Outcomes of epiretinal proliferation embedding technique in the surgery for full-thickness macular hole.

To compare visual and anatomical outcomes between peeling and embedding of epiretinal proliferation in patients with full-thickness macular holes (FTMH) with epiretinal proliferation (EP), this retrospective cohort study classified patients into two groups based on whether EP was completely peeled (peeling group, n = 25 eyes), or embedded into the hole (embedding group, n = 31 eyes) during surgery. Preoperative characteristics and postoperative outcomes, including best-corrected visual acuity and the length of the disrupted external limiting membrane and ellipsoid zone, were compared. Preoperative features including visual acuity and hole size did not differ between the two groups. All studied eyes achieved closure of the macular hole postoperatively. Visual acuity significantly improved at 3, 6, and 12 months postoperatively in both groups. The visual acuity 1-month after surgery was better in the embedding group than that in the peeling group (0.28 ± 0.29 vs. 0.50 ± 0.42 logarithm of the minimum angle of resolution, P = 0.016), although the difference was not noted after 3 months postoperatively. The embedding group showed shorter disruption of the external limiting membrane than the peeling group postoperatively (62.6 ± 40.2 µm vs. 326.2 ± 463.9 µm at postoperative 12 months, P = 0.045). In conclusion, the embedding technique during surgical repair of a FTMH with EP facilitates recovery of the outer foveal layers and promotes earlier restoration of visual function.

Macular hole surgery follow-up with spectral domain-optical coherence tomography-guided facedown posturing.

PURPOSE: The main treatment for macular hole (MH) is pars plana vitrectomy, with or without internal limiting membrane (ILM) peeling, followed by gas tamponade and face-down positioning (FDP). This study aims to present the anatomical and visual outcomes following MH repair with optical coherence tomography (OCT)-guided FDP. METHODS: Thirty-two patients who underwent surgery for idiopathic MH were enrolled. The requirement for the prone position was lifted for those with MH closure observed under gas on postoperative day one OCT. Patients with unclosed MHs were instructed to maintain FDP until the 3rd day. Best-corrected visual acuity at preoperative, postoperative 1st month, and the last visit, closure time post-surgery, duration of prone position, and surgical success rate were recorded. RESULTS: Among the patients, 21 underwent phacovitrectomy + ILM peeling + gas tamponade, while 11 had vitrectomy + ILM peeling + gas tamponade. On postoperative day one, 28 out of 32 MHs closed, with 3 closures on day 3 and one on day 5. There were 18 stage two (56.3%), 13 stage three (40.6%) and 1 stage four (3.1%) MHs. The mean minimum MH diameter was 381.75 ± 68.07 (min 260-max 517) microns. All patients with MH closure time over postoperative day one had non-combined vitrectomy instead of phacovitrectomy. No late complications were observed. CONCLUSIONS: OCT-guided FDP approach yields excellent closure rates with no late complications and ensures good patient comfort.

Giant retinal pigment epithelial tear following photodynamic therapy for the bullous variant of central serous chorioretinopathy: A case report.

RATIONALE: The bullous variant of central serous chorioretinopathy (CSC) is a severe form of chronic CSC. Patients with the bullous variant of CSC have an increased risk of experiencing multiple pigment epithelial detachments (PEDs) and retinal pigment epithelium (RPE) tears. Photodynamic therapy (PDT) is a treatment for the bullous variant of CSC. RPE tear is a possible postoperative complication of PDT for eyes with PEDs. To our knowledge, no cases of giant RPE tears following PDT for the bullous variant of CSC have been reported previously. This case report presents the first instance of a giant RPE tear after half-time PDT for the bullous variant of CSC, accompanied by a series of images depicting the tear development. PATIENT CONCERNS: A 63-year-old male patient presented with rapidly deteriorating vision in his left eye over a 3-month period. He also reported a previous episode of vision loss in his right eye 2 years prior. Best-corrected visual acuity (BCVA) in the left eye was 0.2. DIAGNOSIS: The right eye was diagnosed with chronic non-bullous CSC, while the left eye was diagnosed with the bullous variant of CSC with a large PED. INTERVENTIONS: Half-time PDT was administered to the left eye. OUTCOMES: One month after half-time PDT, a giant RPE tear exceeding 3 clock-hours in size was confirmed in the lower temporal quadrant of the left eye. Three months after the initial half-time PDT, a second half-time PDT was performed owing to recurrent retinal detachment. Two months after the second half-time PDT, the retinal detachment resolved, and BCVA improved to 0.4, 6 months after the second half-time PDT. LESSONS: In cases where the bullous variant of CSC is complicated by extensive PED, clinicians should consider the potential development of a giant RPE tear as a treatment complication.

