Congenital simple hamartoma of the retinal pigment epithelium: 4 cases with multimodal imaging.

BACKGROUND: Congenital simple hamartoma of the retinal pigment epithelium is often identified as an incidental finding. One important issue is the differentiation of these benign lesions from other lesions which could be potentially sight-threatening. METHODS: This study describes 4 cases of congenital simple hamartoma of the retinal pigment epithelium that were referred to a university-based hospital. Multimodal imaging including fundus photo, multicolor fundus photo, fundus autofluorescence, optical coherence tomography (OCT), OCT angiography, fluorescein angiography and multifocal electroretinogram is provided. RESULTS: The first case is a young man with an incidental finding of this lesion. The second and third cases are diabetic patients with congenital simple hamartoma of the retinal pigment epithelium and diabetic macular edema and the fourth one is a case of congenital simple hamartoma of the retinal pigment epithelium with a full-thickness macular hole. CONCLUSIONS: Differentiation of congenital simple hamartoma of the retinal pigment epithelium from other potentially sight-threatening lesions is important. Multimodal imaging can be helpful regarding this issue. Besides typical findings described in the literature, unique features in our cases include concurrent diabetic macular edema and association with a full-thickness macular hole.

OIMHS: An Optical Coherence Tomography Image Dataset Based on Macular Hole Manual Segmentation.

Macular holes, one of the most common macular diseases, require timely treatment. The morphological changes on optical coherence tomography (OCT) images provided an opportunity for direct observation of the disease, and accurate segmentation was needed to identify and quantify the lesions. Developments of such algorithms had been obstructed by a lack of high-quality datasets (the OCT images and the corresponding gold standard macular hole segmentation labels), especially for supervised learning-based segmentation algorithms. In such context, we established a large OCT image macular hole segmentation (OIMHS) dataset with 3859 B-scan images of 119 patients, and each image provided four segmentation labels: retina, macular hole, intraretinal cysts, and choroid. This dataset offered an excellent opportunity for investigating the accuracy and reliability of different segmentation algorithms for macular holes and a new research insight into the further development of clinical research for macular diseases, which included the retina, lesions, and choroid in quantitative analyses.

Photoreceptor Outer Segment Loss at the Macular Hole Border: Clinical Characteristics and Surgical Prognosis.

INTRODUCTION: During macular hole (MH) formation, the vitreofoveal traction may lead to foveal neural tissue avulsion and consequent photoreceptor loss. However, the clinical significance of the photoreceptor outer segment disruption at the MH border remains unclear. This study aims to investigate the clinical features and surgical outcomes of MHs with photoreceptor outer segment disruption at the MH border. METHODS: This study retrospectively reviewed 86 eyes from 85 patients who underwent vitrectomy combined with internal limiting membrane peeling for idiopathic MHs. Baseline and postoperative best-corrected visual acuity (BCVA) and foveal microstructure on optical coherence tomography images were compared between eyes with smooth and bumpy morphology, the latter of which was defined as those with an uneven and irregular surface with evident lumps and indentations at the MH border. RESULTS: The bumpy morphology was identified in 59 of 86 eyes (68.9%). At baseline, eyes with a bumpy MH morphology had a significantly larger minimum linear diameter (p = 0.043), a longer external limiting membrane defect (p = 0.013), and a worse baseline BCVA (p = 0.017) than those with a smooth morphology. Postoperatively, in a multivariate regression model adjusting preoperative confounding effects, eyes with bumpy borders were associated with a longer ellipsoid zone defect (p = 0.006) and a thinner central fovea (p = 0.002) at 1 month, and a thinner central fovea (p = 0.005) and a worse BCVA (p = 0.015) at 10 months. CONCLUSION: A severe photoreceptor outer segment loss is common at the MH border, which represents a chronic pathogenic process and may be an independent predictor for an incomplete photoreceptor recovery and worse long-term visual outcomes after surgery.

Effect of peripheral laser photocoagulation retinopexy on macular morphology and optic nerve fiber layer thickness; a prospective case series.

