SPONTANEOUS CLOSURE OF MACULAR HOLE AFTER DRAINAGE OF SUBFOVEAL PERFLUOROCARBON LIQUID.

PURPOSE: To report a rare case of macular hole formation after drainage of subretinal perfluorocarbon liquid (PFCL), which closed spontaneously. METHODS: Retrospective case report. A 60-year-old was noted to have subfoveal PFCL after a macula-involving retinal detachment repair with silicone oil tamponade. Spectral domain optical coherence tomography (Spectralis; Heidelberg Engineering, Heidelberg, Germany) was used for postoperative imaging. RESULTS: Two months postdetachment repair, the patient underwent removal of silicone oil and drainage of subfoveal PFCL using a 41-gauge cannula through a extrafoveal retinotomy. A full-thickness macular hole was noted 2 weeks postoperatively. This closed spontaneously 4 months later, with an improvement in vision, although there was evidence of subfoveal atrophy. CONCLUSION: Macular hole formation can occur after drainage of subfoveal PFCL, with a favorable prognosis if managed conservatively. The resultant foveal atrophy highlights the importance of early identification and removal of subretinal PFCL.

Ophthalmology trainees' self-assessment of cataract surgery.

AIMS: To investigate whether ophthalmology trainees are able to assess their own competence in cataract surgery and whether this judgement improves as they progress through training. METHODS: A prospective, blinded, single-centre comparative study of ophthalmology trainee surgeons was performed. 16 junior trainees (150-499 cataract operations) and 16 senior trainees (>500 cataract operations) were recruited. They performed a single videotaped cataract operation and filled in the validated Objective Structured Assessment of Cataract Surgical Skill (OSACSS) assessment form. The videotapes were anonymised, randomised and then graded by a single expert reviewer using the OSACSS assessment. Trainees' OSACSS scores were compared with Mann-Whitney tests and inter-rater agreement between the assessor and the trainees was compared using Cohen's κ coefficient. RESULTS: Senior trainees performed statistically better than junior trainees at all task-specific and global OSACSS indices, apart from draping (p=0.23) and overall score (p=0.09). Overall, trainees were better at assessing their OSACSS performance in global indices such as tissue handling, iris protection and overall speed. They were worse at assessing their performance in task-specific indices, particularly use of the phacoemulsification probe and second instrument. Comparing the two trainee groups, senior trainees had a higher level of agreement with the assessor in more OSACSS indices (15/19) than junior trainees (4/19). CONCLUSIONS: Trainees were more proficient at assessing their own competence at the global indices of cataract surgery, rather than task-specific components. Compared with junior trainees, senior trainees performed better surgically and were more proficient at assessing their own competence in cataract surgery. TRIAL REGISTRATION NUMBER: SALH1001.

RESCUE PNEUMATIC RETINOPEXY IN PATIENTS WITH FAILED PRIMARY RETINAL DETACHMENT SURGERY.

PURPOSE: To describe the outcome of a series of patients who underwent pneumatic retinopexy (PR) for recurrent retinal detachment after scleral buckling and vitrectomy. METHODS: This is a retrospective review of 42 consecutive cases who underwent secondary PR after either scleral buckling (n = 22) or vitrectomy (n = 20) between 1995 and 2011. Fisher's exact and nonparametric tests were used for comparison. RESULTS: Hundred percent of patients in the scleral buckle group and 90% of the vitrectomy group were repaired with 1 PR procedure (P = 0.67). The two patients in the vitrectomy group failed because of presumed new breaks and proliferative vitreoretinopathy. The median time between the primary procedure and PR was 8.5 days for the scleral buckle group (interquartile range, 5-55 days) and 31.5 days for the vitrectomy group (interquartile range, 21-52 days) (P = 0.003). Postoperative median visual acuity improved by more than 2 logMAR lines in both the scleral buckle group (P = 0.0008) and the vitrectomy group (P = 0.007), with no difference between groups (P = 0.19). The overall complication rate in our patients was 16%, including transient intraocular pressure rise and development of tears requiring further indirect laser retinopexy within 3 months. None of the patients had vitreous hemorrhage, subretinal gas, or endophthalmitis. CONCLUSION: Rescue PR seems to be a safe and effective method of treating recurrent retinal detachment after both unsuccessful scleral buckling and vitrectomy.

Spectral domain optical coherence tomography findings in long-term silicone oil-related visual loss.