Short-term results of surgical treatment in large idiopathic macular hole cases.

PURPOSE: To evaluate results of the surgical treatment for large stage (Stage 3 and 4) idiopathic macular hole cases with and without ILM flap technique. METHODS: Sixty eyes of 60 patients diagnosed with idiopathic macular hole (MH) were included in the study. Complete ophthalmologic examination and SD-OCT examination were performed in all eyes. MH stages, MH base diameter, height and closest distance were measured quantitatively. Postoperative and 3 months visits were evaluated. RESULTS: The mean age of the cases was 65.0 ± 8.0 (range 30-84) years, there were 31 (51.7%) female and 29 (48.3%) male patients with a mean follow-up period of 18.1 ± 16.7 (range 3-63) months. The mean best corrected visual acuity recorded at preoperative and third month control visits were 0.89 ± 0.40(preoperative) logMAR, 0.82 ± 0.60(3 month) logMAR (p < 0.05). The mean MH index was 0.48 ± 0.16, the closest hole distance was 517.86 ± 210.89 µm and mean basal diameter of holes was 947.78 ± 361.90 µm and the average height was 448.93 ± 79.80 microns. There was no statistically significant difference between anatomic results of macular hole surgery with (n = 22) and without (n = 38) flap in terms of hole closure (86.4% vs. 92.1% p > 0.05). In 90% (54 cases) of the cases, closure was observed after the first surgery. Two eyes that failed macular hole surgery were reoperated. In one of these eyes, anatomical success was obtained with macular hole massage and mechanical cytumulation. However, anatomical success could not be achieved in the other eye. CONCLUSiON: In the treatment of large macular holes, pars plana vitrectomy, internal limiting membrane peeling with/without flap and gas tamponade demonstrated high anatomical and functional success.

Management of macula-on giant retinal tear detachments- outcome of pars-plana-vitrectomy with silicone oil versus gas tamponade.

BACKGROUND: To compare the outcome of eyes with a macula-on giant retinal tear (GRT) detachment treated with pars-plana-vitrectomy (PPV) depending on the used endotamponade. METHODS: All consecutive cases with a macula-on GRT-associated rhegmatogenous retinal detachment (RRD) managed with PPV between 2007 and 2022 were retrospectively assessed depending on the selected endotamponade. By reviewing medical charts and surgical protocols the pre- and intraoperative parameters were analysed in detail. The number of vitreoretinal (VR) procedures needed for reattachment, the redetachment rate and the functional outcome were evaluated. Eyes treated with primary silicone oil (SO) tamponade were compared to eyes with primary gas tamponade. Cases with pre-existing conditions affecting outcome e.g. macula-off situation, history of trauma, status after complicated cataract surgery, former VR surgery or proliferative vitreoretinopathy grade C or higher were excluded. RESULTS: Overall, 51 eyes of 45 patients with a macula-on GRT detachment were treated with PPV and SO (n = 32; 63%) or gas (n = 19; 37%) endotamponade in the observed period. Eyes with primary SO tamponade underwent on average 2.3 (SD 0.8) VR procedures and had a redetachment rate of 13% (n = 4). Eyes with gas tamponade showed a higher redetachment rate of 32% (n = 6) with a mean number of 1.6 (SD 1.0) PPV procedures. Postoperative best-corrected visual acuity (BCVA) was significantly better in eyes with primary gas tamponade (mean logMAR BCVA 0.32; SD 0.30) compared to eyes with SO (mean logMAR BCVA 0.60; SD 0.42; p = 0.008). CONCLUSIONS: Surgical management of GRT-associated RRDs is complex. In clinical routine often SO is used as endotamponade. Because of known disadvantages (second procedure necessary for SO removal, unexplained SO-related visual loss, secondary glaucoma, SO emulsification) some VR surgeons prefer a gas tamponade. In our cohort, eyes with a gas compared to SO tamponade showed higher redetachment rates. However, the final postoperative BCVA was significantly better in eyes with gas compared to SO tamponade. TRIAL REGISTRATION: The trial protocol was approved by the local ethics committee on 25th of November 2022 (Ethikkommission der Universität Regensburg, Votum 22-3166-104).