PURPOSE: The goal of the research was to determine the incidence of microstructural alterations in the macula and optic nerve head (ONH) occurred in eyes treated with peripheral laser photocoagulation retinopexy. METHODS: Patients with retinal breaks, retinal holes, retinal dialysis, and lattice degenerations who required peripheral laser photocoagulation retinopexy were recruited in this prospective case series investigation. We performed preoperative and postoperative evaluations, including best corrected visual acuity (BCVA), slit lamp examination, intraocular pressure (IOP) measurement, funduscopic examination, and macular and ONH optical coherence tomography (OCT). RESULTS: Thirty-three eyes of the twenty-three patients enrolled in this study, 14 of which were female. The mean age of the sample was 45.12 ± 9.12 years. The mean refractive error was - 2.45 ± 1.12 Diopters (D). The most prevalent reason for peripheral laser photocoagulation retinopexy was retinal thinning with symptomatic lattice degeneration (90%), followed by retinal hole and break (7%) and retinal dialysis (3%). Between preoperative and postoperative (6-month) evaluation, there was no statistically significant difference in BCVA (P = 0.82), IOP (P = 0.54), central foveal thickness in macular OCT (P = 0.39), or global retinal nerve fiber layer (RNFL) thickness (P = 0.51). There was no association between changes in central foveal thickness and global RNFL thickness and total laser spot numbers (r = - 0.17 P = 0.21, r = 0.06 P = 0.60, respectively). None of patients developed cystoid macular edema (CME) or macular epiretinal membrane (ERM) . CONCLUSION: We found that OCT parameters were not significantly affected by laser retinopexy in patients with high-risk peripheral retinal lesions, also none of our patients had developed ERM, vitromacular traction or CME at 6 months follow up periods.

Structure and mechanics of the vitreoretinal interface.

Vitreoretinal mechanics plays an important role in retinal trauma and many sight-threatening diseases. In age-related pathologies, such as posterior vitreous detachment and vitreomacular traction, lingering vitreoretinal adhesions can lead to macular holes, epiretinal membranes, retinal tears and detachment. In age-related macular degeneration, vitreoretinal traction has been implicated in the acceleration of the disease due to the stimulation of vascular growth factors. Despite this strong mechanobiological influence on trauma and disease in the eye, fundamental understanding of the mechanics at the vitreoretinal interface is limited. Clarification of adhesion mechanisms and the role of vitreoretinal mechanics in healthy eyes and disease is necessary to develop innovative treatments for these pathologies. In this review, we evaluate the existing literature on the structure and function of the vitreoretinal interface to gain insight into age- and region-dependent mechanisms of vitreoretinal adhesion. We explore the role of vitreoretinal adhesion in ocular pathologies to identify knowledge gaps and future research areas. Finally, we recommend future mechanics-based studies to address the critical needs in the field, increase fundamental understanding of vitreoretinal mechanisms and disease, and inform disease treatments.

Internal limiting membrane peeling in macular hole surgery.

Since the era when macular hole was considered untreatable, macular hole surgery has come a long way to being one of the most successful surgeries. Internal limiting membrane (ILM) peeling has been an essential step of macular hole surgery since the establishment of the role of ILM in the aetiopathogenesis and progression of macular hole. However, the novel technique was not all virtuous. It had some vices which were not evident immediately. With the advent of spectral domain optical coherence tomography, short- and long-term effects of ILM peeling on macular structures were known; and with microperimetry, its effect on the function of macula could be evaluated. The technique has evolved with time from total peeling to inverted flap to just temporal peeling and temporal flap in an attempt to mitigate its adverse effects and to improve its surgical outcome. ILM abrasion technique and Ocriplasmin may eliminate the need of ILM peeling in selected cases, but they have their own limitations. We here discuss the role of ILM in the pathogenesis of macular hole, the benefits and adverse effects of ILM peeling, and the various modifications of the procedure, to then explore the alternatives.

PNEUMATIC VITREOLYSIS VERSUS PARS PLANA VITRECTOMY IN FOCAL SYMPTOMATIC VITREOMACULAR TRACTION SYNDROME: A Randomized Trial.

