Treatment Of Lamellar Macular Hole Research Articles

The no-retina-touch technique: vitrectomy and platelet-rich plasma in the treatment of lamellar macular hole. New insights into pathogenesis.

To explore the use of autologous platelet-rich plasma (PRP) as a potential therapeutic adjuvant strategy for treating degenerative lamellar macular holes (LMHs). A prospective interventional case series. Seven consecutive patients (8 eyes) with a diagnosis of LMH underwent a pars-plana vitrectomy with PRP injection under air tamponade. Anatomical results based on spectral domain optical coherence tomography (SD-OCT) and functional results, in terms of best corrected visual acuity (BCVA) and reading performance, were analyzed. At 12 months postoperatively, 7 out of 8 eyes (88%) presented a complete closure of the LMH. The ellipsoid zone (EZ) was restored in 3 eyes (37.5%). The mean (±SD) postoperative BCVA was 0.39 (±0.56) LogMAR, resulting in a statistically significant visual acuity improvement (p = 0.007). The mean (±SD) maximum reading speed (MaxRS) improved to 133.48 (±41.47) wpm, with a significant increase compared to the baseline (p = 0.029). The mean (±SD) reading acuity score (RA score) resulted in 0.44 (±0.04) LogRAD, with an improvement in reading acuity that did not reach statistical significance (p = 0.129). The utilization of the PRP technique with a no-retina-touch approach safeguards the delicate retinal tissues, minimizing the possibility of iatrogenic trauma or post-operative complications, while maintaining a high rate of efficacy in enabling the improvement of the foveal defect in lamellar macular holes.

Lamellar macular hole in highly myopic eyes and insights into its development, evolution, and treatment: a mini-review.

Lamellar macular holes (LMHs) are a manifestation of myopic tractional maculopathy (MTM). Owing to the complex and multidirectional traction force in the elongated eyeball, the clinical features, development, evolution, and treatment algorithms of LMH in highly myopic eyes may differ from those of idiopathic LMH or MTM in general. This review aimed to specifically explore the LMHs in highly myopic eyes. Several developmental processes of LMH and their association with macular retinoschisis have been demonstrated, with the tractional component identified in all processes. Epiretinal proliferation was more prevalent and more extensive in LMHs in highly myopic eyes than in idiopathic LMHs. LMHs in highly myopic eyes may remain stable or progress to foveal detachment and full-thickness macular hole with or without retinal detachment. The predictive factors associated with disease progression were summarized to facilitate monitoring and guide surgical intervention. The treatment of LMHs in highly myopic eyes was based on an algorithm for treating myopic tractional maculopathy, including gas tamponade, pars plana vitrectomy, macular buckling, and a combination of vitrectomy and macular buckling. New internal limiting membrane (ILM) manipulation techniques such as fovea-sparing ILM peeling or fovea-sparing ILM peeling combined with ILM flap insertion could reduce the risk of developing iatrogenic full-thickness macular holes postoperatively. Further research should focus on the treatment of LMH in highly myopic eyes.

Use of a Backflush Needle with a Silicone Tip Cannula to Embed Lamellar Hole-Associated Epiretinal Proliferation.

For the treatment of lamellar macular hole, the recent development of a lamellar hole-associated epiretinal proliferation (LHEP) embedding technique is likely to improve functional and anatomical results. However, the peeling of LHEP is often technically challenging. We have developed a new technique using a backflush needle with a silicone tip cannula that seems safer and more effective for use in LHEP embedding. A 25-gauge vitrectomy system with an enhancing visual acuity system (D.O.R.C., Zuidland, Netherlands) was used in all cases. After core vitrectomy, triamcinolone acetonide (Wakamoto Pharmaceutical Co., Ltd., Tokyo, Japan) was used to visualize the membrane. A 25-gauge backflush needle with a silicone tip cannula was used to remove the thin preretinal membrane centripetally, leaving an LHEP on the edge of the hole. Brilliant Blue G (internal limiting membrane Blue; D.O.R.C.) was then used to stain the internal limiting membrane. This technique was used in six eyes with lamellar macular holes. In all cases, peeling and embedding of the LHEP was effectively performed without damaging the internal limiting membrane or causing retinal hemorrhage. No other intraoperative or postoperative complications were experienced. Using a silicone-tipped backflush needle with passive aspiration was a simple and effective technique for peeling and embedding of LHEPs in this small series.

Internal limiting membrane flap with viscoelastic device for lamellar hole surgery with no postoperative positioning.

