RESTORATION PROCESS OF THE OUTER RETINAL LAYERS AFTER SURGICAL MACULAR HOLE CLOSURE.

PURPOSE: To investigate the interrelationship among the outer retinal layers after macular hole surgery and elucidate the restoration process. METHODS: This retrospective observational study included 50 eyes of 47 consecutive patients with closed macular holes in the first vitrectomy. Optical coherence tomography was obtained before surgery; at 1, 3, and 6 months postsurgery; and at the last visit. The complete continuous layer rate and mean defect length were evaluated for the outer nuclear layer (ONL), external limiting membrane (ELM), and ellipsoid zone (EZ). RESULTS: At all postoperative visits, the complete continuous layer rate was in the descending order of ELM, ONL, and EZ and the mean defect length was in the ascending order of ELM, ONL, and EZ. External limiting membrane was necessary for ONL restoration. External limiting membrane and ONL were necessary for EZ restoration. Hyperreflective protrusions were observed from the area lacking ELM into the subretinal space after surgery. Ellipsoid zone was not formed in coexistence with the hyperreflective protrusions. Intermediate reflective protrusions appeared under the ONL plus ELM after surgery and were eventually replaced by EZ. CONCLUSION: Restoration of the outer retinal layers after surgical macular hole closure occurs in the order of ELM, ONL, and EZ.

Comparative analysis of polypoidal choroidal vasculopathy with and without hemorrhage treated by anti-VEGF monotherapy.

PURPOSE: Visual function and treatment response after anti-vascular endothelial growth factor monotherapy were compared between polypoidal choroidal vasculopathy (PCV) with and without hemorrhage. METHODS: We conducted a retrospective, observational study (mean, 26 months) for 49 eyes of 49 treatment-naive patients with PCV. Patients were classified into PCV with hemorrhage (26 eyes) or without hemorrhage (23 eyes). PCV with massive hemorrhage subgroup has four or more disc-hemorrhagic areas and included five eyes. RESULTS: There were no significant differences in patient age, sex, systolic blood pressure, diastolic blood pressure, presence of choroidal vascular hyperpermeability, number of polyps, maximum polyp size, lesion area, and presence of pigment epithelium detachment (PED) between the two groups. Except for the course of PCV-related hemorrhage, treatment number and its response were similar between the groups. Best-corrected visual acuity at the last visit in PCV with hemorrhage was 0.33 ± 0.51 logMAR (20/41) comparable with 0.28 ± 0.41 logMAR (20/38) without hemorrhage at the last visit (p = 0.944). Maximum polyp size in massive hemorrhagic PCV was significantly larger (314.6 ± 111.4 µm) than that of small hemorrhagic PCV (229.0 ± 119.1 µm; p = 0.037). All PCV with massive hemorrhage was accompanied by large hemorrhagic PED. CONCLUSION: There were no significant differences in the baseline characteristics, treatment intervention, or suppression of disease activity between PCV with and without hemorrhage. Final visual acuity of PCV did not differ with or without hemorrhage. Development of massive hemorrhaging in PCV may be associated with both large polyps and hemorrhagic PED.

Effects of inverted internal limiting membrane technique and insertion technique on outer retinal restoration associated with glial proliferation in large macular holes.

PURPOSE: To compare the effects of inverted internal limiting membrane (ILM) flap technique and ILM insertion technique for large macular hole (MH) on glial proliferation, retinal outer layer restoration, and visual function. METHODS: This retrospective, observational study included 25 eyes with large MH (minimum diameter, ≥ 400 µm) treated using the inverted ILM flap or insertion technique. The inverted flap group was defined as flipping the ILM upside down on the MH (13 eyes) and the insertion group as inserting multiple ILM layers into the MH (12 eyes). RESULTS: Glial proliferation in the photoreceptor layer at 1 month and the final visit was significantly less frequent in the inverted flap group than in the insertion group (61.5% vs. 100%, p = 0.039; 23.1% vs. 100%, p = 0.001). The mean postoperative external limiting membrane defect was 140.4 ± 286.2 µm in the inverted flap group, significantly narrower than that in the insertion group (364.6 ± 181.6 µm; p = 0.016). The mean postoperative ellipsoid zone defect was 235.3 ± 214.2 µm in the inverted flap group, which was almost significantly narrower than that in the insertion group (496.3 ± 445.6 µm; p = 0.068). The change in the best-corrected visual acuity was significantly better in the inverted flap group than that in the insertion group (+ 18.5 vs. + 9.0 letters). CONCLUSION: Compared with patients treated with the insertion technique, those treated with the inverted ILM flap technique had significantly less glial proliferation at the photoreceptor space, more preferable outer retinal formation, and better visual improvement.