PURPOSE: To compare pneumatic vitreolysis and pars plana vitrectomy in the management of focal symptomatic vitreomacular traction (VMT). METHOD: Patients aged 18 years or older, with idiopathic focal symptomatic VMT and best-corrected visual acuity <20/40, without any other retinal pathology were randomized to undergo pneumatic vitreolysis (Group 1) or pars plana vitrectomy (Group 2). The primary outcome measure was resolution of traction confirmed with optical coherence tomography at 3 months. Secondary outcome measures were to compare changes in best-corrected visual acuity, central foveal thickness, and complications if any. RESULTS: A total of 30 eyes of 30 patients were included with 15 eyes in each group. Vitreomacular traction resolved successfully in 12 of 15 (80%) eyes in Group 1 and in all (100%) eyes in Group 2 (P = 0.224). The mean visual acuity improved from 0.80 ± 0.26 (20/126 Snellen's equivalent) to 0.70 ± 0.46 logMAR (20/100 Snellen's equivalent) in Group 1 (P = 0.71) and from 0.904 ± 0.44 (20/160 Snellen's equivalent) to 0.47 ± 0.26 logMAR (20/59 Snellen's equivalent) in Group 2 (P = 0.0016). Although 4 of 15 (26.66%) eyes in Group 1 had formation of full-thickness macular hole and 7 eyes required resurgery (4 for full-thickness macular hole and 3 for unresolved VMT), none in the pars plana vitrectomy group had any complications requiring resurgery (P = 0.0063). Two eyes in the pars plana vitrectomy group had intraoperative deroofing of the fovea leading to full-thickness macular hole. CONCLUSION: Pars plana vitrectomy is better than pneumatic vitreolysis as a single intervention in the management of focal symptomatic VMT.

Effect of inverted internal limiting membrane flap technique on small-medium size macular holes.

Inverted internal limiting membrane (ILM) flap technique was developed to achieve macular hole (MH) closure in large MH and refractory cases. In this study, we evaluate the effect of the technique for small-medium size MH. We recruited patients who underwent vitrectomy for small-medium size (< 400 µm) MH with either inverted ILM flap technique (flap group) or with conventional ILM peeling (peeling group). Using propensity score, 21 eyes of 21 patients in the peeling group were matched against 21 eyes of 21 patients in the flap group. We compared MH closure rate, postoperative visual acuity, and recovery of the external limiting membrane (ELM) and ellipsoid zone (EZ). The MH closure rate was not different between the two groups (flap vs peeling: 90% vs 100%, P = 0.49). Whereas there was no significant difference in visual acuity improvement between the two groups, the flap group showed more disruption of the ELM 3 months after surgery and of the EZ at 3 and 6 months after surgery (P = 0.02, P = 0.03, and P = 0.04, respectively). The result suggested that inverted ILM flap technique does not have additional benefits for small-medium size MHs and may delay recovery of retinal integrity.

Epiretinal large disc of blue-stained lyophilized amniotic membrane to treat complex macular holes: a 1-year follow-up.

PURPOSE: To report the long-term outcomes of large diameter epiretinal lyophilized amniotic membranes (lAMs) in recurrent or persistent macular holes (MHs) with or without rhegmatogenous retinal detachment (RRD), in a prospective interventional case series. METHODS: Ten eyes of 10 patients underwent pars plana vitrectomy for MH-associated RRD (n = 5) or persistent MH without RRD (n = 5), in a university Hospital. A 3 or 4 mm diameter disc of lAM, stained with 0.06% trypan blue, was inserted with a catheter through a sclerotomy and positioned over the MH. Gas or silicone-oil tamponade was used. At 1 year, the main outcome was anatomic success defined as complete MH closure. Secondary outcomes were best corrected visual acuity (BCVA) recovery, changes in ellipsoid zone (EZ) and external limiting membrane (ELM) defects, complications. Mean follow-up was 13.8 ± 2.9 months (range, 12-18). RESULTS: Mean baseline data were minimum and maximum diameters, respectively, 945 ± 330 and 1507 ± 717 µm; axial length 26.58 ± 3.38 mm; and number of prior surgeries 1.4 ± 0.96. At 1 year, anatomic success was achieved in eight eyes (80%), and two had reduced diameter of MH. All RRDs were reattached without recurrence. Mean logMAR BCVA improved from 1.92 ± 0.58 to 1.17 ± 0.57 (p < 0.001), with nine eyes (90%) achieving ≥0.3 logMAR improvement. Mean EZ and ELM defects decreased (p = 0.004, p = 0.003, respectively). Postoperative complications were RRD (n = 1) reattached by subsequent surgery, lAM slightly retracted under silicone (n = 1), foveal atrophy after early lAM displacement (n = 1). CONCLUSION: A 1-year follow-up highlighted that epiretinal large discs of blue-stained lAM can help safely close refractory MHs, and provide satisfactory visual recovery.