To propose a novel technique of an internal limiting membrane (ILM) flap using ophthalmic viscoelastic device (OVD) with no requirement for postoperative head posture for the treatment of lamellar macular hole (LMH) repair. A retrospective analysis of 16 consecutive eyes of LMH patients who underwent vitrectomy with ILM flap with OVD. Best-corrected visual acuity (BCVA), central macular thickness (CMT), simultaneous cataract extraction, and ellipsoid zone disruption preoperatively and at the final follow-up were compared. The mean age was 73.19 ± 7.26 years, and ten patients (62%) were females. The mean follow-up was 5.06±1.43 months (range 3-6). For all patients, BCVA was significantly improved at the final visit, from 0.65±0.36 logMAR units to 0.42±0.29 (p < 0.001). None of the patients had visual loss. Six patients had epiretinal membrane (ERM) foveoschisis, and the rest had LMH with epiretinal proliferation. Both subgroups presented a significant improvement in their BCVA with a trend for better improvement in the latter (p=0.09). Ellipsoid zone disruption was seen in 7 patients including one patient with a macular scar. There was no significant effect of ellipsoid zone disruption on the final BCVA (p=0.33). Twelve eyes (75%) underwent simultaneous cataract extraction. Mean BCVA at the final postoperative visit improved regardless of whether the eyes underwent simultaneous cataract surgery (p=0.39). CMT was also significantly improved at the final visit, from 200.06±46.8 μm preoperatively to 305.00±85.5 μm (p<0.001). No full-thickness macular holes were developed postoperatively. No intraoperative or postoperative complications were observed. Treatment of LMH with ILM flap with OVD showed promising anatomical and functional results with no postoperative head position requirements.

COMPARISON OF THREE INTERNAL LIMITING MEMBRANE PEELING TECHNIQUES FOR MYOPIC TRACTION MACULOPATHY WITH HIGH RISK OF POSTOPERATIVE MACULAR HOLE DEVELOPMENT.

To compare three different internal limiting membrane (ILM) peeling techniques, including standard ILM peeling, fovea-sparing ILM peeling, and inverted ILM flap (ILMF), in the treatment of myopic traction maculopathy with high risk of postoperative macular hole development. This retrospective cohort study enrolled 101 eyes suffering from lamellar macular hole combined with myopic traction maculopathy in 98 consecutive patients who underwent vitrectomy with either standard ILM peeling, fovea-sparing ILM peeling, or ILMF from July 2017 to August 2020. All patients were followed up for at least 12 months after surgery. Best-corrected visual acuity, macular anatomical outcomes, and postoperative full-thickness macular hole (FTMH) formation were evaluated. No significant differences were found among the three surgical groups in baseline characteristics. 12 months after surgery, the mean best-corrected visual acuity was significantly improved ( P < 0.001) and showed no significant differences among groups ( P = 0.452). None of the eyes in the ILMF group, five eyes (15.6%) in the standard ILM peeling group, and six eyes (17.1%) in the fovea-sparing ILM peeling group developed a postoperative FTMH ( P = 0.026). Logistic regression showed that the ILM peeling technique was an independent influencing factor for FTMH formation (OR = 0.209, P = 0.014). Compared with the standard ILM peeling or fovea-sparing ILM peeling technique, the ILMF technique resulted in similar visual outcomes but a relatively low incidence of postoperative FTMH in the treatment of lamellar macular hole combined with myopic traction maculopathy. Inverted ILM flap is an effective technique for treating myopic traction maculopathy with high risk of postoperative FTMH development.

Результаты хирургического лечения ламеллярных макулярных разрывов с применением богатой тромбоцитами плазмы крови

Purpose. To evaluate the results of surgical treatment of lamellar macular holes (LMH) using autologous platelet-rich plasma (PRP) in comparison with the standard surgical technique. Material and methods. The study included 71 patients (71 eyes) with LMH. Of these, 39 patients (39 eyes) of the control group were operated according to the standard technique. In 32 patients (32 eyes), surgery was supplemented by the application of the autologous PRP on the hole area before the completion of the operation (PRP group). The functional and anatomical results of surgical treatment were compared. Results. There was no statistically significant difference in visual acuity improvement between the groups. In all patients of the PRP group and in the majority of patients in the control group, LMH was closed with restoration of the thickness of the retina in the area of the hole. In the control group, 6 patients had only partial closure of the LMR. In 2 cases, splitting or a smaller retinal defect was preserved. In 4 cases, partial closure of the LMR was combined with the preservation or increase of local thinning of the retina in the center of the foveola. In one of these cases, the residual thickness of the retina was only 28µm, which resembled the picture of a fullthickness macular hole. Conclusion. Surgical treatment of LMH with the use of autologous PRP is an affordable, effective surgical intervention that allows to get more favorable treatment outcomes compared to the standard surgical technique. Key words: lamellar macular hole, platelet-rich plasma, surgical treatment, vitrectomy

Novel approaches to the assessment and treatment of lamellar macular hole.

