Tractional Macular Detachment Research Articles

Personalized Management of Patients with Proliferative Diabetic Vitreoretinopathy.

Purpose: To evaluate prognostic factors for visual outcome in patients with diabetes who have undergone vitrectomy (PPV) for severe proliferative diabetic vitreoretinopathy (PDVR) in at least one eye in the past 15 years. Methods: Medical records of 132 eyes of 66 patients were analyzed (median age 52 years 21-80; patients with type 1/2 diabetes 40/26; median follow-up 38 months 9-125). Correlations between final favorable visual outcome defined as 0.5≤ best-corrected visual acuity (BCVA) and prognostic factors (age, sex, type and duration of diabetes, metabolic status, BCVA, diabetic retinopathy status, data of preoperative management, data of vitrectomy, and postoperative complications) were analyzed. Results: BCVA improved significantly in the entire study cohort (from median 0.05 min-max 0.001-1 to 0.32, 0.001-1, p < 0.001). Visual stabilization was achieved in the majority of patients, and good visual acuity (0.5 ≤ BCVA) was maintained in more than one-third of the eyes. Multivariable GEE statistics showed that in addition to the duration of diabetes and stable HbA1c values, only preoperative tractional macular detachment proved to be an independent significant predictor of visual outcome. Conclusions: Pars plana vitrectomy is a useful tool when performed early before tractional macular detachment. However, long-term visual stability can only be achieved with good metabolic control.

Two cases of spontaneous closure of full-thickness macular hole

We report two cases of spontaneous closure of full-thickness macular hole (FTMH). The first was in a patient with relieved traction from tractional macular detachment with spontaneous closure after diagnosis at 16 months. The second case is FTMH that developed after vitrectomy from rhegmatogenous retina detachment with spontaneous closure after diagnosis at 9 months. Spontaneous closure of FTMH is rare and the main treatment is vitrectomy.

Incidence and Risk Factors for Tractional Macular Detachment after Anti-Vascular Endothelial Growth Factor Agent Pretreatment before Vitrectomy for Complicated Proliferative Diabetic Retinopathy.

The study’s purpose was to determine the incidence, risk factors, and outcomes of tractional macular detachment after anti-vascular endothelial growth factor (VEGF) pretreatment before vitrectomy for complicated proliferative diabetic retinopathy. Patients who underwent primary vitrectomy for complicated proliferative diabetic retinopathy, from January 2012 to 31 December 2018, were enrolled. Ophthalmic and pre-operative data were extracted from electronic record systems. All eyes with a valuable Optical Coherence Tomography (OCT)performed within 5 days before injection of anti-VEGF and on the day of vitrectomy were included. Multivariable logistic regression showed that significant risk factors for developing tractional macular detachment included days between anti-VEGF and vitrectomy (OR, 0.71 [95% CI 0.65–0.76]; p < 0.001), vitreous hemorrhage (OR, 0.23 [95% CI 0.11–0.49]; p < 0.001), and age (OR, 1.05 [95% CI 1.02–1.08]; p < 0.001). Decision-tree analysis showed that the stronger predictors of tractional macular detachment were the time between anti-VEGF injection and vitrectomy (p < 0.001). Secondary predictors were the presence of vitreous hemorrhage (p = 0.012) in eyes that underwent vitrectomy between 6 and 10 days after anti-VEGF injection and younger age (p = 0.031) in eyes that underwent vitrectomy 10 days after anti-VEGF injection. Tractional macular detachment occurs in 10% of eyes after anti-VEGF injection, the main risk factors being days between anti-VEGF injection and vitrectomy, vitreous hemorrhage, and age.

An optical coherence tomography study of residual subfoveal fluid after successful pars plana vitrectomy in patients with diabetic tractional macular detachment.

To analyze the prevalence of residual subfoveal fluid (RSF) after pars plana vitrectomy in patients with proliferative diabetic retinopathy complicated by tractional detachment of the macula and the effect of RSF on the postoperative visual outcome. This study was a prospective observational case study of the optical coherence tomography (OCT) records of 23 patients (24 eyes) with macula-off diabetic tractional retinal detachment (TRD) who underwent successful 23-gauge pars plana vitrectomy between July 2012 and December 2015. The prevalence of RSF on OCT examination was 100% at 1 and 2 months, 91.7% at 3 months, 70.8% at 6 months, 25.0% at 9 months and 4.2% at 12 months after surgery (p < 0.001). Internal drainage of subretinal fluid (SRF) during primary surgery was performed in 13 (54.2%) eyes. The significant risk factor that was predictive of long-standing RSF was non-drainage of SRF (p = 0.04). Persistent RSF is a common OCT finding after clinically successful vitrectomy surgery for the treatment of macula-off diabetic tractional retinal detachment. Internal drainage of SRF with active aspiration can be attempted if intraoperative breaks are found or if faster recovery is required. To date, observation seems to be the best option.