The Effect of Intravitreal Ocriplasmin on Hue Discrimination.

SIGNIFICANCE: We report 13 patients who received ocriplasmin for symptomatic vitreomacular adhesion. Farnsworth-Munsell 100 (FM 100) hue test total error score (TES) increased from baseline to month 1, before recovering at year 1. Ocriplasmin may alter hue discrimination. PURPOSE: This study aimed to determine whether intravitreal ocriplasmin affects hue discrimination. METHODS: Thirteen patients with symptomatic vitreomacular adhesion received intravitreal ocriplasmin 125 µg. Patients underwent full ocular examination, optical coherence tomography, and FM 100 hue test at baseline, 1 week, 1 month, and 1 year. RESULTS: Mean age was 74.8 years. The median baseline FM 100 TES was similar in the injected and fellow eyes (272 vs. 252, respectively). Median TES in the injected eye increased from 272 to 348 at 1 week (median difference compared with baseline, +52.0; 98.8% confidence interval of difference, -64.0 to 184.0; P = .29), decreased to 324 at 1 month (median difference compared with baseline, -4.0; 98.8% confidence interval of difference, -44.0 to 256.0; P = .40), and decreased to 268 at 1 year (median difference compared with baseline, -108.0; 93.8% confidence interval of difference, -200.0 to 52.0; P = .19). Two patients (15.4%) had anatomic release of vitreomacular adhesion, occurring within 1 month of injection. CONCLUSIONS: Ocriplasmin may alter hue discrimination, but larger studies are required to provide sufficient power to detect or exclude a statistically significant effect. Longer follow-up is needed to determine the duration of any effect.

Contractility of temporal inverted internal limiting membrane flap after vitrectomy for macular hole.

We investigated the postoperative visual outcomes and morphological changes of the internal limiting membrane (ILM) flap, in patients who underwent the temporal inverted ILM flap technique for macular hole (MH). Between August 2018 and February 2020, 22 eyes of 22 patients with idiopathic or myopic MH who underwent vitrectomy with ILM flap were included in this study and followed-up for more than 6 months. Postoperative MH status, comparison of best-corrected visual acuity (BCVA) before and 6 months after surgery, changes in the ILM flap area at 1 and 6 months postoperatively, and the factors related to changes in ILM flap size, were analyzed. MH closure was achieved in all of the patients. The BCVA at 6 months postoperatively (0.18 ± 0.15) was significantly better than the preoperative BCVA of 0.63 ± 0.37 (P < 0.001, paired t test). The area of the ILM flap decreased significantly from 3.25 ± 1.27 mm2 at 1 month to 3.13 ± 1.23 mm2 at 6 months (P = 0.024, Wilcoxon signed-rank test). Two eyes showed an ILM flap contraction of more than 20%, and one eye required reoperation due to an increase in metamorphopsia and decreased visual acuity. Among age, sex, ILM flap area at 1 month, preoperative BCVA, and axial length, ILM flap contraction was correlated with patient age and ILM flap area. Although vitrectomy with the inverted ILM flap technique confers a good visual outcome, the ILM flap may contract in younger patients.

Molecular pathogenesis of rhegmatogenous retinal detachment.

