retinitis (n=1), and morning glory syndrome (n=1). Surgical procedures, anatomical and functional results, and complications were noted. Thirteen eyes of 13 patients with a median age of 7 years (range, 0-65 years) were included. The follow-up was 15 months (range, 6-30 months). All eyes achieved MH sealing. Sealing occurred after a single surgery in 75% of eyes, while 25% required a second surgery due to hAM contraction/dislocation. The retina was attached and silicone oil could be removed in 92% of eyes during follow-up. The mean logarithm of the minimum angle of resolution visual acuity increased from 2.08±0.49 to 1.78±0.70 (p=0.07). Optical coherence tomography showed good integration of the hAM grafts with the retina, albeit without discernible retinal layer differentiation in any case. Amniotic membrane grafting appears to be promising for anatomical sealing of MHs and posterior retinal tears in complex RDs such as those associated with degenerative myopia, severe trauma, tractional membranes, and retinal shortening, where conventional surgical techniques are likely to fail. Further research is needed to clarify the regenerative potential and functional capacity of hAM grafts in severe retinal pathologies.

Multilayered Inverted Internal Limiting Membrane Flap Technique in Optic Disc Pit Maculopathy.

To evaluate the anatomical and visual outcomes of the multilayered inverted internal limiting membrane (ML-ILM) flap technique in the treatment of optic disc pit maculopathy (ODPM). In this retrospective interventional case series, medical records and macular spectral-domain optical coherence tomography images of patients who underwent combined pars plana vitrectomy with ML-ILM flap surgery for ODPM were analyzed. Best-corrected visual acuity (BCVA) and central macular thickness (CMT) at postoperative 6 months were compared with baseline findings. Intraoperative and postoperative complications, fluid resolution time, and recurrence during follow-up were recorded. Five eyes of 5 patients with ODPM were included in the study. According to the preoperative macular fluid characteristics, 2 patients had only intraretinal fluid, while 3 patients had intraretinal and subretinal fluid. The preoperative median BCVA was 1.0 logarithm of the minimum angle of resolution (logMAR) (range, 1.0-1.3 logMAR), and the CMT was 560 μm (range, 452-667 μm). At the 6-month postoperative follow-up, the median BCVA was 0.40 logMAR (range, 0.1-0.7 logMAR), and CMT was 315 μm (range, 265-326 μm) (p=0.042 and p=0.043, respectively). During the 6-month follow-up period, no recurrence or full-thickness macular hole formation was observed. The ML-ILM flap technique is a preferable surgical option to achieve both high anatomical and functional success and flap stabilization.

Secondary acute angle closure glaucoma after 25-gauge pars plana vitrectomy for a macular hole: a case report

BackgroundPosterior synechiae of the iris rarely cause secondary angle-closure glaucoma after pars plana vitrectomy, mainly reported in cases with high postoperative inflammation. The face-down position with gas tamponade can cause acute angle-closure glaucoma in phakic eyes owing to relative pupillary block. This report presents a rare case of pseudophakic eye with secondary acute angle-closure glaucoma after 25-gauge pars plana vitrectomy and long-term vitreous gas tamponade for a macular hole.Case presentationA 61-year-old Japanese female patient presented with a chief complaint of right-sided visual impairment that had persisted for several months. Slit-lamp examination revealed deep anterior chamber and moderate nuclear sclerotic cataracts in both eyes. The axial length of the eye was 23.53 mm right eye and 24.05 mm left eye, and the fundus examination revealed a full-thickness macular hole (stage 3) in the right eye. The patient underwent simultaneous cataract surgery and pars plana vitrectomy with 7-mm diameter 3-piece monofocal intraocular lens implantation, internal limiting membrane peeling, and air tamponade. There were no complications during surgery. Due to non-closure of the macular hole, a second pars plana vitrectomy with internal limiting membrane inverted flap and SF6 gas tamponade was performed 13 days later. The patient maintained face-down position after both surgeries, and 6 days after the second surgery, intraocular pressure was elevated to 53 mmHg, and acute angle-closure glaucoma with iris bombe was diagnosed in the right eye. A laser peripheral iridotomy was performed, resulting in a deepened anterior chamber, normalized intraocular pressure, and a closed macular hole.ConclusionsThis case presents a rare occurrence of secondary acute angle-closure glaucoma in a pseudophakic eye after 25-gauge minimally invasive pars plana vitrectomy and SF6 gas tamponade for macular hole. The cause was presumed to be posterior synechiae of the iris or relative pupillary block due to forward pushing of the intracapsular intraocular lens by vitreous gas. In cases where surgery is repeated without achieving macular hole closure, necessitating long-term face-down position, where vitreous gas is retained for an extended period, or when a large-diameter intraocular lens is implanted, secondary acute angle-closure glaucoma should be considered. This applies even when the 25-gauge pars plana vitrectomy is performed not for a highly invasive proliferative diabetic retinopathy but for macular hole repair, especially if the patient has a pseudophakic eye.