PURPOSE: To investigate spectral domain optical coherence tomography findings in long-term silicone oil-related visual loss. METHODS: Four symptomatic patients were reviewed 4 years to 9 years after vitrectomy with silicone oil tamponade for macula-on retinal detachment. Three lost vision with oil in situ, with one at the time of oil removal. Eleven control eyes with good vision were included. Patients underwent assessment of best-corrected visual acuity, contrast sensitivity, Farnsworth-Munsell 100 Hue testing, static perimetry, and spectral domain optical coherence tomography imaging of the macula and disk. RESULTS: Long-term best-corrected visual acuity was significantly reduced in affected eyes (range, 0.44-1.02), as was contrast sensitivity (0.75-1.35) and color discrimination (Farnsworth-Munsell-100 Hue score, 151-390). Static perimetry showed a central scotoma in all affected eyes. Optical coherence tomography revealed microcystic macular changes in the inner nuclear layer of all affected eyes associated with severe loss of the papillofoveal retinal nerve fiber layer. In one patient, serial optical coherence tomography images showed development of microcystic macular changes 18 months after oil removal. Control eyes lacked these features, except two asymptomatic eyes that showed microcystic changes on optical coherence tomography with a corresponding paracentral scotoma. CONCLUSION: We have demonstrated microcystic macular changes in the inner nuclear layer of affected eyes, as well as focal severe loss of the papillofoveal projection. These changes share significant morphologic features reported in multiple sclerosis-associated optic neuritis and Leber hereditary optic neuropathy.

Neurotrophic corneal ulceration after retinal detachment surgery with retinectomy and endolaser: a case series.

IMPORTANCE: Trigeminal nerve lesions at differing levels can result in complete or partial corneal anesthesia and ensuing epithelial breakdown. Disease progression can lead to corneal ulceration, melt, and perforation. To our knowledge, neurotrophic corneal ulceration has not previously been reported after retinal detachment surgery and argon endolaser. OBSERVATION: Herein, we report a series of 5 cases of patients without diabetes who developed neuropathic corneal ulceration presumed secondary to long ciliary nerve compromise. This occurred within 5 to 10 weeks following vitrectomy surgery with endolaser and silicone oil tamponade for retinal detachment. CONCLUSIONS AND RELEVANCE: Clinicians should be mindful of the long ciliary nerves intraoperatively and, where possible, avoid heavy confluent treatment at these sites without compromising the need for adequate retinopexy. Where corneal anesthesia occurs, it is important to recognize this early and treat promptly to minimize the risk for ulceration and visual loss.

Using spectral-domain optical coherence tomography imaging to identify the presence of retinal silicone oil emulsification after silicone oil tamponade.

PURPOSE: To describe small hyperreflective areas using spectral-domain optical coherence tomography (SD-OCT) imaging in eyes that have had silicone oil tamponade. METHODS: Retrospective case series of 11 eyes of 11 patients. The authors retrospectively identified patients who underwent vitrectomy and silicone oil tamponade secondary to a rhegmatogenous retinal detachment (nine patients), panuveitis with retinal necrosis (one patient), or recurrent full-thickness macular hole surgery (one patient) who had manifestations of silicone oil emulsion on SD-OCT imaging. Patients were monitored during the postoperative period by clinical examination and using SD-OCT. A model eye in which emulsified silicone oil had been injected in the anterior chamber was used to obtain anterior segment SD-OCT images for comparison. RESULTS: The mean age of our patients was 50 years (range, 39-76 years). In eight eyes, the SD-OCT examination was carried out after silicone oil removal, and in three eyes, the SD-OCT examination was carried out with the oil in situ. Of the nine eyes treated for rhegmatogenous retinal detachment, five had a relieving retinectomy for advanced anterior proliferative vitreoretinopathy or for traumatic retinal incarceration (one eye). The eye treated for full-thickness macular hole had a vitrectomy, internal limiting membrane peel, and silicone oil injection for recurrent macular hole. Ten eyes showed hyperreflective, spherical, tiny droplets using SD-OCT imaging. These were thought to represent silicone oil droplets intraretinally or underneath epiretinal membranes, and one eye showed hyperreflective areas subretinally (retina detached). One additional patient was found to have tiny intravitreal silicone oil droplets after silicone oil removal. Similarly, the silicone oil appeared as multiple hyperreflective spherical droplets as detected by SD-OCT. Anterior segment studies of silicone oil emulsification in the experimental model revealed a similar appearance to that seen with in vivo SD-OCT imaging. CONCLUSION: The authors have found small hyperreflective areas intraretinally, subretinally, and underneath epiretinal membranes on SD-OCT in eyes that have had silicone oil tamponade for a variety of indications. The authors have seen a similar appearance when silicone oil emulsification is examined in vivo. The authors conclude that the hyperreflective areas are likely (but not certain) to be very small bubbles of emulsified silicone. Further studies are required to determine the incidence, clinicopathologic, and functional significance of probable silicone oil emulsification and deposition within the retinal layers.