Fovea-sparing internal limiting membrane peeling versus complete internal limiting membrane peeling for myopic traction maculopathy.

PURPOSE: To compare the outcomes of vitrectomy with fovea-sparing internal limiting membrane peeling (FSIP) and complete internal limiting membrane peeling (ILMP) for myopic traction maculopathy (MTM). STUDY DESIGN: A retrospective, observational study. PATIENTS AND METHODS: In this study, we included 22 eyes of 21 consecutive patients who underwent vitrectomy with FSIP or ILMP for MTM and were monitored for at least 6 months. Eleven eyes were treated with FSIP, and 11, with ILMP. RESULTS: With FSIP, the postoperative best-corrected visual acuity (BCVA) significantly improved from 0.61 (20/82) to 0.34 (20/44; P = .009) logarithm of the minimum angle of resolution (logMAR) units. With ILMP, the postoperative BCVA improved from 0.65 (20/89) to 0.52 (20/66) logMAR units, but was not significant (P = .106). The postoperative final central foveal thickness (CFT) reduced significantly after FSIP (from 557.6 to 128.8 µm, P = .003) and ILMP (from 547.3 to 130.3 µm, P = .008). The postoperative incidence of a macular hole was 0% (0/11 eyes) with FSIP and 27.3% (3/11 eyes) with ILMP. All patients with a macular hole had foveal detachment in association with a thin fovea preoperatively. With ILMP, postoperative BCVA with a macular hole worsened by -3.5 letters; in contrast, postoperative BCVA without a macular hole improved by +10.5 letters. With FSIP, postoperative BCVA without a macular hole significantly improved by +13.5 letters (P = .009). CONCLUSIONS: FSIP resulted in significant improvement in MTM and prevented postoperative macular hole development.

Systemic and Ocular Determinants of Choroidal Structures on Optical Coherence Tomography of Eyes with Diabetes and Diabetic Retinopathy.

Knowledgeof the choroidal structures in eyes with diabetes and diabetic retinopathy (DR) should provide information on the pathogenesis of DR. A prospective study was performed to determine the systemic and ocular factors that affect the choroidal structures in eyes with diabetes. Two-hundred consecutive diabetic subjects consisted of 160 treatment-naïve patients with different stages of DR and 40 patients with proliferative DR with prior panretinal photocoagulation (PRP). All underwent blood and urine tests and enhanced depth imaging optical coherence tomography (EDI-OCT). The cross-sectional EDI-OCT images of the subfoveal choroid were binarized to measure the total choroidal area (TCA), luminal area, and stromal area. Multivariate regression analyses were performed to determine the systemic and ocular factors that were significantly correlated with the choroidal structures. The subfoveal choroidal thickness, TCA, luminal area, and stromal area were larger at more advanced stage of DR, and smaller in eyes with PRP than those without (P < 0.001). The TCA and stromal area were significantly and positively correlated with the degree of albuminuria (P = 0.034, P = 0.025, respectively). The choroidal lumen and stroma may increase as the stages of DR progress and decrease after PRP. Albuminuria may be associated with the choroidal stromal edema.

INFLUENCE OF INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE ON THE OUTER RETINAL LAYER STRUCTURES AFTER A LARGE MACULAR HOLE SURGERY.

PURPOSE: To examine the influence of inverted internal limiting membrane (ILM) flap technique on the outer retinal layer structures after macular hole (MH) surgery. METHODS: We included 24 eyes of 24 patients who underwent vitrectomy for large MHs (≥400 µm) with successful MH closure and observed for at least 6 months. Fourteen eyes were treated with inverted ILM flap technique (inverted group) and 10 with conventional ILM peeling (ILMP group). We evaluated the postoperative recovery rate of the external limiting membrane and ellipsoid zone and the best-corrected visual acuity. RESULTS: The postoperative recovery rates of the external limiting membrane and ellipsoid zone in the inverted group were lower than those in the ILMP group (21.4 vs. 70.0%, P = 0.024; 0 vs. 30.0, P = 0.059, respectively). The external limiting membrane recovery period in the inverted group was significantly longer than that in the ILMP group (11.0 ± 1.7 vs. 3.4 ± 2.8 months, P = 0.015). The best-corrected visual acuity change (letters) in the inverted group was significantly smaller than that in the ILMP group (9.0 vs. 22.5, P = 0.040). CONCLUSION: The poorer anatomical and visual results associated with inverted ILM flap compared with ILM peeling suggest the limitation of the ILM flap technique to repair refractory MHs.