Surgical management of a case of giant retinal tear with closed funnel retinal detachment in a pediatric patient.

BACKGROUND: A 7-year-old male child was brought by his parents with a complaint of low vision in both eyes for 2 months. The child had low vision in both the eyes for 1.5 years, but the parents noticed when it worsened further 2 months back, leading to profound vision loss. On ophthalmic evaluation, the child did not perceive light in the right eye. Furthermore, anterior segment examination showed complicated cataract and open funnel retinal detachment with intra-retinal cysts in ultrasound (USG) B scan. In the left eye, he could appreciate light but with poor fixation. Fundus evaluation of the left eye showed total retinal detachment on indirect ophthalmoscopy, which was confirmed on USG B scan. Since the right eye had poor visual potential, no intervention was done. The left eye underwent pars plana vitrectomy with silicone oil tamponade, which led to successful anatomical outcomes. The immediate and late postoperative periods were uneventful, and the child was kept under follow-up and was observed closely. PURPOSE: To educate regarding the surgical management of giant retinal tears in a pediatric patient. SYNOPSIS: To inform regarding the surgical challenges faced and steps adopted to manage such cases. HIGHLIGHTS: Through this case, we want to highlight the challenges faced, such as delayed presentation, difficult preoperative evaluation, intraoperative difficulties such as mobile retina, absence of posterior vitreous detachment, and tenacious vitreous gel. We also want to emphasize on the steps taken to overcome the challenges. CONCLUSION: In such challenging situations, effective planning, careful manipulation, and persistence are essential for success. VIDEO LINK: https://youtu.be/T0Gy6Wj13zI.

Presence of subfoveal hyperreflective dots as an anatomic and functional prognostic biomarker in macular holes.

OBJECTIVE: To evaluate the presence of subfoveal hyperreflective dots (SfHD) using optical coherence tomography (OCT) in macular holes (MH) and establish whether there is a relationship with postoperative anatomical and functional outcomes. METHODS: An observational cross-sectional study was conducted at the Dr. Elías Santana Hospital. Sixty-eight eyes of 67 patients with a tomographic diagnosis of full-thickness MH who underwent pars plana vitrectomy (PPV) and internal limiting membrane (ILM) peeling were included. Preoperative and postoperative measurements were obtained using radial macular scans and HD raster scans with Optovue and Cirrus 5000 (Zeiss) OCT machines. The main outcome measures were anatomical closure by OCT and functional outcome through best-corrected visual acuity (BCVA). RESULTS: The anatomical closure rate in our study was 63%. MHs that failed to achieve anatomical closure exhibited a higher number of hyperreflective dots and worse postoperative BCVA. A statistically significant association was found between exposed retinal pigment epithelium (RPE) in microns and the number of SfHD (P = .001). CONCLUSION: SfHD is a common tomographic finding in MH, and the presence of a higher number of these points is associated with poorer anatomical and functional outcomes. This imaging finding is a potential prognostic biomarker in this pathology.

Efficacy of inverted inner limiting membrane flap technique for macular holes of ≤400 µm: A systematic review and meta-analysis.

