Treatment of idiopathic macular hole: internal limiting membrane peeling or inverted internal limiting membrane flap / 中华实验眼科杂志

Surgical management of idiopathic macular hole (IMH) is a hot topic in the field of fundus disease,and its classical surgery is internal limiting membrane peeling.In recent years,many researchers explored inverted internal limiting membrane flap technique for IMH.However,how large the IMH is necessary for inverted internal limiting membrane flap technique? Does the inverted internal limiting membrane flap technique have more advantages in operating procedure,anatomical and functional recovery of IMH in comparison with internal limiting membrane peeling? Our clinical researches and relative literature showed that it is better to use inverted internal limiting membrane flap technique for ＞550 μm IMH.There is still no available evidence showed inverted internal limiting membrane flap technique is of more benefit to the anatomical repair and functional restoration in comparison with internal limiting membrane peeling for IMH.Some viewpoints in this field are open to question.

An effectiveness comparison of extensive and standard internal limiting membrane peeling for idiopathic macular hole with closed index less than 0.7 / 中华实验眼科杂志

Objective To evaluate and compare the curative effects between extensive and standard internal limited membrane peeling (ILMP) during vitrectomy for idiopathic macular hole (IMH) with closed index＜0.7 and provide an alternative basis for IMH.Methods The clinical data of ninety-six eyes of 96 patients of IMH with closed index ＜0.7 who received vitrectomy with extensive (48 eyes) or standard ILMP (4-8 eyes) procedures from May 2012 to May 2016 in the Second Affiliated Hospital of Nanchang University under the informed consent of patients were retrospectively analyzed.Best corrected visual acuity (BCVA),central vision,direct ophthalmoscope examination,slit lamp microscope with preset lens,optical coherence tomography (OCT),intraocular pressure,Amsler grid table and fundus photography inspection were performed before surgery and 1 month,6 and 12 months after surgery.The healing rate of IMH and the correction rate of Amsler grid table were also observed.Based on the OCT image,U-like closure was thought to be normal fovea,V-like closure was steep fovea and W-like closure exhibited the defect of sensory layer.Three types were considered as hole closure.Results OCT showed that retinal nurosensory layer was defect at macular area in both extensive ILMP group and standard ILMP group before surgery.At 12 months after operation,43 cases had U type closure,1 case had V type closure and 1 case had W type closure in the extensive ILMP group,while 33 cases had U type closure,1 case had V type closure and 3 cases had W type closure in standard ILMP group.The BCVA was significantly better in the extensive ILMP group than that in the standard ILMP group in postoperative 1 month,6 months and 12 months (all at P＜0.05).Compared with preoperation BCVA,the number of eyes with central and paracentral scotomas was decreased in both extensive ILMP group and standard ILMP group at the end of the following up (central scotoma:x2 =80.98,56.99,both at P＜0.05;paracentral scotoma:x2 =88.21,80.98,both at P＜0.05),and the number of eyes with central scotoma in the extensive ILMP group was significantly less than that in the standard ILMP group (3 vs.11) (x2 =4.10,P＜0.05).The closure rate of IMH was 93.75％ in the extensive ILMP group and 77.08％ in the standard ILMP group,showing a significant difference between the two groups (x2 =4.10,P＜0.05).The corrected rate of Amsler grid abnormality was 93.75％ in the extensive ILMP group,which was evidently higher than 75.00％ in the standard ILMP group,with a significant difference between the two groups (x2 =5.06,P＜0.05).Conclusions Both extensive ILMP and standard ILMP during vitrectomy for IMH with MCHI＜0.7 are effective,and vitrectomy combined with extensive ILMP has a better outcome in comparison to vitrectomy combined with standard ILMP.

The Treatment of Large Macular Holes Using a Multi-layered Inverted Internal Limiting Membrane Flap Technique