Morphologic Stages of Full-Thickness Macular Hole on Spectral Domain Optical Coherence Tomography

ObjectiveTo describe the sequential morphological changes of the outer retina after full-thickness macular hole formation, utilizing a novel, objective staging system based on optical coherence tomography (OCT), and to determine its association with baseline visual acuity, duration of symptoms, and postoperative visual acuity at 3 months. DesignRetrospective, observational, multicenter study. ParticipantsPatients with idiopathic full-thickness macular hole (FTMH) presenting to St. Michael’s Hospital, Toronto, Canada, and Retina Consultants of Texas, Houston, USA, from 2009-2022. MethodsThe medical charts of 1000 patients with FTMH were reviewed and those with at least two preoperative SD-OCTs were analyzed. A staging system was developed by assessing outer retinal morphology on successive SD-OCT central foveal scans. Main Outcome MeasuresSequential outer retinal morphological changes with SD-OCT over time and their association with baseline visual acuity, duration of symptoms, and postoperative functional outcomes. ResultsFifty-two eyes of 52 patients with a mean age of 65.4 ±8.4 years were included. Sequential outer retinal morphologic changes at the FTMH borders occurred in 4 distinct and reproducible stages as follows: Stage A: separation of the neurosensory retina from the RPE with the well-defined external limiting membrane (ELM), ellipsoid zone (EZ) and interdigitation zone (IDZ) (4/52, 7.6%); Stage B: thickening of EZ (27/52, 51.9%); Stage C: patchy (moth-eaten) photoreceptor loss (16/52, 30.7%) and Stage D: severe or complete loss of ISs and OSs and/or bare ELM (5/52, 9.6%). When assessing the preoperative OCT scans closest to the time of surgery, over a mean follow-up period of 288.9 days (SD 350.4,[5 -1841]), 28.8%(15/52 ) of eyes were in Stage B, 28.8% (15/52) were in Stage C and 42.3 %(22/52 ) were in Stage D.There was a statistically significant association between increasing stage at baseline and longer duration of macular hole symptoms (p=0.032) and worse visual acuity at baseline (p<0.001). Additionally, patients presenting with Stages B and C at the time point closest to surgery had better visual acuity outcomes three months postoperatively compared to those with Stage D(P=0.04). ConclusionsThis SD-OCT staging system describes the sequential in vivo morphologic changes after FTMH formation providing a novel imaging biomarker.

Comparison of conventional internal limiting membrane versus pars plana vitrectomy without peeling for small idiopathic macular hole

BackgroundThe aim of this study was to compare functional and anatomical changes in patients with small full thickness macular holes (FTMHs) who underwent pars plana vitrectomy (PPV) with or without Internal limiting membrane (ILM) peeling.Methods42 eyes of 42 patients diagnosed for FTMHs (< 250 micron) were included in our prospective interventional study. Main outcome measures were: Best Corrected Visual Acuity (BCVA), Macular hole closure rate, Ellipsoid Zone (EZ) and External Limiting Membrane (ELM) recover, Vessel Density in both Superficial (VDSCP) and deep (VDDCP) capillary plexus, Macular pigment Optical density (MPOD) and mean Central Macular Sensitivity (CMS).Patients were randomly divided into “peeling group” (21 patients), in which the ILM peeling maneuver was performed and “no-peeling group” (21 patients) in which the ILM was not peeled off. Examinations were repeated one month (T1), three months (T2) and six months (T3) after surgery.ResultsAlthough significant improvements in terms of MPOD, CMS, VDSCP and VDDCP over time (p < 0.001) no significant differences were found between the peeling and no peeling group. Conversely, FTMHs closure was achieved in all cases (100%) in the peeling group, whereas 10% of cases in the no peeling group experienced the hole re-opening at T3, with reported different rates of ELM/EZ recover between the two groups. Nevertheless, BCVA improved significantly (p < 0.001) but without significant differences between the two groups.ConclusionsNo significant differences were found in terms of anatomical and functional outcomes between the peeling or not the ILM in small FTMHs at 6 months follow-up.