The international forum of ophthalmic simulation: developing a virtual reality training curriculum for ophthalmology.

BACKGROUND: To investigate the effect of a structured, supervised, cataract simulation programme on ophthalmic surgeons in their first year of training, and to evaluate the level of skill transfer. METHODS: Trainees with minimal intraocular and simulator experience in their first year of ophthalmology undertook a structured, sequential, customised, virtual reality (VR) cataract training programme developed through the International Forum of Ophthalmic Simulation. A set of one-handed, bimanual, static and dynamic tasks were evaluated before and after the course and scores obtained. Statistical significance was evaluated with the Wilcoxon sign-rank test. RESULTS: The median precourse score of 101.50/400 (IQR 58.75-145.75) was significantly improved after completing the training programme ((postcourse score: 302/400, range: 266.25-343), p<0.001). While improvement was evident and found to be statistically significant in all parameters, greatest improvements were found for capsulorhexis and antitremor training ((Capsulorhexis: precourse score=0/100, range 0-4.5; postcourse score=81/100, range 13-87.75; p=0.002), (antitremor training: precourse score=0/100, range 0-0; postcourse score=80/100, range 60.25-91.50; p=0.001)). CONCLUSIONS: Structured and supervised VR training can offer a significant level of skills transfer to novice ophthalmic surgeons. VR training at the earliest stage of ophthalmic surgical training may, therefore, be of benefit.

Patient safety in vitreoretinal surgery: quality improvements following a patient safety reporting system.

AIMS: Vitreoretinal (VR) surgery is complex. Most clinical conditions that VR surgeons manage have a high risk for blindness or severe visual impairment. Reporting of patient safety incidents (PSI) in VR surgery was introduced at the Moorfields Eye Hospital (MEH) in the 1990s. We examine the role of PSI reporting in making VR surgery safer at our institution. METHODS: Qualitative review of PSIs from 1997 to 2009 at MEH, London, UK. RESULTS: Over the 13-year study period, 38 789 VR procedures were undertaken and 579 VR PSIs occurring in theatre or inpatient were reported. Mean rate of PSI reporting was 1.49% (range 0.12-3.35). In comparison, the mean rate of PSI reporting over the same period across all National Health Service ophthalmology in England was 0.59% (range 0.36-0.49). Overall, 0.9% of VR PSI resulted in 'Severe' harm, 11.6% in 'Moderate' harm and 87.5% in 'No' or 'Low' harm. 15 (2.6%) of PSIs directly resulted in a change in clinical practice, 13 of which occurred in the first half of the study period. 12 (3.6%) critical incidents were violations of pre-existing protocols and guidelines, eight of which occurred in the second half of the study period. 61 (10.9%) of PSIs fell into nine main error subtypes that contributed to a change in practice. The most common were ocular hypotony (2.9%), medical device failure (2.8%) and delay in VR surgery (1.2%). CONCLUSIONS: VR PSI reporting resulted in a change in clinical practice. Longitudinal analysis suggests an accompanying increase in patient safety.

Cataract progression in macular hole cases: results with vitrectomy or with observation.

PURPOSE: To quantify the difference in progression of nuclear sclerotic cataract using Scheimpflug image analysis in patients with idiopathic full-thickness macular hole who were randomized to have vitrectomy and gas tamponade or to be observed. SETTING: Moorfields Eye Hospital, London, United Kingdom. DESIGN: Prospective randomized placebo-controlled masked clinical trial. METHODS: As part of the Moorfields Macular Hole Study, patients with full-thickness macular hole who were randomized to have vitrectomy and gas tamponade or who were observed were compared. Patients had Scheimpflug image analysis of the crystalline lens to evaluate nuclear sclerosis progression by the single-masked observer at baseline and 3, 6, 9, and 12 months postoperatively. RESULTS: Ninety-eight patients had sufficient baseline data for analysis. At 3 months and 6 months, vitrectomy patients had significant increases in nuclear density compared with baseline (16.6% and 33.9%, respectively) (both P<.0001). In the observation group, nuclear density increased by 1.4% between baseline and 6 months (P = .92). At 6 months, the increase in nuclear density from baseline was 24 times greater in the surgical group than in the observation group (P<.0001). No correlation between the rate of nuclear sclerosis progression and age or baseline nuclear density was found. CONCLUSIONS: Rapid nuclear sclerosis progression was quantifiable by Scheimpflug image analysis in patients having surgery for idiopathic full-thickness macular hole.There was no [corrected] evidence of a correlation between age groups and the rate of cataract progression. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Outcomes of pseudophakic retinal detachment.

