VERTICAL AND HORIZONTAL METAMORPHOPSIA ONE YEAR AFTER SURGERY FOR MACULAR HOLES ≤ 500 µ m WITH AND WITHOUT INVERTED INTERNAL LIMITING MEMBRANE FLAP.

PURPOSE: To investigate the effect of an inverted internal limiting membrane flap (IF) and other factors on metamorphopsia after macular hole surgery. METHODS: Prospective case series of patients undergoing pars plana vitrectomy with gas tamponade, with either conventional internal limiting membrane peeling (CP) or an IF, for primary idiopathic macular holes ≤ 500 µ m. Vertical and horizontal metamorphopsia were measured as M-scores (degrees) using M-charts preoperatively and at 2, 6, and 12 months postoperatively. RESULTS: Fifty-three eyes of 53 patients were included of whom 27 underwent CP and 26 were treated with an IF. After macular hole surgery, all patients were pseudophakic. Vertical and horizontal metamorphopsia improved from 1.08 (±0.51) and 0.98 (±0.70) preoperatively to 0.58 (±0.37) and 0.45 (±0.36) at 2 months ( P < 0.01), with no further significant improvement at 6 months (0.39 [±0.31], P = 0.07 and 0.31 [±0.28], P = 0.18) or at 12 months (0.37 [±0.30], P = 0.72 and 0.28 [±0.28], P = 0.99). There was no significant difference in the mean vertical and horizontal metamorphopsia between patients with CP and with an IF at 2 months ( P = 0.063, P = 0.10), 6 months ( P = 0.25, P = 0.16), or 12 months ( P = 0.62, P = 0.22). Preoperative vertical M-score improved at 12 months after macular hole surgery by 61% and 64% in the CP and IF groups, respectively ( P = 0.84), and the horizontal M-score by 65% and 71%, respectively ( P = 0.98). CONCLUSION: The use of an IF has no evident bearing on the degree of postoperative metamorphopsia 12 months after surgical repair of macular holes ≤ 500 µ m.

INFLUENCE OF PREOPERATIVE POSTURING ON SUBFOVEAL FLUID HEIGHT IN MACULA-OFF RETINAL DETACHMENTS.

PURPOSE: To evaluate the effect of preoperative posturing on subfoveal fluid height (SFFH) in macula-off retinal detachment. METHODS: A prospective study including patients with macula-off retinal detachment with SFFH measurable on optical coherence tomography (OCT) and duration of loss of central vision (LCV) ≤ 7 days. Linear OCT volume scans were performed at baseline, after 1 minute, 1 hour, 4 hours, and on the next morning. For the first hour, all patients remained in an upright position. Patients were then either instructed to posture until the surgery according to the location of the primary retinal break (posturing group) or were not given any instructions (control group). RESULTS: Twenty-four patients were included in the posturing group and 11 patients in the control group. There was no significant change in SFFH between baseline, 1 minute, 1 hour, and 4 hours. The mean SFFH in the control group increased by 243 µ m from 624 (±268) µ m at baseline to 867 (±303) µ m the next morning ( P < 0.01) but decreased in the posturing group by 150 µ m from 728 (±416) to 578 (±445) µ m ( P = 0.03). There was a significant association of the SFFH the next morning with posturing ( P < 0.01) and SFFH at baseline ( P < 0.01), but not with location of primary break ( P = 0.20). The change in SFFH from baseline to the next morning was significantly associated with posturing and primary break location ( P < 0.01), but not with SFFH at baseline ( P = 0.21). CONCLUSION: Preoperative posturing is an effective measure to prevent progression of macular detachment in macula-off retinal detachment.

Importance of subfoveal fluid height on visual outcome in macula-off retinal detachments.

AIMS: To investigate the effect of subfoveal fluid height (SFFH) on visual outcome after macula-off retinal detachment (RD) repair. METHODS: Prospective interventional case series of consecutive patients undergoing pars plana vitrectomy with gas tamponade (PPV) for primary macula-off RD with duration of symptomatic loss of central vision (LCV) of ≤1 week. Preoperative SFFH was measured on two occasions an hour apart using optical coherence tomography (OCT) by two independent observers. Postoperative best corrected visual acuity (BCVA) was measured at 3 months. RESULTS: Sixty-one patients were included. All patients were pseudophakic after RD repair. The mean preoperative and postoperative BCVA (logarithm of the minimum angle of resolution) at 3 months was 1.41 (±0.71) and 0.15 (±0.12, range 0.00-0.70). Twenty-six patients with SFFH of ≤1500 µm were available for repeat OCT measurements. The variation in SFFH was proportional to the SFFH and showed a logarithmic (base 2) association (r=0.50, p=0.01). Patients were therefore grouped according to their SFFH as group 1: 1-100 µm, group 2: 101-300 µm, group 3: 301-700 µm, group 4: 701-1500 µm and group 5: 1501-3100 µm. BCVA at 3 months significantly reduced with increasing SFFH from 0.04 (±0.03) in group 1 to 0.28 (±0.15) in group 5 (p<0.001) but was not associated with age (p=0.77), preoperative BCVA (p=0.39), duration of LCV (p=0.63) or use of perfluorocarbon liquids (p=0.88). Forty-five patients had SFFH ≤1500 µm and achieved 0.10 (±0.07, range 0.00-0.30) logMAR. CONCLUSION: Visual acuity following PPV for macula-off RD is related to preoperative SFFH regardless of the duration of symptomatic LCV within the first week.

