Macular Hole Surgery as a Historical Perspective.

Purpose: To evaluate the outcomes of macular hole (MH) surgery as a historical perspective after its inception in 1991. Patients and Methods: Retrospective review of 1032 eyes of 949 patients with an idiopathic MH who were followed for at least one year after the initial surgery. All surgeries were performed from 1990 to 2016 by one surgeon (NO) and included phacovitrectomy for patients of ≥40-years-of-age, a removal of the posterior hyaloid and epiretinal membrane, and SF6 gas tamponade with a 1-week face-down. After 1998, internal limiting membrane (ILM) peeling became the conventional procedure. All surgeries were classified into four periods based on the year of the initial surgery. The first period was 1990~1995 (n = 222), the second period was 1996~1999 (n=327), the third period was 2000~2004 (n = 234), and the last period was 2005~2016 (n=249). Results: The mean follow-up period was 81.3, 79.8, 88.4, and 77.3 months; hole size was 0.33, 0.28, 0.25, and 0.24 disk diameter; hole duration was 15.1, 10.6, 8.2, and 6.1 months; the decimal visual acuity (VA) was 0.13, 0.15, 0.17, and 0.19. The initial closure rate was 61.3, 78.0, 96.6, and 96.4%. The final decimal visual acuity was 0.33, 0.50, 0.66, and 0.79. The rate of a final decimal VA of 0.5 or better was 48.2, 66.4, 82.1, and 88.8%. The rate of a final decimal visual acuity of 1.0 or more was 17.6, 29.3, 43.6, and 58.2%. Multiple regression analyses showed that hole duration and ILM peeling were significantly associated with both the anatomic and functional outcomes. Conclusion: The favorable outcomes of MH surgery was primarily achieved by earlier surgery and conventional ILM peeling. Favorable results might be obtained using only conventional ILM peeling.

Foveal Morphology of Normal Fellow Eyes of Patients with Unilateral Macular Hole.

PURPOSE: To determine the morphology of the fovea in the ophthalmoscopically and tomographically normal fellow eyes of patients with a unilateral idiopathic macular hole (MH) and determine the association between foveal morphological parameters and foveal outer nuclear layer (ONL) thickness. DESIGN: Retrospective observational study. PARTICIPANTS: Two hundred three normal fellow eyes of patients with a unilateral MH and 216 normal eyes of 216 healthy subjects. METHODS: All the eyes were examined using swept-source OCT. A built-in software was used to measure the average retinal and choroidal thickness in the center and in the inner 4 subfields defined in ETDRS. The total retinal thickness, thickness of 3 retinal layers at the fovea and parafovea (0.25 and 0.5 mm nasal and temporal from the fovea), and foveal floor width (FFW) were measured on a scan image of a horizontal line passing through the center of the fovea. We defined the thickness between the internal limiting membrane and outer plexiform layer as inner retinal thickness and the thickness between the external limiting membrane and retinal pigment epithelium as outer retinal thickness. Multiple regression analyses were performed with age, sex, axial length, and the presence of a posterior vitreous detachment as the dependent variables. MAIN OUTCOME MEASURES: OCT measurements and correlations between foveal parameters and foveal ONL thickness. RESULTS: The fellow eyes had a thinner central retinal subfield, thinner fovea, thinner ONL at all points except at 0.5 mm nasal, significantly thicker outer retina at all points, and a wider FFW (P = 0.040 to P < 0.0001). The foveal ONL thickness was significantly and positively correlated with the central subfield retinal thickness and foveal thickness and negatively correlated with the FFW (all P < 0.0001). CONCLUSIONS: The thinner and deeper fovea and the thinner ONL of the fellow eyes of patients with a unilateral MH make these eyes more susceptible to the formation of an MH.

Elevated retinal artery vascular resistance determined by novel visualized technique of laser speckle flowgraphy in branch retinal vein occlusion.

We aimed to investigate the increase in resistivity of the retinal artery in the branch retinal vein occlusion (BRVO)-affected area, and to visualize it. Thirty-two eyes of 32 patients with BRVO were measured by laser speckle flowgraphy (LSFG). The retinal artery and vein running to the BRVO-affected area and vertically symmetrical vessels in the unaffected area were examined. We applied the LSFG parameter beat strength over mean blur rate (BOM), calculated using a similar method to the pulsatility index used in Doppler flowmetry to evaluate resistivity of the vessels. Our results showed that the BOM map could clearly visualize the increase of resistivity in the retinal artery as a two-dimensional map. The BOM of the arteries in the affected area was significantly higher than that of the unaffected area (P = 0.001). Multiple regression analysis showed that the ratio of BOM in retinal arteries of the affected area to the unaffected was significantly associated with the extent of retinal hemorrhage (ß = 0.447, P = 0.009). In conclusion, the index of resistivity of the retinal artery in the BRVO-affected area was higher and could be visualized in a two-dimensional map. These findings and techniques would contribute to elucidate the pathophysiology of BRVO.