Rhegmatogenous retinal detachment (RRD) is an ophthalmic emergency, which usually requires prompt surgery to prevent further detachment and restore sensory function. Although several individual factors have been suggested, a systems level understanding of molecular pathomechanisms underlying this severe eye disorder is lacking. To address this gap in knowledge we performed the molecular level systems pathology analysis of the vitreous from 127 patients with RRD using state-of-the art quantitative mass spectrometry to identify the individual key proteins, as well as the biochemical pathways contributing to the development of the disease. RRD patients have specific vitreous proteome profiles compared to other diseases such as macular hole, pucker, or proliferative diabetic retinopathy eyes. Our data indicate that various mechanisms, including glycolysis, photoreceptor death, and Wnt and MAPK signaling, are activated during or after the RRD to promote retinal cell survival. In addition, platelet-mediated wound healing processes, cell adhesion molecules reorganization and apoptotic processes were detected during RRD progression or proliferative vitreoretinopathy formation. These findings improve the understanding of RRD pathogenesis, identify novel targets for treatment of this ophthalmic disease, and possibly affect the prognosis of eyes treated or operated upon due to RRD.

Factors predicting normal visual acuity following anatomically successful macular hole surgery.

PURPOSE: To assess the incidence of normal vision following anatomically successful macular hole surgery and associated clinical variables. METHODS: Multicentre, retrospective chart review. Preoperative, intraoperative and postoperative clinical data were extracted from electronic medical records from seven European vitreoretinal units. Inclusion criteria were as follows: eyes undergoing primary vitrectomy for idiopathic full-thickness macular hole from January 2015 to January 2018; postoperative macular hole closure confirmed by spectral domain optical coherence tomography (OCT); preoperative pseudophakia or phakic eyes receiving combined cataract surgery; one-year follow-up. The primary outcome was 'normal vision' defined as a final best-corrected visual acuity (BCVA) ≥ 20/25. Univariate, multivariate and decision-tree analyses were conducted to evaluate the clinical variables associated with 'normal vision'. Odds ratios (OR) and confidence intervals (CIs) were calculated. RESULTS: Of 327 eligible cases, 91 (27.8%) achieved 'normal vision' at 1 year. Multivariate analysis identified variables significantly associated with 'normal vision': shorter symptom duration (odds ratio [OR]=1.05; 95% confidence interval [CI]:1.02-1.09; p = 0.002), smaller preoperative OCT minimum linear diameter (OR per 100-micron increase = 1.65; 95%CI:1.31-2.08; p < 0.001) and better mean preoperative BCVA (OR = 15.13; 95%CI: 3.59-63.65; p < 0.001). The decision-tree analysis found that the most significant variable associated with 'normal vision' was symptom duration. 'Normal vision' was achieved in 70.6% of eyes operated within one week from symptom onset and in 45% of eyes with symptom duration between 1 and 3 weeks. CONCLUSIONS: These findings suggested urgent surgery is justified for small macular holes of short duration.

Correlations between vitreous cytokine levels and inflammatory cells in fibrovascular membranes of patients with proliferative diabetic retinopathy.

Purpose: The purpose of this study was to investigate the levels of cytokines in the vitreous, and their correlation with the density of inflammatory cells in fibrovascular membranes (FVMs) in patients with proliferative diabetic retinopathy (PDR) to evaluate intraocular inflammatory conditions with regard to disease activity. Methods: Thirty-three patients (33 eyes) with PDR requiring vitreoretinal surgery because of FVMs and tractional detachment were enrolled in the study, and compared with 20 patients (20 eyes) with macular hole (MH; control group). All patients underwent complete ophthalmological examinations before surgery. The activity of the disease was noted in patients with PDR. Samples of vitreous and blood were taken, and cytokine (MCP-1, IL-8, IL-6, VEGF, IL-1ß, TNF-α, MIP-1α, MIP-1ß, IL-10, and IL-12) levels were measured using cytometric bead array (CBA). Samples of FVMs were analyzed with immunohistochemical methods for the presence of inflammatory cells (CD45+, CD14+, CD3+, CD4+, CD8+, and CD19+ cells), and the numerical areal density was calculated (NA). Spearman's correlation was used to assess the association between variables. The Mann-Whitney test was used to assess the differences between independent groups. The Wilcoxon signed-rank test was used for assessing differences between two related groups. A p value of less than 0.05 was considered statistically significant. Results: Patients with active PDR had statistically significantly higher levels of MCP-1 (p = 0.003), VEGF (p = 0.009), and IL-8 (p = 0.02) in the vitreous in comparison with those with inactive PDR. CD45+, CD14+, CD3+, CD4+, CD8+, and CD19+ cells were identified in FVMs for patients with PDR. Statistically significantly higher numerical areal density of T lymphocytes (CD3+, CD4+, and CD8+) was demonstrated in patients with active PDR in comparison with patients with inactive PDR. Moderate to strong correlations were found between either MCP-1 or IL-8 in the vitreous, and the numerical areal density of cells (CD45+, CD3+, CD4+, and CD8+) in the FVMs, and weaker between either MCP-1 or IL-8 in the vitreous and the numerical areal density of CD14+ cells in the FVMs. Conclusions: The correlation of cytokine (MCP-1 and IL-8) vitreous levels with the density of inflammatory cells in FVMs, and differences in cytokine levels in the vitreous between patients with active and inactive PDR, and between the vitreous and serum in PDR indicate the importance of local intraocular inflammation in patients with PDR.