Detection of SARS-CoV-2-RNA in post-mortem samples of human eyes.

PURPOSE: To detect SARS-CoV-2 RNA in post-mortem human eyes. Ocular symptoms are common in patients with COVID-19. In some cases, they can occur before the onset of respiratory and other symptoms. Accordingly, SARS-CoV-2 RNA has been detected in conjunctival samples and tear film of patients suffering from COVID-19. However, the detection and clinical relevance of intravitreal SARS-CoV-2 RNA still remain unclear due to so far contradictory reports in the literature. METHODS: In our study 20 patients with confirmed diagnosis of COVID-19 were evaluated post-mortem to assess the conjunctival and intraocular presence of SARS-CoV-2 RNA using sterile pulmonary and conjunctival swabs as well as intravitreal biopsies (IVB) via needle puncture. SARS-CoV-2 PCR and whole genome sequencing from the samples of the deceased patients were performed. Medical history and comorbidities of all subjects were recorded and analyzed for correlations with viral data. RESULTS: SARS-CoV-2 RNA was detected in 10 conjunctival (50%) and 6 vitreal (30%) samples. SARS-CoV-2 whole genome sequencing showed the distribution of cases largely reflecting the frequency of circulating lineages in the Munich area at the time of examination with no preponderance of specific variants. Especially there was no association between the presence of SARS-CoV-2 RNA in IVBs and infection with the variant of concern (VOC) alpha. Viral load in bronchial samples correlated positively with load in conjunctiva but not the vitreous. CONCLUSION: SARS-CoV-2 RNA can be detected post mortem in conjunctival tissues and IVBs. This is relevant to the planning of ophthalmologic surgical procedures in COVID-19 patients, such as pars plana vitrectomy or corneal transplantation. Furthermore, not only during surgery but also in an outpatient setting it is important to emphasize the need for personal protection in order to avoid infection and spreading of SARS-CoV-2. Prospective studies are needed, especially to determine the clinical relevance of conjunctival and intravitreal SARS-CoV-2 detection concerning intraocular affection in active COVID-19 state and in post-COVID syndrome.

SPONTANEOUS RESOLUTION OF SUBMACULAR PERFLUOROCARBON LIQUIDS.

PURPOSE: To demonstrate a case of spontaneous resolution of submacular heavy liquid. METHODS: This is a case report analyzing consecutive data and optical coherence tomography scans of a patient who underwent revisional retinal detachment surgery with pars plana vitrectomy using perfluorocarbon liquid (PFCL) as an adjunct. Postoperatively submacular PFCL bubbles were noted, and after an only partially successful surgical attempt to remove them, the residual PFCL bubbles were monitored over the course of several months. The primary outcome measure was the anatomical appearance and size of the PFCL bubbles on optical coherence tomography. The secondary outcome measure was the functional outcome based on the best-corrected visual acuity. RESULTS: We present a case of retained submacular PFCL after complex retinal detachment repair, which could only partially be removed surgically. However, the remaining PFCL droplets resolved spontaneously over several months, with partial anatomical restoration of the retinal layers and improvement in visual acuity. CONCLUSION: We hypothesize that the PFCL bubble was resorbed presumably by the retinal pigment epithelium.

Defining a Cutoff for Progression of Macular Holes.