PURPOSE: To evaluate the efficacy of inverted internal limiting membrane (ILM) flap technique in full-thickness macular holes (MHs) with a size of ≤400 µm compared to the ILM peeling technique. METHODS: Related literatures that compared inverted ILM flap and ILM peeling in MHs ≤ 400 µm were reviewed by searching electronic databases including Pubmed, EMbase, ClinicalTrials.gov, and Cochrane Library up to April 2023. The primary outcome measure was hole closure rate, and the secondary outcome measures were the mean postoperative best-corrected visual acuity (BCVA), retinal sensitivity, and outer status of the retinal layers, including the external limiting membrane and ellipsoid zone. The quality of the articles was assessed according to the revised version of the Cochrane risk-of-bias tool for randomized trials or the Newcastle-Ottawa scale. In the case of heterogeneity, a sensitivity analysis was conducted, and publication bias was visually evaluated using a funnel plot. RESULTS: This review included six studies with 610 eyes for the primary outcome and 385 eyes for the secondary outcomes, which were two randomized control trials and four retrospective studies. Pooled data revealed that the overall MH closure rate was 99.4% in the inverted ILM flap group and 96.2% in the ILM peeling group, without significant difference between the two groups (odds ratio = 3.91; 95% confidence interval, 0.82~18.69; P = 0.09). The inverted ILM flap technique did not have a favorable effect on the BCVA, retinal sensitivity, or recovery of the outer retinal layers. These results were consistent with those of the subgroup analysis of the different follow-up periods. No significant publication bias was observed. CONCLUSION: In eyes with MHs of ≤400 µm, both techniques demonstrated excellent surgical outcomes without significant differences. Therefore, surgical techniques can be selected according to surgeon preferences.

Relationship between lymphocytes and idiopathic macular hole.

BACKGROUND: An idiopathic macular hole (IMH) is a full-thickness anatomic defect extending from the internal limiting membrane to the photoreceptor layer of the macula without any known cause. Recently, clinical laboratory markers of systemic inflammatory status derived from complete blood counts have been evaluated in ocular diseases. This study aimed to explore whether they could predict the development and progression of IMHs. METHODS: A retrospective review of 36 patients with IMH and 36 sex-and-age-matched patients with cataracts was conducted. We collected complete blood counts of all participating individuals and calculated systemic immunoinflammatory indicators. The maximum base diameter of the IMH (BD), minimum diameter of the IMH (MIN), height of the IMH (H), area of the intraretinal cyst (IRC), and curve lengths of the detached photoreceptor arms were measured on optical coherence tomography (OCT) images. We used these values to calculate the macular hole index (MHI), tractional hole index (THI), diameter hole index (DHI), hole form factor (HFF), and macular hole closure index (MHCI). We performed a receiver operating characteristic (ROC) curve analysis of 30 patients with IMH who were followed up 1 month after surgery. RESULTS: Lymphocyte counts were significantly higher in the IMH group. No other significant differences were observed between the IMH and control groups. Lymphocyte counts in the IMH group were significantly negatively correlated with MIN and BD and were significantly positively correlated with MHI, THI, and MHCI. However, lymphocyte counts were not significantly correlated with H, IRC, DHI, and HFF. In the ROC analysis, BD, MIN, MHI, THI, and MHCI were significant predictors of anatomical outcomes. According to the cut-off points of the ROC analysis, lymphocyte counts were compared between the above-cut-off and below-cut-off groups. Lymphocyte counts were significantly higher in the MIN ≤ 499.61 µm, MHI ≥ 0.47, THI ≥ 1.2, and MHCI ≥ 0.81 groups. There were no significant differences between the above-cut-off and below-cut-off BD groups. CONCLUSIONS: Although inflammation may not be an initiating factor, it may be involved in IMH formation. Lymphocytes may play a relatively important role in tissue repair during the developmental and postoperative recovery phases of IMH.

Accuracy of generative deep learning model for macular anatomy prediction from optical coherence tomography images in macular hole surgery.

