Ultrastructural analyses of internal limiting membrane excised from highly myopic eyes with myopic traction maculopathy.

PURPOSE: To evaluate the ultrastructure of the internal limiting membranes (ILMs) excised during vitrectomy from highly myopic eyes with myopic traction maculopathy (MTM). The clinical findings before and after the vitrectomy were compared. METHODS: Seven eyes of 7 patients with macular retinoschisis were studied. Four of these eyes also had a foveal detachment but without a retinal break. All the eyes underwent vitrectomy with the creation of a posterior vitreous detachment and ILM peeling. The excised ILMs were examined by transmission electron microscopy (TEM). RESULTS: The retinas were reattached in all eyes after the vitrectomy. No retinal breaks including macular holes were identified intraoperatively. Transmission electron microscopy showed glial cells in 4 eyes, retinal pigment epithelium-like cells in 4 eyes, and myofibroblast-like cells in 4 eyes on the excised ILMs. A newly produced basement membrane appeared to merge with the ILM in 5 eyes. Thick collagen was seen in 2 eyes, and fibrous long-spacing collagen in the newly synthesized collagen fibers was seen in 3 eyes. The cellular components of the glial cells appeared to have migrated through the thinner parts of the retina or through a defect of the ILM in 2 eyes. CONCLUSIONS: Cells that migrate onto the surface of the ILM synthesize new collagen, which can create tangential traction. This may explain the success of vitrectomy with ILM peeling in treating MTM in highly myopic eyes.

[Clinical Characteristics of Rhegmatogenous Retinal Detachment in Highly Myopic and Phakic Eyes].

PURPOSE: To evaluate clinical characteristics of rhegmatogenous retinal detachment in high myopic and phakic eyes. SUBJECTS AND METHOD: The subjects were 1174 eyes of phakic rhegmatogenous retinal detachment detected in 1199 eyes that underwent initial vitreoretinal surgery between April 2006 and March 2011. Eyes with macular hole retinal detachment or secondary retinal detachment were excluded. The 486 eyes with high myopia (spherical equivalent ≤ -6.0 D or axial length ≥ 26.5 mm) and the 688 eyes with non-high myopia were compared. RESULTS: The mean age was significantly younger in the high myopia group (42.7 ± 14.2 years old, p < 0.001) with a single peak of higher incidence in 40 years old. The retinal detachment caused by retinal hole was significantly frequent in the high myopia group (p < 0.001) and that caused by retinal tear was less frequent (p = 0.021). The initial retinal attachment rate and the final attachment rate were not significant. In the fellow eye of the high myopia group, the incidence of retinal detachment and lattice degeneration were more frequent (16.7%, 20.4%, respectively). CONCLUSIONS: The incidences of the retinal detachment in younger age and those caused by retinal holes were higher in the high myopia group. Higher incidence of retinal detachment and lattice degeneration in the fellow eyes of the high myopia group indicated that careful observation also in the fellow eyes was recommended.

[Comparison of Retinal Detachment Associated with Atopic Dermatitis with that of a Blunt Trauma].

PURPOSE: Retinal detachment associated with atopic dermatitis has been reported to have several similarities to retinal detachment with blunt trauma both in location and types of retinal breaks. To clarify the difference between these two types of retinal detachment, the clinical features of retinal detachment associated with atopic dermatitis to those with blunt trauma were compared. METHOD: Among phakic eyes of rhegmatogenous retinal detachment which underwent surgery in our clinic between 2006 and 2011, 51 eyes of 41 cases of retinal detachment associated with atopic dermatitis (Atopy group) and 53 eyes of 51 cases of retinal detachment with blunt trauma (Trauma group) were compared. RESULTS: In the Atopy group, the patients were younger, and the incidence of cataracts and bilateral detachment were more frequent. In the Trauma group, the occurence was more frequent in men and associated vitreous hemorrhage and iritis were more frequent. Shallow retinal detachments and ciliary breaks located at the superotemporal quadrant were more frequent in the Atopy group and bullous detachments and retinal breaks located at the superonasal quadrant were more frequent in the trauma group. Oral dialysis and ciliary breaks were frequent in both groups. The initial retinal reattachment rates were similar between both groups but the final reattachment rate was worse in the trauma group. CONCLUSIONS: Retinal detachment associated with atopic dermatitis had many similarities to the detachment with blunt trauma in types of retinal breaks. However, it was distinct in featuring higher incidence of bilateral retinal detachment, cataracts, and ciliary breaks at the superotemporal quadrant.