Purpose: The purpose of this study was to determine a cutoff for progression of idiopathic full-thickness macular hole (MH) size. Methods: Retrospective analysis of consecutive patients waiting 4 weeks for MH surgery. Two observers performed 3 repeat sets of MH size measurements on optical coherence tomography (OCT) high-density radial scans taken at first presentation and 4 weeks later before surgery. Primary outcome was the definition of a cutoff for true enlargement of MH size versus measurement error. Secondary outcomes were risk factors for change in minimum linear diameter (MLD) size and best-corrected visual acuity (BCVA). Results: Fifty-one patients were included with a mean MH size of 334 µm (±179 µm; range 39 to 793 µm). The cutoff for an increase in MLD size calculated as the outer confidence limit for the 99.73% limits of agreement was 31 µm. This was independent of MH size. Using this cutoff, MLD size increased in 9/34 (26.5%) of patients without and in 14 of 17 (82.4%) of patients with vitreomacular traction (VMT; P < 0.001). Mean BCVA deteriorated in patients in whom the MH had progressed from 0.62 (±0.23) logMAR to 0.82 (±0.29; P < 0.001), whereas there was no significant change in BCVA in patients without MH progression (P = 0.25). In 31% (16/51) of patients, classification of their MHs (small ≤250 µm, medium 251-400 µm, and large >400 µm) changed over the 4-week period. Conclusions: Using a cutoff discriminates change from measurement error. A significant proportion of MHs progressed by 4 weeks, particularly in the presence of VMT. Translational Relevance: The established cutoff enables clinicians to differentiate true MH enlargement from measurement error.

Predictive Association of Pre-Operative Defect Areas in the Outer Retinal Layers With Visual Acuity in Macular Hole Surgery.

Purpose: The purpose of this study was to develop methods to model the external limiting membrane (ELM) and ellipsoid zone (EZ) within the elevated cuff surrounding a macular hole (MH) to determine if the predicted size of the defect in these layers after virtual flattening was associated with the actual postoperative defect and best-corrected visual acuity (BCVA). Methods: Patients were included who had undergone successful MH surgery. The defects in the ELM and EZ after virtual flattening were modeled using in-house software. Main outcomes were postoperative defects in ELM and EZ at 2 months and BCVA at 12 months. Results: Fifty-eight patients were included. BCVA improved from 0.87 (0.31) logMAR pre-operatively to 0.26 (0.21) at 12 months (P < 0.001). For both the ELM and EZ, the predicted virtually flattened pre-operative defects were associated with the actual postoperative defects at 2 months (R2 = 0.33, P < 0.01 and R2 = 0.50, P < 0.01, respectively). There was a significant association of BCVA at 12 months (adjusted R2 = 0.85) with the pre-operative modeled area of the defect in the ELM (P < 0.01) and to a lesser extent with the defect in the EZ (P < 0.01) and base of the MH (P < 0.01). Conclusions: Virtually flattening of the pre-operative defect in the ELM provides important predictive information of visual acuity. Incorporation of tools into commercially available optical coherence tomography (OCT) devices to facilitate such measurements would provide the clinician with important prognostic information. Translational Relevance: We have developed methodology that can potentially be used to predict the postoperative state of the outer retinal layers and the associated visual outcome in patients undergoing surgery for MH.

FUNCTIONAL AND MORPHOLOGICAL OUTCOMES OF THE INVERTED INTERNAL LIMITING MEMBRANE FLAP TECHNIQUE IN SMALL-SIZED AND MEDIUM-SIZED MACULAR HOLES <400 µm.

PURPOSE: To assess the effect of an internal limiting membrane flap (IF) in macular hole surgery on the best-corrected visual acuity (BCVA) and integrity of the ellipsoid zone (EZ) and external limiting membrane. METHODS: Patients were included who had successful surgery for macular hole <400 µm with or without an IF. Main outcome measures were BCVA and restoration of the external limiting membrane and EZ at 12 months. RESULTS: Sixty patients were included, 36 with conventional peeling and 24 with an IF. The best-corrected visual acuity improved from 0.74 (±0.30) logarithm of the minimum angle of resolution (20/110 Snellen) to 0.26 (±0.20) (20/36 Snellen) in patients without and from 0.77 (±0.32) logarithm of the minimum angle of resolution (20/118 Snellen) to 0.18 (±0.12) (20/30 Snellen) in patients with an IF, respectively. There was no difference in the integrity of the EZ and external limiting membrane in patients with or without an IF at either 3 (P = 0.58, P = 0.20), 6 (P = 0.81, P = 0.10), or 12 months (P = 0.60, P = 0.20) or in the BCVA at 3 (P = 0.24), 6 (P = 0.18) and 12 months (P = 0.11). In the multivariable model, only preoperative BCVA (P < 0.01), EZ integrity (P = 0.001), and age (P < 0.01) were associated with the post-operative BCVA. CONCLUSION: In patients undergoing surgery for macular hole <400 µm, the use of an IF did not affect the BCVA or the integrity of the EZ and external limiting membrane.