This study aims to propose a generative deep learning model (GDLM) based on a variational autoencoder that predicts macular optical coherence tomography (OCT) images following full-thickness macular hole (FTMH) surgery and evaluate its clinical accuracy. Preoperative and 6-month postoperative swept-source OCT data were collected from 150 patients with successfully closed FTMH using 6 × 6 mm2 macular volume scan datasets. Randomly selected and augmented 120,000 training and 5000 validation pairs of OCT images were used to train the GDLM. We assessed the accuracy and F1 score of concordance for neurosensory retinal areas, performed Bland-Altman analysis of foveolar height (FH) and mean foveal thickness (MFT), and predicted postoperative external limiting membrane (ELM) and ellipsoid zone (EZ) restoration accuracy between artificial intelligence (AI)-OCT and ground truth (GT)-OCT images. Accuracy and F1 scores were 94.7% and 0.891, respectively. Average FH (228.2 vs. 233.4 µm, P = 0.587) and MFT (271.4 vs. 273.3 µm, P = 0.819) were similar between AI- and GT-OCT images, within 30.0% differences of 95% limits of agreement. ELM and EZ recovery prediction accuracy was 88.0% and 92.0%, respectively. The proposed GDLM accurately predicted macular OCT images following FTMH surgery, aiding patient and surgeon understanding of postoperative macular features.

Posterior vitreous detachment rates post-uncomplicated phacoemulsification surgery: a systematic review.

PURPOSE: It is commonly accepted that phacoemulsification surgery is a risk factor for the development of posterior vitreous detachment (PVD) and may accelerate the process. This is an important consideration particularly in cases involving young patients who pre-operatively have no PVD, given the increased risk of retinal tears and detachments. METHODS: A comprehensive literature search was conducted to identify studies reporting incidence of PVD post-uncomplicated phacoemulsification surgery. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used for search strategy. Of 3071 titles, 7 studies met the inclusion criteria; The outcomes measured were PVD occurrence by (1) time, (2) type, (3) age, (4) gender and (5) axial length, with all statistical analysis performed using Review Manager. RESULTS: A total of 2034 eyes were included for analysis with a mean follow-up time of 28.3 months. 33.3% of patients developed a PVD, either partial or complete, with rates increasing in a time dependent manner. No significant difference was noted in sub-group analysis by age, gender or axial length. CONCLUSIONS: The results from our systematic review show that uncomplicated phacoemulsification accelerates the physiological process of PVD development. Pre-operative evaluation of the vitreoretinal interface should be performed with careful post-operative follow-up advised in those without a pre-existing PVD.

Ophthalmologists' assessment of the handling characteristics of the novel Finesse Reflex Handle in comparison to those of a conventional handle.

Internal limiting membrane (ILM) peeling requires a delicate handling technique. It is also important that ophthalmologists can use the ILM forceps handle of their preference. This study objectively and subjectively evaluated the handling of the novel Finesse Reflex Handle (Reflex) in comparison with that of a conventional handle. The force required to close the forceps tips, evaluated using a digital force gauge, was significantly lesser for Reflex than for the conventional handle (3.14 ± 0.09 N vs. 3.84 ± 0.06 N, P < 0.001). Twenty-one ophthalmologists with various levels of experience answered a questionnaire after using both handles, and the total questionnaire score for Reflex was higher than that for the conventional handle (35.0 ± 3.7 vs. 30.0 ± 6.9, P = 0.01). Furthermore, the duration of experience as an ophthalmologist was negatively correlated with the vertical motion, assessed by video analysis, for the conventional handle (P = 0.02, r = - 0.50) but not for Reflex (P = 0.26). In conclusion, objective and subjective analyses revealed that compared with the conventional handle, the novel Reflex handle had more favourable handling characteristics. Most ophthalmologists preferred the handling of Reflex. Reflex may compensate for a lack of surgical experience.

Delayed macular hole secondary to Terson syndrome: a case report and literature review.