To analyse morpho-functional foveal changes in eyes with lamellar macular hole (LMH) by an integrated assessment of short-wavelength fundus autofluorescence (SW-FAF) and microperimetry (SW-FAF/microperimetry integrated assessment) before and after treatment with a technique of double-inverted flaps of epiretinal proliferation (EP) and internal limiting membrane (ILM). Clinical and tomographic parameters were best-corrected visual acuity (BCVA), LMH size, central retinal thickness (CRT) and outer retinal layer integrity. SW-FAF/microperimetry integrated assessment allowed to analyse retinal sensitivity (RS) and FAF status of the fovea by an overlay of RS map on SW-FAF image. Follow-up was at baseline, 1, 3, 6 and 12 postoperative months. Forty pseudophakic eyes. Hyper-FAF area was associated with larger LMH size (p = 0.0073) and inversely correlated with CRT (p = 0.021). Lower preoperative RS was observed in hyper-FAF than normo-FAF areas (p = 0.0117). External limiting membrane (ELM) defect was associated with worse BCVA (p = 0.0004). After surgery, BCVA improved (p = 0.001) and it was related to ELM recovery (p = 0.00483), hyper-FAF area decreased (p = 0.001), and RS increased (p = 0.440). Hyper-FAF points that normalized their FAF were associated with higher RS improvement compared to unchanged points. Short-wavelength fundus autofluorescence/microperimetry integrated assessment provides important information on the entity of damage of LMH and on postoperative recovery. Double-inverted EP and ILM flap technique is safe and effective for LMH treatment.

Embedding and sparing of lamellar hole-associated epiretinal proliferation in the treatment of lamellar macular holes.

Compare the outcomes of two surgical techniques, lamellar hole-associated epiretinal proliferation (LHEP) embedding and LHEP sparing, in treating idiopathic lamellar macular holes (LMHs). Retrospective consecutive case series with 34 LMHs with LHEP that underwent operation. LHEP-sparing technique was used before July 2015 and LHEP-embedding after July 2015. Morphological features in optical coherence tomography (OCT) images were identified, including the presence of LHEP, ellipsoid zone (EZ) defects, and types of LMH closure, along with best-corrected visual acuity (BCVA) before and after surgery. No baseline differences were observed between the embedding (17 patients) and sparing (17 patients) groups in LMH size, retinal defect depth, or preoperative BCVA. The two groups' mean postoperative BCVAs were similar (embedding vs sparing: 0.388 ± 0.337 vs 0.465 ± 0.418 [Snellen: 20/49 and 20/58], P = 0.812). Postoperatively, a U-type closure was observed in 77 and 65% of patients in the embedding and sparing groups, respectively. Both groups exhibited V-type and T-type closures in half of the remaining patients (P = 0.753). Older age, postoperative external limiting membrane defect, postoperative EZ disruption, and non-U-type closure were associated with worse final BCVA. Both the LHEP-embedding and LHEP-sparing techniques significantly improved vision in patients with LMHs and produced similar visual and anatomical outcomes. Most patients achieved a normal U-type closure with either technique. Preservation of LHEP during surgery is vital and could facilitates successful surgery.

Применение богатой тромбоцитами плазмы крови в лечении ламеллярных макулярных разрывов

Применение богатой тромбоцитами плазмы крови в лечении ламеллярных макулярных разрывов

Natural course of lamellar macular holes

To study natural course of LMH and to develop criteria of their progression. The study analyses retrospective data of patients with LMH observed in S. Fyodorov Eye Microsurgery Federal State Institution from 2013 to 2018 who were examined by optical coherence tomography (OCT) at least 2 times with an interval between the initial and last examinations of at least 6 months. The examinations were carried out to evaluate the types of LMH and epiretinal membrane, the ellipsoid zone of photoreceptors and vitreoretinal interface, as well as calculate the changes in the quantitative parameters of the LMH. One hundred and three patients with LMH were identified; data of 65 patients (65 eyes) was studied in detail. The follow-up lasted 20.5±12.9 months on average. Statistically substantiated criteria for the progression of tractional and degenerative LMH were developed, taking into account the OCT changes most significant for each type of LMH. According to the proposed criteria, signs of marked progression were found in 2 (5.3%) of 38 patients with tractional and 4 (14.8%) of 27 patients with degenerative LMH. Moderate progression was detected in 2 (5.3%) patients with tractional and 2 (7.4%) patients with degenerative LMH. In two patients who were not included in the groups for calculating the criteria for progression, the formation of a full-thickness macular hole has occurred. One of the variants of the natural course of LMH can be its progression up to transition into a full-thickness macular hole. The proposed statistically substantiated criteria allows identifying dangerous progression of LMH, which should be taken into account when determining the treatment tactics.