Vitrectomy and scleral imbrication in patients with myopic traction maculopathy and macular hole retinal detachment

PurposeTo determine the outcomes of vitrectomy with scleral imbrication in highly myopic eyes with either myopic traction maculopathy (MTM) or macular hole retinal detachment (MHRD).MethodsThe medical records of 17 patients who had undergone vitrectomy with internal limiting membrane (ILM) peeling and scleral imbrication for MTM or MHRD were reviewed. The best-corrected visual acuities (BCVAs), the axial length, the macular hole (MH) closure rate, and the shape of the posterior segment determined by optical coherence tomography were evaluated. Three-dimensional magnetic resonance imaging (3D-MRI) was also performed on five eyes.ResultsThe postoperative BCVA improved significantly from 0.76 ± 0.39 logarithm of the minimum angle of resolution (logMAR) units to 0.53 ± 0.35 logMAR units (P = 0.0004). The axial length decreased from 29.42 ± 1.81 mm to 27.97 ± 1.71 mm at 1 month. The MTM was resolved or decreased in all eyes. The MH was closed in 44 % of the MHRD eyes, and the retina was reattached in all of the MHRD eyes. The horizontal distance between the optic disc and the bottom of the posterior staphyloma was significantly decreased at 1 month (P = 0.012) but not at later times. The 3D-MRI images showed a reduction in the distance between the bottom of the posterior staphyloma and the center of the eye (P = 0.029) and a flattening of the posterior staphyloma (P = 0.010).ConclusionsVitrectomy with ILM peeling and scleral imbrication may be helpful in treating MTM and MHRD by reducing the degree of curvature of the posterior staphyloma.

The outcomes and prognostic factors of vitrectomy in chronic diabetic traction macular detachment.

PurposeTo investigate the outcomes of pars plana vitrectomy (PPV) for chronic diabetic traction macular detachment (CTMD).MethodsNinety-six eyes that underwent PPV for CTMD of at least 6 months duration were retrospectively analyzed. Retinal reattachment rate, final vision, and prognostic factors for poor visual outcome were the main outcome measures.ResultsAll eyes had long-standing TMD (median 12, range: 6–70 months). The median postoperative follow-up was 15 (range: 3–65) months. Eighty-seven eyes (90.6%) had their retina and macula reattached after one PPV. At final examination, 84 eyes (87.5%) had stable vision or at least one line improvement, and three had no light perception. Seventeen (17.7%) and 41 (43%) eyes had preoperative visual acuity of ≥20/200 and ≥5/200 as compared to 40 (41.6%; P=0.0005) and 64 (66.7%; P=0.0014) eyes at final follow-up, respectively. Age >50 years (Odds ratio [OR] =5.84, 95% confidence interval [CI] =1.53–22.19, P=0.01), preoperative vision <20/400 (OR =7.012, 95% CI =1.82–26.93, P=0.005), and ischemic macula (OR =14.13, 95% CI =3.61–55.33, P<0.001) were significantly associated with final vision <20/400.ConclusionPPV for CTMD may be beneficial particularly in patients who are relatively younger and have good baseline vision and no macular ischemia.

VITRECTOMY WITH OR WITHOUT INTERNAL LIMITING MEMBRANE PEELING FOR EACH STAGE OF MYOPIC TRACTION MACULOPATHY

To evaluate the effect of vitrectomy on the best-corrected visual acuity (BCVA) and postoperative complications in highly myopic eyes with myopic traction maculopathy. The medical records of 71 eyes of 64 patients with myopic traction maculopathy and high myopia (≤-8.0 diopters and axial length, ≥26.0 mm) were reviewed. Twenty-six eyes had only macular retinoschisis, 30 eyes had foveal detachment, and 15 eyes had macular hole. The BCVA and complications were studied in eyes that underwent vitrectomy with or without internal limiting membrane (ILM) peeling. The postoperative BCVA at the final visit significantly improved in the macular retinoschisis and the foveal detachment groups (P = 0.003 and P = 0.010, respectively) but not in the macular hole group (P = 0.069). The BCVA in the macular retinoschisis group and the foveal detachment group with ILM peeling significantly improved at the final visit (P = 0.003 and P = 0.010, respectively). The BCVA at the final visit significantly correlated with age (P = 0.026) and ILM peeling (P = 0.034). A recurrence of tractional macular detachment developed more frequently in eyes without ILM peeling (P = 0.018). These results indicate that vitrectomy with ILM peeling can lead to improvement in vision in patients with macular retinoschisis or foveal detachment with visual impairments.