PURPOSE: To describe a multi-layered inverted internal limiting membrane (ILM) flap technique and to evaluate the surgical outcomes of this surgery in patients with macular holes > 800 µm in base diameter. METHODS: The medical records of patients who received a multi-layered ILM flap technique were retrospectively studied and patients with macular holes > 800 µm were included in the analyses. Best-corrected visual acuity (BCVA) before and after surgery, preoperative hole size, hole base size, vertical size, and hole closure after surgery were checked using spectral domain optical coherence tomography. Pars plana vitrectomy was performed and the ILM was stained using indocyanine green and peeled with the base attached at the hole margin. The ILM flap was inverted over the macular hole with 2~3 layers, and gas injection was performed. RESULTS: The mean age of 12 patients was 65.2 ± 12.3 years. The mean BCVA (logMAR) was 1.27 ± 0.61. The mean hole size was 563.6 ± 221.9 µm, the mean vertical size was 418.8 ± 80.9 µm, and the mean hole base size was 1,182.8 ± 298.5 µm. The mean follow-up period was 174.4 ± 143.3 days. Nine macular holes were closed after surgery but three macular holes were not closed. The postoperative mean BCVA (logMAR) was 0.21 ± 0.51. Eight eyes showed visual improvement while three eyes did not show visual improvement after macular hole surgery. CONCLUSIONS: The macular hole was closed successfully and the visual acuity improved after the multi-layered, inverted ILM flap technique. The multi-layered, inverted ILM flap technique is therefore considered the treatment of choice for large macular holes.

Outcomes of chronic macular hole surgical repair.

Purpose: To report visual and anatomic outcomes of chronic macular hole surgery, with analysis of pre‑operative OCT‑based hole size and post‑operative closure type. Settings and Design: An IRB‑approved, retrospective case series of 26 eyes of 24 patients who underwent surgery for stage 3 or 4 idiopathic chronic macular holes at a tertiary care referral center. Statistical Analysis: Student’s t‑test. Results: Nineteen of 26 eyes (73%) had visual improvement after surgery on most recent exam. Twenty‑one of 26 eyes (81%) achieved anatomic closure; 16 of 26 eyes (62%) achieved type 1, and five of 26 eyes (19%) achieved type 2 closure. Post‑operative LogMAR VA for type 1 closure holes (0.49) was significantly greater than for type 2 closure and open holes (1.26, P < 0.003 and 1.10, P < 0.005, respectively), despite similar pre‑operative VA (P = 0.51 and 0.68, respectively). Mean pre‑operative hole diameter for eyes with type 1 closure, type 2 closure, and holes that remained open were 554, 929, and 1205 microns, respectively. Mean pre‑operative hole diameter was significantly larger in eyes that remained open as compared to eyes with type 1 closure (P = 0.015). Conclusion: Vitrectomy to repair chronic macular holes can improve vision and achieve long‑term closure. Holes of greater than 3.4 years duration were associated with a greater incidence of remaining open and type 2 closure. Larger holes (mean diameter of 1205 microns) were more likely to remain open after repair.

ILM Peeling Size and Postoperative Foveal Tissue Elongation in Macular Hole Surgery

PURPOSE: To evaluate the relationship between the size of internal limiting membrane (ILM) peeling and the elongation of foveal tissue after macular hole (MH) surgery. METHODS: The medical records of 29 patients (29 eyes) who developed elongation of foveal tissue on spectral domain optical coherence tomography (OCT) after vitrectomy with ILM peeling and gas tamponade for idiopathic MH were retrospectively reviewed. These eyes were classified into 3 subgroups by the size of ILM peeling: group A (9 eyes), smaller than 2 disc diameter (DD); group B (12 eyes), larger than 2 DD and within the major temporal vascular arcade, and group C (8 eyes), till the edge of the major temporal vascular arcade. Inter-outer plexiform layer (OPL) distance, representing elongation of foveal tissue, was measured 1, 3, and 6-8 months (only 18 eyes) postoperatively. 'Asymmetric elongation' was defined as non-uniform elongation of the foveal tissue in certain directions. RESULTS: Horizontal/vertical inter-OPL distances 1 month postoperative, in descending order, were: group B, 436.58 +/- 88.54 / 404.92 +/- 78.55 microm; group A, 421.33 +/- 109.97 / 404.14 +/- 120.9 microm; and C group, 389.25 +/- 48.75 / 400 +/- 52.23 microm. Variations in the horizontal/vertical inter-OPL distance 3 months after MH surgery were: group B, 136.83 +/- 65.64 / 103.92 +/- 73.37 microm; group A, 88.11 +/- 41.57 / 75.89 +/- 53.18 microm; and group C, 140.25 +/- 68.51 / 83.63 +/- 56.62 microm. There were no significant differences in inter-OPL distance, variation in inter-OPL distance, or percent asymmetry in both horizontal and vertical directions among these groups. CONCLUSIONS: Elongation of the foveal tissue and asymmetric elongation after MH surgery were not associated with the size of ILM peeling.