Effects of Exercise on the Structure and Circulation of Choroid in Normal Eyes.

AIMS: To determine the effects of dynamic exercise on the circulation and the luminal and stromal areas of the choroid in normal eyes. METHODS: This was a prospective interventional study of 38 eyes of 38 normal subjects enrolled by invitation. The systolic and diastolic blood pressures, heart rate, intraocularpressure, mean ocular perfusion pressure (MOPP), choroidal blood velocity, and enhanced depth imaging optical coherence tomographic (EDI-OCT) images were recorded before, and immediately after mild dynamic exercise. The same measurements were recorded after 10 min of rest. The choroidal blood velocity was measured bylaser speckle flowgraphy, and the mean blur rate was used for the evaluations. The horizontal EDI-OCT images of the subfoveal choroid were converted to binary images. The central choroidal thickness (CCT), total cross sectional choroidal area, luminal areas, stromal areas, and the ratio of luminal area to total choroidal area (L/C ratio) were determined from these images. RESULTS: The systolic and diastolic blood pressures, heart rate, MOPP, and the mean blur rate were significantly increased immediately after the exercise and significantly decreased 10 minutes after the exercise. There wereno significant changes in the mean CCT, the mean total choroidal area, the mean luminal and stromal areas, and the mean L/C ratio after the exercise. CONCLUSIONS: Our results suggest that a rest period is needed before measurements of blood flow velocity but not necessary for the EDI-OCT imaging to determine the choroidal thickness and area.

Two-year results of metamorphopsia, visual acuity, and optical coherence tomographic parameters after epiretinal membrane surgery.

PURPOSE: To determine the 2-year results of metamorphopsia, visual acuity, and optical coherence tomographic (OCT) parameters after epiretinal membrane (ERM) removal, and to evaluate the correlations among them. METHODS: We studied 75 eyes of 75 patients with an ERM who underwent vitrectomy and membrane peeling. The best-corrected visual acuity (BCVA), metamorphopsia scores, and OCT parameters were measured at the baseline, and 1, 3, 6, 9, 12, 18, and 24 months postoperatively. M-CHARTS were used to quantify the degree of metamorphopsia. RESULTS: The mean BCVA, degree of metamorphopsia, and all of the OCT parameters except the photoreceptor outer segment (PROS) length improved significantly from that at the baseline at 24 months (P < 0.001). However, they were not significantly different from those at 12 months. The better BCVA at 24 months was correlated with the longer PROS length at the baseline (P < 0.01). The degree of metamorphopsia at 24 months was significantly correlated with that at baseline (P < 0.01). CONCLUSIONS: A postoperative follow-up period of 12 months may be sufficient to assess the improvements induced by the ERM surgery. The preoperative PROS length was the prognostic factor for the postoperative BCVA. The preoperative degree of metamorphopsia was the prognostic factor for the postoperative degree of metamorphopsia, suggesting that surgery for ERM should be performed before development of severe metamorphopsia.

DETECTION OF CHOROIDAL FOLDS IN PATIENTS WITH VOGT-KOYANAGI-HARADA DISEASE BY RETROMODE SCANNING LASER OPHTHALMOSCOPY.

PURPOSE: To determine whether the choroidal folds in patients with Vogt-Koyanagi-Harada disease can be detected by retromode of a scanning laser ophthalmoscopy (SLO) with infrared laser light source. METHODS: The authors examined two patients with Vogt-Koyanagi-Harada disease at the acute stage by retromode imaging scanning laser ophthalmoscopy with an infrared laser before and after steroid treatment. RESULTS: The retromode imaging by scanning laser ophthalmoscopy clearly and noninvasively delineated the choroidal folds in both cases. The folds disappeared after steroid treatment and reappeared with recurrences of uveitis. CONCLUSION: The retromode imaging by scanning laser ophthalmoscopy can detect the choroidal folds and should be useful for detecting and monitoring the choroidal folds in Vogt-Koyanagi-Harada disease.