Partial-thickness macular hole in vitreomacular traction syndrome: a case report and review of the literature

IntroductionVitreomacular traction syndrome has recently been recognized as a distinct clinical condition. It may lead to many complications, such as cystoid macular edema, macular pucker formation, tractional macular detachment, and full-thickness macular hole formation.Case presentationWe report a case of vitreomacular traction syndrome with eccentric traction at the macula and a partial-thickness macular hole in a 63-year-old Pakistani Punjabi man. The patient was evaluated using optical coherence tomography, and he underwent a successful pars plana vitrectomy. After the operation, his foveal contour regained normal configuration, and his visual acuity improved from 20/60 to 20/30.ConclusionsPars plana vitrectomy prevents the progression of a partial thickness macular hole in vitreomacular traction syndrome. The relief of traction by vitrectomy restores foveal anatomy and visual acuity in this condition.

Tractional macular detachment associated with optic disc astrocytic hamartoma

Tractional macular detachment associated with optic disc astrocytic hamartoma

Composite Spectral Domain Optical Coherence Tomography Images of Diabetic Tractional Retinal Detachment

This article describes the spectral domain optical coherence tomography (SD-OCT) findings in three patients with diabetic tractional retinal detachment. Three patients underwent fundus photography and SD-OCT imaging before and after pars plana vitrectomy, endola-ser, and membrane peel. On SD-OCT, all three patients exhibited significant improvement or resolution of subretinal fluid after the surgical release of traction. In this case series, a clinically useful method of visualizing SD-OCT images is demonstrated. Composite images were manually constructed with commercially available software by merging high-density B-scans from the macula and optic nerve. The composite image allowed simultaneous visualization of the effects of proliferative diabetic retinopathy on the macula and optic nerve and is particularly helpful in evaluating tractional macular detachment.

Visualization of vitreomacular tractions with en face optical coherence tomography

In vitreomacular traction syndrome, an incomplete vitreous detachment with persistent vitreous traction on the macula is present. This condition may determine formation of epiretinal membranes, macular puckering, macular oedema, and traction macular detachment. Recently introduced en face optical coherence tomography (OCT) provides not only longitudinal B-scan but also coronal C-scan images of the retina. Fifteen eyes of 11 non-diabetic patients presenting vitreomacular traction syndrome have been evaluated with en face OCT (OTI, Toronto, Ontario, Canada). In 12 eyes, cystoid macular oedema was detectable at fundus examination and was associated with a broad-based adherence of the posterior hyaloid to the macula. In three eyes, foveal detachment appeared to be associated with focal foveal vitreoretinal traction. In all eyes, the lateral extent of the hyaloidal tractions on the macula was clearly detectable at coronal C-scan. They appeared as sigmoid hyper-reflective bands in the hyporeflective vitreous chamber. Overlay of C-scans on red-free confocal images allowed the visualization of the edges of the adherences in relation to the structures of the posterior pole. The C-scan images allowed clear visualization of the total extension of the posterior vitreomacular adherences and their relationships with the vascular arcades, the optic disc, and the fovea.

Closure of macular hole following vitrectomy for diabetic tractional macular detachment

Closure of macular hole following vitrectomy for diabetic tractional macular detachment

Paramacular Von Hippel Angioma With Tractional Macular Detachment

A rare case of paramacular angioma with tractional macular detachment that was managed successfully with laser, followed by surgical intervention with good visual outcome, is presented. A 23-year-old female patient with paramacular Von Hippel angioma was treated with argon laser photocoagulation. Three-months following photocoagulation, vitrectomy with epiretinal tractional membrane removal was attempted successfully. Visual acuity improved from a preoperative level of 20/200 to 20/50 at the 6 months postoperative period. No recurrence of epiretinal membrane or exudation was observed during the follow-up period. Photocoagulation, followed by surgical intervention for removal of epiretinal traction membranes, resulted in relieving the tractional macular detachment and recovering useful visual acuity in paramacular Von Hippel angioma.