Comparison of microinsicion vitrectomy and conventional 20-gauge vitrectomy for severe proliferative diabetic retinopathy.

PURPOSE: To compare the outcomes of 23-gauge (G) and 25G vitrectomy to 20G vitrectomy on eyes with severe proliferative diabetic retinopathy (PDR). METHODS: The medical records of 424 eyes of 347 patients with severe PDR were reviewed. There were 80 eyes that had 23G, 174 eyes that had 25G, and 170 eyes that had 20G vitrectomy. The incidences of postoperative vitreous hemorrhage, intraoperative retinal breaks, retinal detachment, and neovascular glaucoma were compared. RESULTS: The incidence of intraoperative retinal breaks was significantly lower in the 23G group (21 %) than in the 20G group (35 %, P = 0.03) but not in the 25G group (26 %, P = 0.057). The incidence of postoperative retinal detachment was not significantly different among the three groups (P = 0.73). The incidence of postoperative vitreous hemorrhage that developed ≥1 month after vitrectomy was not different whether the eyes had panretinal photocoagulation or not (P = 0.15). The incidence of postoperative neovascular glaucoma was significantly lower in the 25G group (3 %) than in the 20G group (11 %, P = 0.01) but not significant compared with that in the 23G group (8 %, P = 0.72). CONCLUSION: The lower incidence of intraoperative retinal breaks and postoperative neovascular glaucoma after microincision vitrectomy indicates that microincision vitrectomy should be considered for eyes with severe PDR.

Correlation between foveal interdigitation zone band defect and visual acuity after surgery for macular pseudohole.

PURPOSE: To determine the correlation between the integrity of the foveal microstructures and the best-corrected visual acuity (BCVA) after pars plana vitrectomy for a macular pseudohole. METHODS: Thirty-one eyes of 31 patients with a macular pseudohole underwent vitrectomy with internal limiting membrane removal. The foveal area was examined by spectral domain optical coherence tomography preoperatively and postoperatively. The correlations between the BCVA and the lengths of the photoreceptor interdigitation zone (IZ), the ellipsoid zone, and the external limiting membrane band defects, and central foveal thickness were determined. RESULTS: The BCVA improved significantly and the length of the IZ band defect decreased significantly after the surgery. Simple linear regression analyses showed that the BCVA was significantly correlated with the length of the IZ band defect preoperatively and also at 1 to 12 months postoperatively (P < 0.001 for all). The BCVA was not significantly correlated with the length of the ellipsoid zone, external limiting membrane band defect, and the central foveal thickness. CONCLUSION: The significant correlation between the length of the foveal IZ band defect and the BCVA preoperatively and postoperatively indicates that the foveal IZ band is related to the visual recovery in patients with macular pseudohole.

Macular retinoschisis associated with glaucomatous optic neuropathy in eyes with normal intraocular pressure.

PURPOSE: The purpose of this study was to evaluate the clinical features, optical coherence tomography (OCT) findings, and surgical outcomes of eyes with macular retinoschisis associated with glaucomatous optic neuropathy and normal intraocular pressure (IOP). METHODS: In this retrospective interventional observational study, 11 eyes of 11 patients who underwent pars plana vitrectomy for macular retinoschisis and glaucomatous optic neuropathy were studied. All eyes had a vertical cup-to-disc ratio of ≥ 0.7 and retinal nerve fiber layer (RNFL) defects. Intraocular pressure (IOP) was <21 mmHg in all eyes, and there was no presence of congenital optic disc pits or high myopia in any eyes. The best-corrected visual acuity (BCVA) and the appearance of the fundus and OCT images were evaluated. RESULTS: The retinoschisis extended from the optic disc to the macula in all 11 eyes, and foveal detachment was present in 10 eyes. OCT showed vitreous adhesions near the RNFL defects and over the retinal vessels. The retinoschisis in the RNFL resolved immediately after the vitrectomy, and the BCVA improved significantly (p = 0.004). Macular retinoschisis resolved or decreased in all cases, although it required an average of 11 ± 3 months. The optic disc cup and RNFL defects were more clearly visible after resolution of the retinoschisis. CONCLUSIONS: Macular retinoschisis can develop from vitreous traction near the RNFL defect in eyes with glaucomatous optic neuropathy and normal IOP. We suggest that the traction on the structurally fragile RNFL contributed to the retinoschisis.