MANCHESTER REVISIONAL MACULAR HOLE STUDY: Predictive Value of Optical Coherence Tomography Parameters on Outcomes of Repeat Vitrectomy, Extension of Internal Limiting Membrane Peel, and Gas Tamponade for Persistent Macular Holes.

PURPOSE: To evaluate the efficacy of repeat pars plana vitrectomy and gas tamponade for persistent macular holes (MHs), especially looking at a predictive value of optical coherence tomography parameters in revisional surgery. METHODS: Retrospective, nonrandomized interventional case series of consecutive patients with a persistent MH that underwent revisional pars plana vitrectomy and gas tamponade. The primary outcome measure was anatomical closure of the MH after revisional surgery. The secondary outcome measure was a functional outcome of the MH closure based on the best-corrected visual acuity. The changes of minimum linear diameter and MH index after the primary surgery were evaluated to see if they were prognostic markers of success for the revisional surgery. RESULTS: A total of 27 patients with a persistent MH after primary MH surgery were identified, all of whom underwent a second operation with pars plana vitrectomy and gas tamponade with an internal limiting membrane peel extension in 20 cases. The MH closure rate after revisional surgery was 89% (24/27). Twenty-two cases were included in the optical coherence tomography analysis, of which 14 MHs that showed both a reduction of the minimum linear diameter and an increase in the MH index after the primary repair closed after revisional surgery. The mean best-corrected visual acuity before revisional surgery was 0.86 logMAR (20/145 Snellen) but increased significantly postoperatively to 0.69 (±0.15) logMAR (20/98 Snellen) at 3 months and to 0.49 logMAR (20/62 Snellen) at 12 months. CONCLUSION: For a persistent idiopathic MH, simple repeat pars plana vitrectomy with gas tamponade has a good anatomical and functional success rate in selected cases. The minimum linear diameter and MH index can be useful optical coherence tomography markers for prognostic guidance.

Spontaneous Necrosis of a Large Choroidal Melanoma: Unusual Presentation in a 49-Year-Old Male.

PURPOSE: To demonstrate a case of massive vitreous haemorrhage obscuring the underlying diagnosis of a large mixed-cell choroidal melanoma which had undergone spontaneous necrosis. CASE REPORT: A 49-year-old man in good general health suddenly lost vision in his right eye due to an extensive vitreous haemorrhage 1 day after a workout at the gym. He reported good vision prior to that without any symptoms of flashes, floaters, or shadows. He was referred to the vitreoretinal department of a tertiary eye hospital, where he presented with a drop in vision to light perception only in the right phakic eye. Pars plana vitrectomy was performed in the right eye, which revealed intraoperatively massive retinal ischemia and choroidal haemorrhage, but no obvious tumour mass that could have been biopsied. The vitrectomy cassette specimen was sent for histopathology, where "ghost-like" melanoma cells were identified. The eye was subsequently enucleated, revealing an extensively necrotic and haemorrhagic choroidal melanoma of mixed cell type with only small viable tumour foci at the base and almost complete lysis of the detached retina. CONCLUSION: Some uveal melanomas (UMs) undergo spontaneous necrosis due to rapid growth, with the centre of the tumour outstripping its established blood supply in the "watershed area" of the eye, and becoming hypoxic with associated necrosis of intraocular structures. Such UMs are often associated with haemorrhage and/or inflammation and usually cause significant destruction of ocular tissues, resulting in enucleation as the only treatment option.

EFFECT OF INVERTED INTERNAL LIMITING MEMBRANE FLAP ON CLOSURE RATE, POSTOPERATIVE VISUAL ACUITY, AND RESTORATION OF OUTER RETINAL LAYERS IN PRIMARY IDIOPATHIC MACULAR HOLE SURGERY.