PURPOSE: To provide data on the outcome of pseudophakic retinal detachment (PRD). METHODS: In a retrospective case-control study, we identified a consecutive series of 63 298 cataract extractions (45 520 patients) performed in a single institution between 1994 and 2003. We included 249 cases with PRD and 845 controls that had cataract surgery on the same day as cases but without PRD. Outcome measures were the risk of impaired vision (6/18-6/60) or blindness (<6/60). A multinomial logistic regression model evaluated risk factors for impaired vision or blindness, while multivariable regression models measured the relative risk of poor visual outcome for posterior capsule tear (PCT) and PRD. RESULTS: Primary pars plana vitrectomy was performed on 207 (84.5%) of the 245 cases treated with surgery, of which 175 (71.4%) needed one procedure. The final acuity was <6/60 in 62 cases (24.9%) and 34 controls (4.0%). After PRD, the relative risk for a final visual outcome <6/60 was 6.8 [95% confidence interval (CI) 4.3-10.6; p < 0.001], and we estimated that the proportion of blindness attributable to PRD was 1.1% (CI 0.7-1.9%). A PCT prior to a PRD was not associated with an increased risk of macular detachment (p = 0.165), but it did carry an increased risk of blindness [odds ratio 4.8 (CI 2.2-10.2; p < 0.001]. CONCLUSION: Although a PCT has an adverse effect on visual outcome after cataract surgery, a PRD is the foremost surgery-related risk for a poor visual outcome. Patient education of symptoms and prompt treatment may limit the visual consequences.

Transscleral albumin diffusion and suprachoroidal albumin concentration in uveal effusion syndrome.

PURPOSE: To test the hypothesis that uveal effusion syndrome is caused by reduced transscleral albumin permeability. METHODS: Surgical scleral specimens were obtained from a 55-year-old patient with nanophthalmic uveal effusion syndrome. Specimens were clamped in a modified Ussing chamber, and the rate of transscleral diffusion of fluorescein isothiocyanate-albumin was measured over 12 hours, using a spectrophotometer and predetermined standard curves. The diffusion coefficient was determined at 20°C, and then adjusted to body temperature using Einstein's equation. Results in 3 scleral samples were compared with 10 age-matched controls. Albumin and total protein concentration were measured in choroidal fluid and serum. RESULTS: Histologic staining with Alcian blue showed interfibrillary acid mucin deposits. Transmission electron microscopy showed deposits measuring 1 µm to 10 µm and collections of expanded, degenerate collagen fibrils. The mean (±SD) albumin diffusion coefficient was 12% of that in controls (1.22 ± 0.67(-8) × 10 vs. 10.3 ± 7.0 × 10(-8) cm2/second) and below the lower 95% confidence limit of the control group. The diffusion coefficient was calculated to increase 53% to 1.87 ± 1.03 × 10(-8) cm2/second at 37°C. Choroidal albumin concentration was much higher than physiologic levels, measuring 200 g/L (total protein 321 g/L), 5 times the serum albumin concentration of 42 g/L (total protein 70 g/L). CONCLUSION: Nanophthalmic uveal effusion syndrome can be associated with reduced scleral permeability to albumin, and a very high concentration of retained suprachoroidal albumin. This will lead to an osmotic gradient that retains fluid and may partly explain the pathogenesis of uveal effusion syndrome in some patients.

Risk of iatrogenic peripheral retinal breaks in 20-G pars plana vitrectomy.