Changes in metamorphopsia in daily life after successful epiretinal membrane surgery and correlation with M-CHARTS score.

PURPOSE: To determine the correlation between the changes in metamorphopsia in daily life environment and the M-CHARTS scores after epiretinal membrane (ERM) removal, and to determine the criterion for determining whether clinically significant changes in the metamorphopsia score have occurred in M-CHARTS. METHODS: We studied 65 eyes undergoing vitrectomy for unilateral ERM. Self-administered questionnaires were used to examine the metamorphopsia in their daily life. The degree of metamorphopsia was determined by M-CHARTS. The receiver operating characteristic curve was used to determine the best predictor of the changes in metamorphopsia in daily life. To determine the reproducibility of the M-CHARTS score, another set of 56 eyes with ERM was tested twice on two different days. RESULTS: The postoperative changes in the logarithm of the M-CHARTS score was defined as M2-value. The area under the receiver operating characteristic curve for the M2-value as a predictor of the changes in metamorphopsia in daily life was larger than area under the receiver operating characteristic curve obtained for any other parameter. The optimal cutoff value was -0.4. The 95% limits of agreement between test and retest measurements had a reproducibility of ±0.3 logarithm of the M-CHARTS score. Taking into account not only the reproducibility but also the consistency with the subjective changes, we determined the criterion for clinically significant changes in the M-CHARTS scores as a change of the M2-value by ≥0.4. CONCLUSION: Evaluating the changes in the M-CHARTS scores in logarithmic form is favorable not only theoretically but also from the perspective of consistency with the subjective changes.

[Detection for retinal pigment epithelial lesions in fellow eye of age-related macular degeneration by retro-mode].

PURPOSE: Using the Retro-mode (RM), to detect drusen and other minute lesions of the retinal pigment epithelium (RPE) invisible in current imaging methods in the fellow eye of Japanese patients with exudative age-related macular degeneration(AMD). DESIGN: A retrospective cross-sectional study. PATIENTS AND METHODS: The fellow eyes of nineteen Japanese patients with unilateral exudative AMD were examined using RM imaging (F-10 fundus camera, Nidek), in contrast with fluorescein angiography, indocyanine green angiography, and optic coherence tomography (3D OCT-1000, Topcon Co). We were able to identify the type of drusen and minute granular lesions (MGLs) in the RPE. RESULTS: In all patients, RM imaging gave easier to identify images of all types of drusen than other current imaging methods. Moreover, MGLs of the RPE either adjacent to drusen or without drusen, invisible in other current methods, were detected by RM imaging. CONCLUSIONS: The RM provides clearer imaging of all kind of drusen, and MGLs of the RPE invisible with current methods. These MGLs are possible precursors of drusen.

Time course of changes in metamorphopsia, visual acuity, and OCT parameters after successful epiretinal membrane surgery.

PURPOSE: To follow the changes in the metamorphopsia, visual acuity, and OCT parameters after epiretinal membrane (ERM) removal. METHODS: The study included 49 eyes of 49 patients with an ERM who underwent vitrectomy and membrane peeling. The changes in the best-corrected visual acuity (BCVA), metamorphopsia, and central foveal thickness (CFT) were evaluated at baseline and 1, 3, 6, 9, and 12 months postoperatively. M-CHARTS were used to quantify metamorphopsia. RESULTS: The mean BCVA, metamorphopsia scores for horizontal lines (MH) and vertical lines (MV), and CFT improved significantly at 12 months after surgery (P < 0.001). The baseline BCVA, MH score, and MV score were significantly correlated with the corresponding BCVA, MH score, and MV score at 12 months after surgery (P < 0.01). The MH and MV scores at 12 months was significantly correlated with the BCVA at 12 months (P < 0.01), and the baseline MV score was significantly correlated with the BCVA at 12 months (P < 0.05). The MH score but not the MV score was significantly correlated with the CFT at baseline and 12 months (P < 0.05). CONCLUSIONS: The preoperative BCVA, MH score, and MV score were prognostic factors for the corresponding postoperative BCVA, MH score, and MV score. These results suggest that surgery for ERM should be considered before severe reduction in the BCVA or the degree of metamorphopsia. In addition, the preoperative MV score was a prognostic factor for postoperative BCVA. The MH score but not the MV score was correlated with the CFT preoperatively and postoperatively.