Outer retinal morphological changes and visual function after removal of epiretinal membrane.

OBJECTIVE: To determine the relation between the recovery of the cone outer segment tips (COST) line and the best-corrected visual acuity (BCVA) after epiretinal membrane (ERM) surgery. DESIGN: Retrospective, consecutive, interventional case series. PARTICIPANTS: Sixty-one eyes of 56 patients with an idiopathic ERM were studied. All participants underwent a complete ophthalmic examination including spectral-domain optical coherence tomography before and after ERM removal surgery. METHODS: The integrities of the photoreceptor layer including the external limiting membrane line, photoreceptor inner segment/outer segment (IS/OS) line, and COST line in the spectral-domain optical coherence tomography images at the fovea were determined. The associations of these morphological parameters to the BCVA were determined. RESULTS: Better BCVAs were found more frequently in eyes with an intact COST line than in eyes with a disrupted or absent COST line at 1 (p < 0.001), 6 (p = 0.003), and 12 months (p < 0.001). Among the external limiting membrane, IS/OS, and COST line parameters, the IS/OS line had higher correlations with the BCVA by multivariate analysis. No significant difference was observed in central retinal thickness between eyes with intact and nonintact COST lines. Eight (30.8%) of 26 eyes with BCVA ≥ 20/20 had nonintact COST lines at 12 months after the ERM surgery. CONCLUSIONS: Eyes with an intact COST line had better BCVA after ERM surgery. However, even at 12 months after ERM surgery, COST lines remained disrupted in many eyes with good BCVA.

Asymmetrical recovery of cone outer segment tips line and foveal displacement after successful macular hole surgery.

PURPOSE: To determine whether the photoreceptor outer segments recover symmetrically after successful macular hole surgery, and whether the recovery is correlated with the degree of foveal displacement. METHODS: This was a retrospective, interventional case series. The medical records of 35 patients (n = 35 eyes) with a surgically closed macular hole were reviewed. Spectral-domain optical coherence tomography (SD-OCT) was used to obtain cross-sectional images across the fovea horizontally and vertically. The lengths of cone outer segment tips (COST) line defect in the temporal, nasal, superior, and inferior sectors of the fovea, the best-corrected visual acuity (BCVA), and the papillofoveal distance were measured before and at 6 and 12 months after the surgery. RESULTS: The temporal COST line defect was significantly longer than the nasal length defect preoperatively (P = 0.031), at 6 months (P < 0.001), and at 12 months (P = 0.038) postoperatively. The length of the temporal COST line defect was significantly correlated with the BCVA preoperatively (P = 0.014) and at 6 months postoperatively (P = 0.001). The papillofoveal distance was significantly shorter at 6 months (P = 0.029) and 12 months (P = 0.043) postoperatively than at the baseline. The center of the COST line defect was located further temporally from the fovea postoperatively, and the distance was shorter than the nasal foveal displacement at 6 months (158.8 ± 167.0 µm, P = 0.13) and 12 months (244.8 ± 172.7 µm, P = 0.008). CONCLUSIONS: The restoration of the temporal COST line was delayed after successful macular hole surgery. In addition, the fovea was displaced more nasally than the center of the COST line defect which recovered centripetally. (ClinicalTrials.gov number, NCT01959776.).

Correlation between foveal cone outer segment tips line and visual recovery after epiretinal membrane surgery.

PURPOSE: To determine whether there is a significant correlation between the integrity of the foveal microstructures and the best-corrected visual acuity (BCVA) after pars plana vitrectomy for epiretinal membrane (ERM) removal. METHODS: This was a retrospective, interventional case series. Forty-six eyes of 45 patients with an ERM underwent vitrectomy. The foveal area was examined by spectral-domain-optical coherence tomography (SD-OCT) preoperatively and postoperatively. The correlation between the length of the photoreceptor cone outer segment tips (COST) line defect, the inner segment/outer segment junction (IS/OS) line defect, the external limiting membrane (ELM) line defect, and the BCVA was determined. RESULTS: The length of the COST line defect was significantly correlated with the BCVA at postoperative 1, 3, 6, 9, and 12 months (P < 0.001 for all). Forward stepwise regression analyses showed that the postoperative BCVA was significantly correlated with the length of COST line defect (P < 0.001) but not with the IS/OS line and ELM line defects for up to 6 months. The preoperative length of the COST line defect was significantly correlated with the postoperative BCVA at 12 months (P = 0.005), but the lengths of the IS/OS line defect and ELM line defect were not. The factor that best predicted the postoperative BCVA was the length of the preoperative COST line defect (P = 0.04) but not the preoperative BCVA (P = 0.69). CONCLUSIONS: The recovery of the foveal COST line defect is correlated with the BCVA after ERM surgery. The length of the preoperative COST line defect can predict the potential foveal function. (ClinicalTrials.gov number, NCT01549249.).