PURPOSE: To investigate the role of an internal limiting membrane (ILM) flap in macular hole (MH) surgery on closure rate, visual acuity, and integrity of the outer retinal layers. METHODS: Retrospective, nonrandomized interventional analysis in which 117 eyes of 117 patients were included who had undergone pars-plana vitrectomy (PPV) and gas tamponade for primary idiopathic MH >400 µm with either conventional ILM peeling or with inverted ILM flap technique at The Royal Liverpool University Hospital between January 2016 and April 2018. Main outcome measures were closure of MH, best-corrected visual acuity (BCVA) at 3, 6, and 12 months, and restoration of external limiting membrane and ellipsoid zone (EZ) using optical coherence tomography. RESULTS: Macular hole closure rate was significantly higher in patients with an ILM flap (67/68; 98.53%) than in those with conventional ILM peeling (43/49; 87.76%) (P = 0.02). Both groups showed significant improvements in their preoperative to postoperative BCVA at 3 months from 1.07 (0.43) logarithm of the minimum angle of resolution (logMAR) (20/235 Snellen) to 0.71 (0.34) logMAR (20/103 Snellen) (P <0.001), but there was no significant difference between the two groups (P = 0.45, P = 0.71). We found significant associations between postoperative BCVA and preoperative BCVA (P < 0.01) and the integrity of the EZ (P < 0.01). In 35 patients who had follow-up to 12 months, there was a significant improvement in BCVA between 3, 6, and 12 months from 0.73 (0.45) logMAR (20/107 Snellen) to 0.53 (0.24) logMAR (20/68 Snellen) and to 0.35 (0.18) logMAR (20/45 Snellen), respectively (P < 0.01). There was no significant difference at these time periods between the two groups (P = 0.62, P = 0.21, P = 0.31). The integrity of the EZ also improved significantly between 3, 6, and 12 months (P = 0.01), irrespective of the presence of an ILM flap (P = 0.58), but with a trend toward delay in restoration in those patients with an ILM flap. The improvement in BCVA at 12 months, taking into account the age of the patient, size and duration of the MH, presence of an ILM flap, and preoperative BCVA was dependent on the state of the EZ (P = 0.01). CONCLUSION: In patients undergoing primary pars-plana vitrectomy for MH >400 µm, the presence of an inverted ILM flap was associated with a significantly higher closure rate than a conventional ILM peeling. Best-corrected visual acuity showed a strong correlation with the integrity of the EZ and both improved significantly between 3, 6, and 12 months, irrespective of the presence of an ILM flap.

The Manchester Large Macular Hole Study: Is it Time to Reclassify Large Macular Holes?

PURPOSE: To evaluate anatomic and functional outcomes of full-thickness macular holes (FTMH) larger than 400 µm following vitrectomy, internal limiting membrane peel, gas tamponade, and face-down posturing. DESIGN: A retrospective interventional case series. METHODS: A total of 258 consecutive eyes with FTMH larger than 400 µm were enrolled at the Manchester Royal Eye Hospital study over a 5-year period from 2012 to 2017. All eyes underwent pars plana vitrectomy, ILM peel, and gas tamponade. Anatomic success rates were measured. A correlation between macular hole size and closure was evaluated. RESULTS: A total of 258 eyes were analyzed. The anatomic closure rate was 89.92%. When divided into quartiles, the closure rate of FTMH was 98% (64/65) in the 400-477 µm quartile, 91% (59/65) in the 478-558 µm quartile, 94% (60/64) in the 559-649 µm quartile, and 76% (49/64) in the 650-1416 µm quartile. Using receiver operating characteristic and area under the curve analysis, the maximum sensitivity and specificity was obtained with a cutoff ≤ 630 µm (sensitivity 76.7%, specificity 69.2%) giving a Youden index (J) of 0.46. One hundred and forty-six eyes (56.6%) improved by 0.3 logMAR units from their preoperative best-corrected visual acuity at 3 months following surgery. CONCLUSION: This study shows that standard FTMH surgical repair has very high success rate up to 650 µm. It may suggest that there is a need for a reclassification of large FTMH, and new surgical techniques such as internal limiting membrane flaps should be reserved for macular holes larger than 650 µm.

Cataract surgery in small adult eyes.

AIM: To evaluate the clinical outcomes of phacoemulsification cataract surgery in microphthalmos. METHODS: Retrospective consecutive case series of eyes with axial length <20.9 mm, and requiring a high intraocular lens (IOL) power (≥30 or ≥35 dioptres for anterior or posterior chamber fixation, respectively), with no history of previous ocular surgery, and undergoing planned phacoemulsification cataract surgery with IOL implantation at Moorfields Eye Hospital was investigated to observe the incidence of intraoperative and postoperative complications. RESULTS: During a 5-year study period, 47 of 22,093 eyes were treated in two locations (0.21%). Thirty-nine eyes met the study inclusion criteria. No serious intraoperative adverse events were recorded. Severe postoperative complications (retinal detachment and chronic postoperative uveitis) occurred in two cases. The postoperative corrected distance visual acuity (CDVA) was logMAR 0.30 or better in 24 eyes (62%), and only three eyes obtained worse vision. The overall ocular comorbitidy rate was 53%; 10 microphthalmic eyes (26%) presented with associated congenital or hereditary pathology, and had worse visual outcomes (p<0.0001). CONCLUSIONS: Microphthalmic eyes requiring high IOL power are rare, and their presence is often associated with other ocular congenital or acquired disorders. Overall, the clinical outcomes were satisfactory and the surgical procedure affected by a low complication rate.