ILM Peeling Size and Postoperative Foveal Tissue Elongation in Macular Hole Surgery

PURPOSE: To evaluate the relationship between the size of internal limiting membrane (ILM) peeling and the elongation of foveal tissue after macular hole (MH) surgery. METHODS: The medical records of 29 patients (29 eyes) who developed elongation of foveal tissue on spectral domain optical coherence tomography (OCT) after vitrectomy with ILM peeling and gas tamponade for idiopathic MH were retrospectively reviewed. These eyes were classified into 3 subgroups by the size of ILM peeling: group A (9 eyes), smaller than 2 disc diameter (DD); group B (12 eyes), larger than 2 DD and within the major temporal vascular arcade, and group C (8 eyes), till the edge of the major temporal vascular arcade. Inter-outer plexiform layer (OPL) distance, representing elongation of foveal tissue, was measured 1, 3, and 6-8 months (only 18 eyes) postoperatively. 'Asymmetric elongation' was defined as non-uniform elongation of the foveal tissue in certain directions. RESULTS: Horizontal/vertical inter-OPL distances 1 month postoperative, in descending order, were: group B, 436.58 +/- 88.54 / 404.92 +/- 78.55 microm; group A, 421.33 +/- 109.97 / 404.14 +/- 120.9 microm; and C group, 389.25 +/- 48.75 / 400 +/- 52.23 microm. Variations in the horizontal/vertical inter-OPL distance 3 months after MH surgery were: group B, 136.83 +/- 65.64 / 103.92 +/- 73.37 microm; group A, 88.11 +/- 41.57 / 75.89 +/- 53.18 microm; and group C, 140.25 +/- 68.51 / 83.63 +/- 56.62 microm. There were no significant differences in inter-OPL distance, variation in inter-OPL distance, or percent asymmetry in both horizontal and vertical directions among these groups. CONCLUSIONS: Elongation of the foveal tissue and asymmetric elongation after MH surgery were not associated with the size of ILM peeling.

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

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

A Case of Choroidal Neovascularization Occurring after Macular Hole Surgery

PURPOSE: To report a case of choroidal neovascularization after successful macular hole surgery in an eye with macular drusen. CASE SUMMARY: A 66-year-old woman visited our clinic complaining of decreased visual acuity in her right eye. Fundoscopy showed a full thickness macular hole in the right eye and bilateral scattered drusen. The patient underwent uncomplicated pars plana vitrectomy, internal limiting membrane peeling using triamcinolone, and perfluoropropane (C3F8) gas tamponade. One month after vitrectomy, the macular hole was closed. Twenty-four months following the macular hole surgery, the patient presented with defective vision in the right eye. Fluorescein angiography showed classic subfoveal choroidal neovascularization. Intravitreal bevacizumab was administrated three times in the right eye; however, visual improvement was not observed. CONCLUSIONS: In eyes with macular hole and drusen, the possibility of choroidal neovascularization developing after macular hole surgery should be considered.

Evaluation of Correlation Between OCT Findings and Delayed Visual Acuity Improvement After Macular Hole Surgery

PURPOSE: We evaluated the relationship between the delayed visual acuity (VA) improvement and retinal features, including in the photoreceptor layer, after a successful macular hole surgery using optical coherence tomography (OCT) images during long-term post-operative observation. The goal was to find the mechanism in delayed VA improvement. METHODS: Postoperative OCT scans were analyzed in nine eyes of eight patients who underwent idiopathic macular hole surgery between June 2003 to June 2005. Horizontal and vertical OCT scans taken of the operated eyes immediately after absorption of intraocular gas and after VA improvement were exported to Adobe Photoshop 7.0. We measured changes in parameters of the central foveal thickness (central 1 mm area), photoreceptor layer thickness, relative reflectivity of photoreceptor to retinal pigment epithelium, and the defective area of photoreceptor layer. RESULTS: The median visual acuity was determined to be 0.2 (range: 0.15~0.3) at the VA unimproved period and 0.5 (range: 0.3~1.0) at VA improved period. The mean central foveal thickness decreased from 221.3 micrometer (range: 155~265 micrometer) to 191.2 micrometer (range: 150~231 micrometer), as VA improved (p=0.007). The mean photoreceptor layer thickness increased from 15.2 micrometer (range: 4.2~27.6 micrometer) to 22.6 micrometer (range: 4.2~35.8 micrometer) as VA improved (p=0.032), and mean relative reflectivity of photoreceptor layer increased from 0.43 (range: 0.08~0.67) to 0.48 (range: 0.10~0.70), as VA improved (p=0.415). The defective area of photoreceptor layer decreased from 70% (range: 90~45%) to 27% (range: 8~5), as VA improved (p=0.001). CONCLUSIONS: A decrease of the central foveal thickness and of photoreceptor layer defective signal, and an increase of photoreceptor layer thickness were observed on OCT during delayed vision improvement after a successful macular hole surgery. Improvement of macular edema and photoreceptor reorganization are suggested as important parts of the mechanism toward vision recovery.