Macular involvement in eales disease

Aretrospective study of macular involvement was undertaken in 112 cases (175 eyes) of Eales disease. One or more macular lesions were observed in 51 eyes (28.1%). Macular edema (12.57%), intraretinal hemorrhages (10.85%), retinal pigment epithelial abnormalities (9.14%), hard exudates (8.57%), microaneurysms (7.42%), traction macular detachment (7.42%), macular nonperfusion (1.71%), and epiretinal membrane (1.71%) were observed. Macular involment in Eales disease is not uncommon.

Vitrectomy for traction macular detachment in diabetic retinopathy.

A small number of eyes with proliferative diabetic retinopathy develop massive central fibrovascular membranes characterized by vitreoretinal tractions along the arcades and optic disk and retinal traction lines extending through the macula. The aim of our study was first to present the results of vitrectomy for removal of these central membranes and second to determine the correlation between preoperative parameters and postoperative visual outcome. We treated 28 eyes with severe central fibrovascular diabetic membranes by a modified bi-manual en bloc excision technique during vitrectomy. Preoperative examination included general status, visual acuity, slit-lamp investigation, binocular funduscopy, ultrasound investigation and visual evoked potentials (VEP). Further, we analyzed intraoperative complications and postoperative anatomic and functional outcomes. The retinas of 27 eyes with central traction retinal detachments were reattached by surgery. With a minimum of 6 months' follow-up, the macula remained attached in 24 eyes, while the retinas were completely attached in 22 eyes. Preoperative visual acuity was defective light perception to 0.1; an increase in visual acuity to maximal 0.1 was seen in 50% of the patients postoperatively. Preoperative visual acuity of light perception was associated with no functional improvement. Preoperative ultrasound investigation gave information about the real anatomic situation of the retina, especially if funduscopy was not possible. The other preoperative parameters could not predict correctly the functional outcome of vitrectomy in diabetics with severe central fibrovascular membranes because of the damage of the optic nerve and the retina. The high rate of anatomical reattachment after vitrectomy in diabetic eyes with severe central fibrovascular membranes is associated with a slight improvement of function; only preoperative visual acuity of hand motions or better was associated with an improvement of function.

Ocular echography in the prognosis of vitreous haemorrhage in type II diabetes mellitus.

In this study, we have attempted to demonstrate the presence of various echographic parameters which could be associated with a non-spontaneous resorption of vitreous haemorrhage in type II diabetes mellitus and correlate these parameters with clinical outcome. We studied 297 eyes of 257 patients with diabetic retinopathy and vitreous haemorrhage without tractional macular retinal detachment ophthalmoscopically and echographically. Of the total eyes studied, a 3-month follow-up visit (including ultrasound) was available in 208 eyes. We retrospectively reviewed the medical records of each patient. The echographic parameters associated with non-resorption of the vitreous haemorrhage were: extramacular tractional retinal detachment, fibrovascular membranes and location of the haemorrhage within the subhyaloidal space (in contrast to within the intragel space). In addition, the duration of the vitreous haemorrhage and the presence of panretinal laser photocoagulation at the time of presentation with a vitreous haemorrhage influenced the resolution of the vitreous haemorrhage. We were also able to construct a logarithmic function that could be used to predict the prognosis of a vitreous haemorrhage in type II diabetes mellitus. When employed to evaluate vitreous haemorrhages in non-insulin-dependent diabetes mellitus, ocular ultrasound can provide useful prognostic information regarding the lack of resorption of vitreous haemorrhages in type II diabetics.

Vitrectomy in Eyes with Peripheral Retinal Angioma Associated with Traction Macular Detachment

Peripheral angiomas have been associated with epiretinal membranes and traction retinal detachment. The authors investigated the timing, results, and complications of vitreous surgery to remove the retinal traction and treat the peripheral vascular tumor. The authors reviewed the results of ten eyes that had undergone vitrectomy for macular pucker and/or traction retinal detachment. These eyes had either preoperative or intraoperative treatment of the peripheral tumor. Patients were followed 4 to 95 months. Six eyes had nonfamilial peripheral acquired retinal hemangioma, three had von Hippel angiomas, and one had multiple large peripheral retinal angiomas associated with extensive retinal telangiectasis. Four eyes received cryotherapy and/or laser photocoagulation 2 to 3 months before surgery. In the remaining six eyes, initial treatment to the peripheral angioma was performed at the time of vitreous surgery. At final follow-up, all eyes were attached without retinal traction. Vision improved in all eyes; six (60%) achieved 20/50 or better visual acuity. Complications included recurrent epiretinal membrane (n=3); nonregressed angiomas (n=3); increased nuclear sclerosis (n=2); and retinal detachment (n=1). Vitreous surgery, when applied to epiretinal membranes or traction retinal detachments associated with peripheral vascular tumors, has a good chance of improving vision. Treatment of the hemangioma, before or during vitrectomy, usually results in tumor regression.