Two-year outcomes of pro re nata ranibizumab monotherapy for exudative age-related macular degeneration in Japanese patients.

PURPOSE: To describe outcomes of intravitreal ranibizumab using a pro re nata regimen for treatment-naive exudative age-related macular degeneration (AMD), in Japanese patients over the first 2 years. METHODS: Clinical records were retrospectively reviewed of 48 eyes of 48 patients with treatment-naive exudative AMD who underwent intravitreal ranibizumab therapy. After three monthly injections (induction), patients were examined monthly, and subsequent injections were performed as needed (pro re nata) for any residual activity, by fundus biomicroscopy and imaging studies, regardless of severity. RESULTS: Twenty-nine (60%) of the patients were men, and 19 (40%) were women; the mean age was 76.1 years. Of the 48 eyes evaluated, 17 (35%) had findings consistent with polypoidal choroidal vasculopathy, and five (10%) with retinal angiomatous proliferation. A mean of 6.0 ranibizumab injections were given in the first year, 3.5 in the second year, and 9.5 over the 2-year period. The best-corrected visual acuity (logarithm of minimum angle of resolution) improved significantly, from 0.35 at baseline to 0.21 at 12 months (P < 0.01), and remained stable at 0.21 at 24 months (P < 0.01). The mean central macular thickness decreased significantly, from 355.4 µm at baseline to 237.9 µm at 12 months (P < 0.01) and 247.7 µm at 24 months (P < 0.01). CONCLUSION: Improved visual acuity and decreased central macular thickness were observed and maintained over a 2-year period, in a Japanese population receiving 3 monthly induction injections followed by a pro re nata regimen of ranibizumab for exudative AMD.

Comparative findings in childhood-onset versus adult-onset optic disc pit maculopathy.

PURPOSE: To compare the clinical characteristics of eyes with childhood-onset to those with adult-onset optic disc pit maculopathy. METHODS: Twenty-seven eyes of 25 patients with optic disc pit maculopathy were reviewed. The clinical characteristics, clinical history including a history of blunt trauma, ophthalmoscopic evaluations and intraoperative findings in the childhood-onset (age <15 years, four eyes of four patients) cases were compared with those in the adult-onset (≥15 years, 23 eyes of 21 patients) cases of optic disc pit maculopathy. The strength of the vitreous adhesions was graded by what was required to create a posterior vitreous detachment (PVD); grade 1 = with vitreous cutter, grade 2 = by microhook or forceps and grade 3 = by forceps with removal of remnants of Cloquet's canal. RESULTS: The incidence of visual impairments following blunt trauma was significantly higher in childhood-onset (three of four eyes) than that of adult-onset (0 of 23 eyes, p = 0.0014). Vitreous surgery with creation of a PVD was performed in the four childhood-onset eyes and 18 adult-onset eyes after an absence of a spontaneous resolution. The grade of the vitreous adhesions was significantly higher in childhood-onset than in adult-onset eyes (p = 0.0096). CONCLUSIONS: An ocular trauma may provide an opportunity to detect optic disc pits. However, childhood-onset optic disc pit maculopathy was noted most commonly following blunt ocular trauma in eyes with a strong vitreous adhesion to the optic disc margin.

Correlation between length of foveal cone outer segment tips line defect and visual acuity after macular hole closure.