Birth Year-Dependent Increase in Axial Length of Japanese Adult.

PURPOSE: To determine whether the correlations between the axial length and the aging-dependent and birth year-dependent age are significant. DESIGN: Retrospective cross-sectional study. METHODS: This study included Japanese patients ≥50 years who had undergone cataract surgery at numerous clinics from 2002 to 2020. Only 1 eye/patient was analyzed. The axial length was measured with the IOL Master. The age-dependent changes were determined by the significance of the correlation between the axial length and age by the birth year. The birth year-dependent changes were determined by the significance of the correlation between the axial length and birth year in the different age groups. The age refers to the age at the time of the cataract surgery. Spearman correlations were calculated. The turning points were identified by the LOESS, NLIN, and HPMIXED procedures. RESULTS: A total of 62,362 eyes (35,508 women, 26,854 men) were studied. The mean age was 72.9 ± 8.4 (standard deviation) years (range, 50-101 years), and the mean axial length was 23.90 ± 1.66 mm (standard deviation) (range, 19.20-37.07 mm). The birth year ranged from 1908 to 1970. Analyses of the birth year-dependent changes showed significant positive correlations in 48 of 81 (59.3%) groups for women and men. The increase in the axial length was birth year-dependent, and the turning point was 1939.4 for women and 1936.7 for men. CONCLUSIONS: The negative and significant correlation between the axial length and age is due to birth year-dependent changes. A birth year-dependent increase in axial length might have continued for several decades from the birth year of the late 1930s.

Removal of foveal hard exudates by subretinal balanced salt solution injection using 38-gauge needle in diabetic patients.

PURPOSE: To examine the anatomic and visual outcomes after removal of foveal hard exudates through a macular hole created by subretinal balanced salt solution (BSS) injection. METHODS: This was a retrospective, consecutive, case series. Six patients (7 eyes) underwent vitrectomy with removal of foveal hard exudates. All patients were women and the mean age was 65 years (range from 55 to 71). All patients had a history of panretinal photocoagulation. Previous treatments included intravitreal anti-vascular endothelial growth factor injection in one eye and vitrectomy in both eyes of one patient. The geometric mean preoperative decimal visual acuity was 0.11 (range from 0.08 to 0.3). The mean postoperative follow-up period was 12 months (range from 6 to 19). The status of lens was two phakic and five pseudophakic. Surgical procedures included simultaneous cataract surgery if phakic, creation of posterior vitreous detachment if not present, internal limiting membrane (ILM) peeling and a gas or air tamponade. Manual subretinal BSS injection using 38-gauge needle was performed at ILM-peeled area. Removal of foveal hard exudates was conducted by the water flow through the macular hole created during subretinal BSS injection. RESULTS: Foveal hard exudates decreased in all cases early after surgery. The geometric mean final decimal visual acuity was 0.31 (range from 0.1 to 0.9). Visual acuity improved more than 0.2 LogMAR units in six eyes and unchanged in one eye. There was no severe complication and recurrence of macular edema. CONCLUSION: This procedure may be effective for foveal hard exudates in diabetic patients.

Vitrectomy for macular edema due to retinal vein occlusion.

Purpose: To determine the long-term outcomes of vitrectomy for the macular edema associated with a retinal vein occlusion (RVO). Methods: This was a retrospective, consecutive, interventional case series. The intraoperative procedures included internal limiting membrane peeling, arteriovenous sheathotomy, radial optic neurotomy, and intravitreal triamcinolone acetonide injection at the end of the surgery. The main outcome was the best-corrected visual acuity (BCVA). Results: Eight hundred and fifty-four eyes of 854 patients were studied. The eyes consisted of 602 with branch RVO (BRVO), 74 with hemi-central RVO (hemi-CRVO), 87 with nonischemic central retinal vein occlusion (CRVO), and 91 with ischemic CRVO. The mean follow-up period was 68.6 months with a range of 12 to 262 months. The mean BCVA was significantly improved at the final visit (P<0.0001 to 0.0016). The final BCVA improved in 74.4% of the BRVO eyes, in 58.1% of the hemi-CRVO eyes, in 57.4% of the nonischemic CRVO eyes, and in 51.6% of the ischemic CRVO eyes. Multiple regression analysis showed there was no significant relationship between the intraoperative combined procedures and the final BCVA. Conclusions: The results indicate that the type of RVO is significantly associated with the final BCVA, and vitrectomy is a treatment option to improve and maintain BCVA for a long term.