Neodymium:YAG Laser Treatment for Hemorrhages under the Internal Limiting Membrane and Posterior Hyaloid Face in the Macula

A dense premacular hemorrhage may occur from proliferative diabetic retinopathy, a ruptured retinal artery macroaneurysm, or Valsalva retinopathy. Spontaneous clearing of the hemorrhage in Valsalva retinopathy usually occurs, taking several months. In diabetic retinopathy, a traction macular detachment may result as early as 5 weeks after the hemorrhage. In diabetic retinopathy or a macroaneurysm, only a fibrotic epiretinal membrane overlying the macula may develop. Observation or vitrectomy is the current way of managing a dense premacular hemorrhage. This study was undertaken to investigate an alternative, neodymium:YAG (Nd:YAG) laser membranotomy, in treating this type of hemorrhage. Six eyes in six patients had Q-switched Nd:YAG laser treatment to open trapped hemorrhage overlying the macula. One to three laser membranotomies were performed. Colored fundus photographs were obtained before and after the hemorrhage was treated. In some cases, fluorescein angiography was done before the hemorrhage was treated. The size of the pretreated hemorrhage was estimated from the photographs and expressed in disc diameters. Patients with diabetes had panretinal laser before Nd:YAG laser membranotomy. The premacular bleeding originated from proliferative diabetic retinopathy in four eyes and from a retinal artery macroaneurysm in two. Average estimated area of the pretreated hemorrhage was 14 disc diameters. Five eyes had marked clearing of hemorrhage and rapid improvement of vision after Nd:YAG laser membranotomy. Average follow-up after laser treatment was 20 months. One diabetic eye required vitrectomy for rebleeding. One eye had little visual improvement due to pre-existing subretinal bleeding. Neodymium:YAG laser membranotomy seems helpful in rapid clearing of premacular hemorrhage in certain eyes. A randomized prospective study is needed to evaluate observation, vitrectomy, and Nd:YAG laser treatment of dense premacular hemorrhage.

A Modified En Bloc Excision Technique during Vitrectomy for Diabetic Traction Retinal Detachment: Results and Complications

The visual results and complications were determined for a modified en bloc excision technique for management of diabetic traction macular detachment. A consecutive series of 30 eyes with this condition underwent pars plana vitrectomy, during which all posterior hyaloid except for portions essential for membrane dissection were excised. Bimanual dissection techniques then allowed excision of fibrovascular membranes "en bloc" with the retained hyaloid. After 6 to 44 months of follow-up, visual acuity of 5/200 or better was obtained in 23 (77%) of 30 eyes, with complete reattachment in 29 (97%) of 30 eyes. Iatrogenic retinal breaks occurred in 6 (20%) of 30 eyes. Two eyes required repeat vitrectomy. The modified en bloc excision technique allowed similar visual outcome, a higher reattachment rate, and less postoperative morbidity than previously reported surgical approaches to diabetic traction macular detachment.

Vitrectomy for Diabetic Macular Heterotopia

The authors performed 15 vitrectomies for diabetic macular heterotopia, and then compared visual prognoses and postoperative complications with those of 88 macular detachments to determine the role of, and indications for, vitrectomy for diabetic macular heterotopia. Fifteen patients with diabetic macular heterotopia and 88 with traction macular detachment, in which the vitreous cavities were sufficiently clear for posterior poles to be observed, underwent vitrectomies. Preoperative and postoperative visual acuity and postoperative complications were assessed and documented retrospectively. There was no statistically significant difference between the two groups in terms of eyes showing improvement in visual acuity postoperatively. However, a final postoperative visual acuity better than 20/20 was documented in 93% of patients with macular heterotopia and 48% of patients with macular detachment (P < 0.002), whereas 47% of the former and 10% of the latter had visual acuities better than 20/40 (P < 0.001). Postoperative neovascular glaucoma and retinal detachment developed in 10% and 13%, respectively, of patients with macular detachments. None of the patients with macular heterotopia experienced these complications. Based on the above results, the authors conclude that diabetic macular heterotopia is a very good indication for early vitrectomy.