Terson syndrome refers to intraocular haemorrhage that occurs due to subarachnoid bleeding associated with an acute increase in intracranial pressure. No previous study has reported a delayed macular hole (MH) secondary to Terson syndrome. A 17-year-old boy visited our department and presented with vitreous bleeding and a history of subarachnoid haemorrhage. Sub-internal limiting membrane (ILM) haemorrhage with ILM detachment and intraretinal haemorrhage were detected during pars plana vitrectomy. Additionally, a delayed MH was detected 1 week after the surgery. There was no sign of MH closure during a 2-month follow-up. Subsequently, an MH massage was performed to close the MH. Our findings suggest that a delayed MH can occur secondary to Terson syndrome. Elevated hydrodynamic pressure and hydrostatic pressure, which are caused by sub-ILM and intraretinal haemorrhages of the fovea, contribute to the formation of an MH. Additionally, ILM peeling may cause damage to the macula and facilitate the formation of MHs. Although the MH may close by itself, early surgical intervention is recommended when there is no sign that the MH will close spontaneously because a prolonged MH can lead to retinal damage.

[Reflections on the inner limiting membrane peeling and its derivatives in macular hole surgery].

Internal limiting membrane (ILM) peeling is a critical step in the process of macular hole surgery, giving rise to various modified techniques such as ILM flip-over coverage, ILM and other tissue tamponade procedures, and foveal-sparing ILM peeling. All these approaches aim to improve the postoperative closure rate of macular holes. The goal of macular hole surgery is to better preserve the integrity of the foveal center structure, with the aim of achieving functional recovery on the basis of anatomical restoration. However, in clinical practice, there is a tendency to excessively choose certain surgical methods solely to pursue the closure rate of the hole, which may not be beneficial for the visual function recovery of the patients. This article discusses how to correctly select the internal limiting membrane and its derivative procedures in macular hole surgery, combining clinical practice and relevant domestic and international research literature. It aims to provide insights for colleagues performing macular hole surgery as a reference regarding this clinical focus issue.

[Analysis of the therapeutic efficacy of pars plana vitrectomy without intraocular tamponade in the treatment of high myopic eyes with myopic foveoschisis and central foveal detachment].

Objective: To investigate the efficacy of pars plana vitrectomy (PPV) without intraocular tamponade in the treatment of high myopic eyes with myopic foveoschisis (MF) accompanied by foveal detachment (FD). Methods: A retrospective case series study was conducted. The medical records of patients diagnosed with unilateral MF accompanied by FD at the Eye & ENT Hospital of Fudan University between May 2018 and December 2021 were collected. All patients underwent 23-gauge PPV with posterior vitreous cortex clearance, and no intraocular tamponade was applied. The cases were divided into groups based on whether the internal limiting membrane was peeled during surgery or retained. Follow-up was conducted for at least 12 months. The main outcome measures included postoperative best-corrected visual acuity (BCVA, converted to logarithm of the minimum angle of resolution), central foveal thickness (CFT), MF resolution, and complications. Statistical analyses were performed using t-tests, chi-square tests, Fisher's exact tests, and univariate and multivariate linear regression. Results: A total of 40 patients (40 eyes) with MF and FD were included in the study, with 30.0% being male and 70.0% female. The mean age was (56.9±11.7) years, and the axial length of the eyes was (29.1±1.9) mm. At 12 months postoperatively, BCVA improved from baseline 1.15±0.58 to 0.73±0.39 (t=6.11, P<0.001), and CFT decreased from baseline (610.1±207.2) µm to (155.9±104.1) µm (t=13.47, P<0.001). Complete resolution of MF with foveal reattachment was observed in 80.0% of eyes, with a median time of 6 (5, 8) months. There was no significant difference in BCVA and CFT between the internal limiting membrane peeled group and retained group [0.68±0.39 vs. 0.79±0.40, t=0.85, P=0.403; (148.3±63.8)vs.(164.3±137.2)um,t=0.48, P=0.634]. One eye experienced macular hole and another eye developed retinal detachment postoperatively. Correlation analysis showed a positive correlation between BCVA at 12 months postoperatively and baseline BCVA (ß=0.433, P<0.001). Conclusions: Pars plana vitrectomy without intraocular tamponade is effective in treating MF accompanied by FD. The choice between internal limiting membrane peeling and retention does not significantly affect visual prognosis.