Comparison of Indocyanine Green and Triamcinolone Acetonide for Internal Limiting Membrane Peeling in Macular Hole

PURPOSE: To compare the surgical outcomes and complications of triamcinolone acetonide (TA) with those of indocyanine green (ICG) staining of the internal limiting membrane (ILM) during idiopathic macular hole surgery. METHODS: Twenty-four eyes of 23 consecutive patients with an idiopathic macular hole underwent vitrectomy, ILM peeling, and intravitreal gas injection. For enhanced visualization of ILM, ICG was used in 13 eyes and TA in the remaining 11 eyes. Functional and anatomical success rates and surgical complications were compared between the groups. RESULTS: The mean follow-up periods were 10.8 months (ICG group) and 7.5 months (TA group). Best corrected visual acuity increased by two or more lines in 10 eyes (76.9%) of the ICG group and in eight eyes (72.7%) of the TA group (P=1.000). Anatomical closure after the first surgery was achieved in 10 eyes (76.9%) of the ICG group and in all 11 eyes of the TA group (100%) (P=0.223). Postoperative atrophic changes in the retinal pigment epithelium (RPE) in the macular hole bed was found in two eyes of the ICG group and in three eyes of the TA group. All of these (5 eyes) showed the photoreceptor outer segment defect in the closed macular areas by optical coherence tomography and had a postoperative best corrected visual acuity of 0.3 or less. CONCLUSIONS: In view of the potential toxicities of ICG, TA appears to be a promising alternative adjuvant for ILM peeling during macular hole surgery. However, postoperative RPE atrophy was detected as a postoperative complication in both the ICG and TA groups. Further study is needed to evaluate the TA toxicity in macular hole surgery.

The Outcomes After Indocyanine Green-assisted Peeling of the Internal Limiting Membrane in Macular Hole Surgery

PURPOSE: To investigate whether indocyanine green (ICG) staining of the internal limiting membrane (ILM) improves surgical and visual outcomes in macular hole surgery. METHODS: Three consecutive groups of patients with stage 3 and stage 4 macular hole underwent standard vitrectomy. Group I (45 eyes) underwent an adjunctive peeling of ILM stained with intravitreal application of 0.1 ml of 0.5% ICG dye, group II (23 eyes) an adjunctive ILM peeling without use of ICG dye, and group III (23 eyes) no adjunctive technique. Postoperative anatomic closure rates of the hole and the logarithm of the minimal angle of resolution (logMAR) visual acuity improvement were compared among the groups. RESULTS: The mean age was 61 years, and the mean follow-up period was 11 months. The rate of macular hole closure, as determined by optical coherence topography was 70% in group I, 61% in group II, and 61% in group III, and the difference were not statistically significant (p=0.726). The differences between preoperative and postoperative logMAR visual acuities among the three groups were not statistically significant (p=0.898). CONCLUSIONS: Intravitreal ICG-assisted ILM peeling did not improve anatomic outcomes in macular hole surgery. (Ed-confirm, something appears to be missing here)

Evaluation of Macular Hole Surgery using Confocal Laser Tomography

Macular hole can be quantitated by measuring its diameter, depth and volume with Heidelberg retina tomograph(HRT). In this study, effectiveness of macular hole surgery was investigated using HRT. Patients with good preoperative visual acuity showed better visual improvement after surgery. The macular holes of stage 1 and stage 2 had better visual prognosis than those of stage 3 and stage 4. Idiopathic holes had better visual prognosis than traumatic holes. Following surgery, the diameters of the macular holes were significantly decreased in eyes with postoperative visual improvement, and significantly increased in eyes with decrease in visual acuity. The diameter of a macular hole is a good indicator for the correlation of vision in macular hole surgery. Initial visual acuity and stage of macular holes were the most significant prognostic factors.