PURPOSE: To estimate the frequency and risk factors for entry site and other peripheral iatrogenic retinal breaks in eyes undergoing standard 20-G 3-port pars plana vitrectomy. DESIGN: Single-center, retrospective, interventional case series. PARTICIPANTS: A total of 645 eyes undergoing pars plana vitrectomy at Moorfields Eye Hospital during the period June 1, 2005, to June 1, 2006, for indications excluding rhegmatogenous retinal detachment. METHODS: Case note review. Exclusion criteria were preexisting retinal breaks or rhegmatogenous retinal detachment, previously vitrectomized eyes, and iatrogenic breaks posterior to the equator. MAIN OUTCOME MEASURES: Frequency, anatomic location, and risk factors associated with iatrogenic peripheral retinal breaks and rate of postoperative rhegmatogenous retinal detachment. RESULTS: Iatrogenic peripheral retinal breaks occurred in 98 of 645 eyes (15.2%) intraoperatively. Eleven of 645 cases (1.7%) experienced postoperative rhegmatogenous retinal detachment caused by undetected or new peripheral retinal breaks. Breaks were most common during surgery for tractional retinal detachment (22.2%), macular hole (18.1%), dislocated intraocular lens implants (16.7%), and epiretinal membrane (13.9%). Overall, breaks were more common in the superior retina (P<0.01), with 41.5% occurring in the 10 and 2 o'clock positions. Eyes requiring surgical induction of a posterior vitreous detachment had 2.9 times greater odds of developing iatrogenic peripheral retinal breaks (95% confidence interval, 1.8-4.7, P<0.001) than eyes with preexisting posterior vitreous detachment. Similarly, phakic eyes had 2.4 times higher odds (95% confidence interval, 1.42-3.96, P = 0.001) of break formation. CONCLUSIONS: Iatrogenic peripheral retinal breaks caused by vitrectomy are more common than previously indicated. Approximately 4 in 10 breaks are related to traction at sclerotomy entry sites. Eyes undergoing surgery for tractional retinal detachment seemed to have the highest risk for break formation. Similarly, phakic eyes and eyes that require induction of a posterior vitreous detachment have more than double the risk for break formation.

Scleral hydraulic conductivity and macromolecular diffusion in patients with uveal effusion syndrome.

PURPOSE: To determine whether uveal effusion syndrome (UES) is caused by altered scleral permeability to water and large molecules. METHODS: Transscleral water movement was measured using surgically removed sclera clamped in a modified Ussing chamber and connected to a water column set at intraocular pressure. Sclera was also clamped between two hemichambers, and transscleral diffusion of FITC-dextrans (4.4-77 kDa) was measured with a spectrophotometer. Clinical data were prospectively collected using postal questionnaires. RESULTS: Ten patients (mean age, 63 years; mean spherical equivalent, +4.7 D) had a median preoperative visual acuity of 0.20 that improved to 0.33 after surgery. Nine eyes showed visual improvement, three worsened, and two were unchanged. Histology showed disorganization of collagen fibrils, with amorphous deposits expanding the interfibrillary spaces. The mean thickness (+/-1 SD) of the excised scleral specimens was 585 +/- 309 microm, and the mean specific hydraulic conductivity was 23.9 +/- 27.5 x 10(-14) cm(2), compared with 5.8 +/- 3.9 x 10(-14) cm(2) in age-matched control specimens (P = 0.068). Three specimens had hydraulic conductivity above the 95% CI of the controls. Control eyes showed a significant reduction in diffusion coefficient (D) with age. Eyes had a mean D of 5.69 +/- 5.35 x 10(-8) cm(2) x s(-1), similar to control eyes (6.14 +/- 2.40 x 10(-8) cm(2) x s(-1), 20 kDa dextran). In one eye, the result was higher than the 95% CI of the control; in three, it was lower. CONCLUSIONS: UES is not caused by reduced scleral hydraulic conductivity, which tends to be higher than expected. Reduced macromolecular diffusion may impede the normal transscleral egress of albumin with subsequent osmotic fluid retention in some, but not all eyes.

Human scleral hydraulic conductivity: age-related changes, topographical variation, and potential scleral outflow facility.