PURPOSE: To determine whether the postoperative length of the photoreceptor cone outer segment tips (COST) line defect is significantly correlated with best-corrected visual acuity (BCVA) after macular hole closure. DESIGN: Retrospective, consecutive, observational case series. PARTICIPANTS: Fifty-one eyes of 51 patients with a surgically closed macular hole were studied. METHODS: Spectral-domain optical coherence tomography (SD-OCT) was used to obtain images of the foveal area, and the lengths of the COST line defect were measured in the images obtained 1, 3, 6, 9, and 12 months after macular hole surgery. The correlation between the length of COST line defect and the BCVA was determined. MAIN OUTCOME MEASURES: The lengths of the COST line defect, the inner segment/outer segment (IS/OS) junction defect, the external limiting membrane (ELM) line defect in the SD-OCT images, and the BCVA. RESULTS: The COST line defect was gradually restored centripetally 1 to 12 months postoperatively. The length of the COST line defect was significantly correlated with the BCVA at 1, 3, 6, 9, and 12 months postoperatively (P < 0.001). Forward stepwise regression analyses showed that the postoperative BCVA was significantly correlated with the length of the COST line defect (P < 0.001) but not with that of the IS/OS junction and ELM line defects after 6 months. The preoperative length of the COST line defect was significantly correlated with postoperative BCVA at 12 months (P = 0.020), but the length of the IS/OS junction and ELM line defects was not. The preoperative length of the COST line defect was significantly longer than the fluid cuff diameter of the macular hole (P = 0.020), indicating that the influence of the elevated neurosensory retina at the fluid cuff on the SD-OCT signals of the COST line was probably minimal. The postoperative BCVA at 12 months can be calculated by the following regression equation: BCVA = 0.00020 × (length of preoperative COST line defect [µm]) - 0.23 (F value = 15.4; P < 0.001). CONCLUSIONS: The recovery of the foveal COST line defect is related to visual recovery after macular hole closure. The length of the preoperative COST line defect may predict the BCVA after macular hole surgery.

Foveal cone outer segment tips line and disruption artifacts in spectral-domain optical coherence tomographic images of normal eyes.

PURPOSE: To determine the incidence of a continuous cone outer segment tips (COST) line at the fovea in spectral-domain optical coherence tomographic (SD-OCT) images of normal eyes. DESIGN: Prospective, interventional case series. METHODS: Forty-six right eyes of 46 normal individuals with visual acuities (VA) ≥20/20 were studied. SD-OCT images were obtained with a Cirrus HD-OCT instrument with both the standard 5-line raster and the high-definition (HD) 5-line raster scan modes. Images with signal strengths weaker than 5 (on a scale from 0 to 10) were excluded. The appearances of the COST line, photoreceptor inner segment/outer segment (IS/OS) junction, and external limiting membrane (ELM) line were determined in a masked way. RESULTS: The incidence of eyes with an intact foveal COST line was about 95%, and the incidence was not significantly associated with the age, sex, refractive error, signal strength, horizontal or vertical scans, and the use of either the standard or HD scans. Fragmented COST lines appeared to be attributable to blocking artifacts caused by a hyperreflectivity at the foveal surface because the COST fragmentation had corresponding fragmentation of the ELM and IS/OS junction lines. The correlation between a fragmented COST line and the hyperreflectivity on the retinal surface was significant for the vertical HD scans (P = .011) but not for the vertical standard, horizontal standard, or horizontal HD scans. CONCLUSIONS: Commercial SD-OCT instruments can detect the COST line. Fragmentations of the COST lines in normal eyes are most likely artifacts caused by a parabolic reflection of a surface hyperreflectivity of the foveal pit.

Significant correlation between visual acuity and recovery of foveal cone microstructures after macular hole surgery.

PURPOSE: To determine whether a recovery of the microstructures of the foveal photoreceptors after macular hole closure is correlated with best-corrected visual acuity (BCVA). DESIGN: Retrospective, consecutive, observational case series. SETTING: Single-center academic practice. STUDY POPULATION: Forty-one eyes of 41 patients with surgically closed macular holes. OBSERVATIONAL PROCEDURES: The presence and intactness of the cone outer segment tips (COST) line were determined by spectral-domain optical coherence tomography and compared with the presence of the inner segment/outer segment (IS/OS) junction and the external limiting membrane (ELM) at 1, 3, 6, 9, and 12 months after the macular hole surgery. MAIN OUTCOME MEASURE: The correlation between the integrity of the foveal photoreceptor microstructures and the BCVA. RESULTS: A distinct COST line was first seen at 6 months after the surgery. A distinct or irregular COST line was observed only in eyes with an intact IS/OS junction and ELM. Eyes with a distinct or irregular COST line had significantly better BCVA than those with a disrupted COST line in eyes with an intact IS/OS junction and ELM at 12 months (P = .030). The BCVA was ≥20/25 at 12 months in 91% of the eyes with a distinct or irregular COST line but in only 44% of the eyes without a COST line (P = .015). CONCLUSIONS: The significant correlation between the BCVA and a distinct or irregular COST line after successful macular hole surgery indicates that the recovery of foveal cone microstructure is associated with good postoperative BCVA.