Embedding of lamellar hole-associated epiretinal proliferation combined with internal limiting membrane inversion for the treatment of lamellar macular hole: a case report

BackgroundWe recently reported that lamellar macular hole (LMH) with lamellar hole-associated epiretinal proliferation (LHEP) can be effectively treated by embedding the LHEP into the retinal cleavage to improve foveal contour and visual acuity. Here, we report a case of LMH with LHEP for which we performed embedding of the LHEP combined with internal limiting membrane (ILM) inversion. We then evaluated the effects of this surgery on macular morphology and visual functions.Case presentationA 62-year-old man presented with visual disturbance (20/29) and metamorphopsia in his right eye. B-scan optical coherence tomography (OCT) imaging revealed the presence of both partial-thickness defect of the macula with degenerative retinal cleavage and LHEP at the surface of the retina. En face OCT imaging showed the absence of retinal fold. We performed phacoemulsification with intraocular lens implantation, vitrectomy, embedding of LHEP into the retinal cleavage, and ILM inversion. Three months after the surgery, both foveal contour and visual acuity (20/20) were improved and metamorphopsia was reduced.ConclusionEmbedding of the LHEP combined with ILM inversion may be an effective treatment for LMH with LHEP.

SURGICAL TREATMENT OF LAMELLAR MACULAR HOLE ASSOCIATED WITH EPIMACULAR MEMBRANE

Although the surgical treatment of full-thickness macular hole is well established, the utility of pars plana vitrectomy in the treatment of lamellar macular hole (LMH) remains less clear. The purpose of the study is to report functional results of surgical treatment of LMH associated with epiretinal membrane. Retrospective chart review of patients undergoing pars plana vitrectomy and peeling of epiretinal membrane and internal limiting membrane, with or without air or gas tamponade, for symptomatic LMH associated with epimacular membrane. Forty-five eyes of 44 patients were operated for LMH associated with epimacular membrane between May 2000 and July 2009. Pars plana vitrectomy and membrane peeling were combined with air or gas tamponade in 43 of 45 cases. Mean logarithm of the minimum angle of resolution best-corrected visual acuity improved from 0.4 preoperatively to 0.13 postoperatively (P < 0.0001). Improvement in visual acuity ranged from 0 Early Treatment Diabetic Retinopathy Study (ETDRS) lines to 8.9 ETDRS lines (mean, 2.65 ETDRS lines). Visual acuity improved by ≥ 1 ETDRS line(s) in 40 of 45 eyes (89%) and by ≥ 2 ETDRS lines in 26 of 45 eyes (58%) after the surgical procedure. No patient lost vision. This small retrospective study suggests that surgical treatment of LMH associated with epimacular membrane may improve visual acuity in symptomatic patients.

Surgical treatment of lamellar macular holes

The aim of this study is to present functional and anatomical results of pars plana vitrectomy without gas tamponade in lamellar macular holes. Additionally, the study determines factors influencing final outcome. Twenty-six eyes of 26 patients with lamellar macular hole were diagnosed using spectral domain optical coherence tomography (SD-OCT). The diameters of the lamellar defects were measured. Pars plana vitrectomy with epiretinal membrane (ERM) removal and internal limiting membrane (ILM) peeling without endotamponade followed. Follow-up examinations were conducted with SD-OCT for a period of 12 months after surgery. The following factors were examined: maximum and minimum diameter of the lamellar defect, maximum diameter of the disruption of the photoreceptors, representing the photoreceptor layer, central macular thickness, paracentral macular thickness 1000 microm from the centre of the fovea, and maximum paracentral retinal thickness. Retina thickness was measured manually from the inner retina surface to the upper line of retinal pigment epithelium. Prior to surgery, mean visual acuity was 0.2. Twelve months after surgery, the mean visual acuity was 0.51. Lower visual acuity was observed in patients with photoreceptor layer defects localized under the fovea. Epiretinal membranes and complete or partial posterior hyaloid detachment were observed in all cases. The size of the lamellar defect had no influence on final visual acuity. The results obtained show that intraocular gas tamponade is not a crucial step in achieving closure and visual improvement in lamellar macular holes.