PURPOSE: To measure the specific hydraulic conductivity (K) of human sclera over a range of ages, to assess topographical variation, and to provide a theoretical estimate of potential scleral outflow facility. METHODS: Human donor sclera (n = 18; mean age 56.7 +/- 25.9 years; range 4-89) was clamped in a modified Ussing chamber connected to a water column set at 15.7 mm Hg. Column descent was measured over 24 hours at 20 degrees C with a digital micrometer. Scleral thickness of glutaraldehyde-fixed specimens was measured by light microscopy, taking the mean of 15 measurements per donor. Topographical variation in hydraulic conductivity (HC) was determined in an additional 10 donor eyes (mean age, 54.1 +/- 26.4 years; range 12-89), comparing anterior, equatorial, and posterior sclera. The potential transscleral outflow facility was calculated by multiplying HC by total scleral surface area and adjusting water viscosity to core body temperature. RESULTS: Mean K +/- 1SD in adults (>18 years) was 5.85 +/- 3.89 x 10(-18) m(2). K tended to be higher in pediatric donors, but there was no statistically significant age-related change. However, when all data sets were combined (n = 28), HC showed a significant decline with age. There was no significant topographical variation in HC. The potential transscleral outflow facility was 0.33 microL.min(-1).mm Hg(-1). CONCLUSIONS: Quantifying HC may help refine ocular pharmacotherapy, as transscleral water movement increases intraocular drug elimination and impedes transscleral drug delivery. The potential scleral outflow is two to three times higher than that which occurs in vivo; hence, medical or surgical interventions that fully exploit this pathway have considerable capacity to lower intraocular pressure.

Periorbital ecchymosis as a sign of perforating injury of the globe.

The distinction between penetrating eye injury with retained intraocular foreign body and perforating globe injuries is not always easy clinically. The case is presented of a 25-year-old man who sustained a perforating eye injury that was through a clear self-sealing corneal entry site and had no conjunctival or periorbital injury. He had periorbital ecchymosis on presentation suggesting that the globe had been perforated with resulting retro-orbital blood tracking to the periorbital region. This sign would not be expected had the foreign body remained intraocular. The management options of these cases are discussed.

Sudden visual loss after removal of silicone oil.

PURPOSE: Removal of silicone oil after vitreoretinal surgery reduces potential complications of glaucoma and cataract and improves visual function in 30% of patients. We report the clinical findings of a series of patients who experienced unexpected and permanent visual loss after removal of silicone oil. METHODS: Seven patients with visual loss after removal of silicon oil were investigated with best-corrected Snellen visual acuity (BCVA) assessment, fundus biomicroscopy, fluorescein angiography, optical coherence tomography, and electrophysiologic examination. RESULTS: Six men and one woman (average age, 42.8 years.) presented with profound BCVA loss, averaging 4.7 Snellen lines (SD 1.4), after silicon oil removal. No other complications associated with oil removal were noted. The retina remained attached in all cases, no patient developed cystoid macular edema or epiretinal membrane, and optical coherence tomographic and fluorescein angiographic findings remained normal. Electrodiagnostic testing showed a range of abnormalities, with the majority of patients showing severe macular dysfunction. CONCLUSIONS: We describe a new phenomenon of unexpected visual loss after oil removal in patients with good visual potential. The pathogenesis remains obscure.

Characteristics and outcomes of choroidal neovascularization occurring after macular hole surgery.

PURPOSE: To study the characteristics and outcomes of choroidal neovascularization (CNV) developing after surgery for idiopathic macular holes. METHODS: Retrospective, noncomparative case series. Search of diagnostic and procedure databases of four participating institutes identified nine eyes of eight patients with CNV after surgery for idiopathic macular hole. Demographic, clinical, and fundus fluorescein angiographic data were abstracted from patients' medical records. RESULTS: Choroidal neovascularization developed 6 weeks to 30 months after macular hole surgery. The macular hole was closed in all cases. The CNV complex involved the foveal region in 9 (100%) eyes, was predominantly classic in 8 (89%) eyes, and was associated with moderate to severe leakage of fluorescein in 8 (89%) eyes. The CNV was crescent-shaped and spared the central area of retinal pigment epithelial mottling that corresponded to the site of the macular hole in 6 (67%) cases. Other fluorescein angiographic features included retinal pigment epitheliopathy in 6 (67%) eyes and presence of drusen in 7 (78%) eyes. The final visual acuity after a mean follow-up period of 11.2 months (range, 3-16 months) was 20/50 to 20/80 in 2 (22%) eyes, 20/100 to 20/200 in 1 (11%) eye, and less than 20/200 in 6 (67%) eyes. CONCLUSION: Choroidal neovascular complexes occurring after macular hole surgery tend to share certain characteristics, including foveal involvement, frequent sparing of the central area corresponding to the site of the closed macular hole, and generally poor visual outcomes. Therapeutic modalities including photodynamic therapy and surgical options may be considered in these patients.