Long-term outcomes of intravitreous bevacizumab or tissue plasminogen activator or vitrectomy for macular edema due to branch retinal vein occlusion.

PURPOSE: The purpose of this study was to determine the long-term outcomes of intravitreal bevacizumab (IVB) or intravitreal tissue plasminogen activator (tPA) or vitrectomy for macular edema associated with a branch retinal vein occlusion (BRVO). METHODS: This was a retrospective, interventional case series. Forty-one patients received a single 1.25 mg of IVB injection and followed by pro re nata protocol, 71 patients received a single intravitreal tPA, and 116 patients underwent phacovitrectomy with intraocular lens implantation. RESULTS: The baseline characteristics and follow-up periods were not significantly different among the three groups. The mean follow-up period was 55.5 months with a range of 12-160 months. Sixteen patients (39.0%) in the IVB group, 24 patients (33.8%) in the tPA group, and two patients (1.7%) in the vitrectomy group underwent additional surgeries during the follow-up period. The best-corrected visual acuity (BCVA) significantly improved in all groups at 1 year after the initial treatment (all, P<0.0001) and at the final visit (all, P<0.0001). The differences in the BCVA between the three groups were not significant at all times after the initial treatment. CONCLUSION: The three groups led to similar long-term good visual outcomes. However, additional surgeries were performed in more than 30% of patients in the IVB and tPA groups.

Diurnal variation of pulse waveform parameters determined by laser speckle flowgraphy on the optic nerve head in healthy subjects.

To investigate the diurnal variation of the pulse waveform parameters determined by laser speckle flowgraphy (LSFG) on the optic nerve head (ONH) in healthy subjects.This prospective cross sectional study was conducted at Nagoya University Hospital. We studied 13 healthy volunteers whose mean age was 33.5 ±â€Š7.6 years. Eight pulse waveform parameters on the ONH were determined by LSFG (LSFG-NAVI) every 3 hours from 6 AM to 12 PM. The intraocular pressure (IOP), systolic (SBP) and diastolic (DBP) blood pressure, and heart rate (HR) in the brachial artery were also recorded. We evaluated the diurnal variations of the parameters and compared the pulse waveform parameters to the other parameters using a linear mixed model.Of the 8 parameters, skew (P < .001), blow out score (BOS, P < .001), blow out time (BOT, P = .028), rising rate (P < .001), falling rate (P < .001), resistivity index (P < .001) had a significant diurnal fluctuation. In addition, IOP (P < .001), SBP (P = .005), DBP (P = .001), and HR (P < .001) had significant diurnal fluctuations. The BOS and resistivity index were significantly correlated with the HR (P = .009, P = .012, respectively), and the BOT were significantly correlated with the DBP and mean ocular perfusion pressure (P = .042, P = .041, respectively).We found that there was significant diurnal variation in 6 waveform parameters on the ONH in LSFG. We believe that our results highlighting diurnal variations in these waveform parameters need to be considered when interpreting pulse waveform parameter data and in understanding the precise underlying mechanism of ocular diseases such as diabetic retinopathy, retinal vein occlusion, and glaucoma.

Changes in Retinal Microcirculation After Intravitreal Ranibizumab Injection in Eyes With Macular Edema Secondary to Branch Retinal Vein Occlusion.

Purpose: To evaluate the effects of an intravitreal ranibizumab (IVR) injection on the retinal microcirculation of eyes with macular edema secondary to a branch retinal vein occlusion (BRVO). Methods: Twenty-six eyes of 26 patients with macular edema due to a BRVO that had received a single IVR injection (0.5 mg/0.05 mL) were studied. The retinal microcirculation was assessed by laser speckle flowgraphy (LSFG) using the mean blur rate (MBR) and relative flow volume (RFV). The size of the retinal arteries and veins surrounding the optic nerve head were measured separately. All of the examinations were made before, and at 1 week, and 1 and 2 months after the IVR. Results: The visual acuity improved significantly, and the mean central macular thickness decreased significantly during the follow-up period (both P < 0.001). The mean MBRall and MBRtissue decreased significantly at 1 week and 1 month after the IVR (both P < 0.001). The total RFV of the arteries and veins decreased significantly at 1 week and 1 month after the IVR injection in the occluded and nonoccluded quadrants (all P < 0.001). The width of the arteries and veins in the LSFG images decreased significantly at 1 week and 1 month after the IVR injection (P < 0.001). Conclusions: An IVR injection leads to a transient vasoconstriction of the retinal arteries and veins and a reduction of the retinal blood flow and velocity in both the occluded and nonoccluded quadrants. The changes in retinal microcirculation might be related to the improvement of the macular edema and vision.