Distinct Serum and Vitreous Inflammation-Related Factor Profiles in Patients with Proliferative Vitreoretinopathy.

INTRODUCTION: Proliferative vitreoretinopathy (PVR), which is regulated by growth factors and cytokines, is the leading cause of failure in vitreoretinal surgery. In this study, we aimed to investigate the role of the human serum and vitreous inflammation-related factors in the development of proliferative vitreoretinopathy (PVR). METHODS: Blood and vitreous samples were obtained from patients undergoing pars plana vitrectomy. Inflammation-related factors were detected using an immunology multiplex assay on a Luminex® xMAP® platform. Patients with PVR and rhegmatogenous retinal detachment (RRD) were compared with macular hole (MH) or epiretinal membrane (ERM) patients without any other ocular or systemic disease. RESULTS: Thirty-six serum samples and 34 vitreous samples were obtained. Thirty-one different growth factors and cytokines were detected in serum samples. However, none of the circulating growth factors and cytokines were found to be different from the controls. Ten different growth factors and cytokines were measured in the vitreous samples. The concentration levels of PDGF-AA, TGF-α, VEGF, IL-6, IL-8, and TNFß were found to have significantly increased in the vitreous of PVR patients. CONCLUSION: Our study found that none of the circulating inflammation-related factors were changed in PVR or RRD patients, indicating the absence of a system inflammatory biomarkers to predict the development of proliferative vitreoretinopathy. As a supplement to previous research, the concentrations of PDGF-AA, TGF-α, VEGF, IL-6, IL-8, and TNFß were significantly upregulated in the vitreous of PVR patients. These factors should be considered for preventing PVR.

Correlations between intraretinal cystoid cavities and pre- and postoperative characteristics of eyes after closure of idiopathic macular hole.

Intraretinal cystoid cavities have been detected at the edges of macular holes (MHs) but their clinical characteristics and their relationship to the MH variables have not been determined. We measured the areas of the intraretinal cystoid cavity in 111 eyes with MHs in the OCT images preoperatively. Our results showed that the intraretinal cystoid cavities were located in the Henle fiber layer-outer nuclear layer (HFL-ONL) complex in 106 eyes and in the inner nuclear layer (INL) in 89 eyes. All were resolved after the initial vitrectomy to close the MH. The mean area of the cystoid cavity was greater in the HFL-ONL complex (55.9 ± 42.7 × 103 µm2) than in the INL (9.1 ± 9.8 × 103 µm2; P < 0.001). The area of the cystoid cavities was significantly correlated with the basal MH size (r = 0.465,P < 0.001), the external limiting membrane height (r = 0.793, P < 0.001), and the maximum retinal thickness (r = 0.757, P < 0.001). The area of the cystoid cavities was significantly correlated with the preoperative best-corrected visual acuity (BCVA; r = 0.361, P < 0.001), but not with the postoperative BCVA or the integrity of any of the outer retinal microstructural bands. The presence of intraretinal cystoid cavities was related to some morphological characteristics, but not to the postoperative BCVA or the restoration of the outer retinal bands.

Cost-effectiveness analysis of ocriplasmin versus watchful waiting for treatment of symptomatic vitreomacular adhesion in the US.

Aim: Evaluate the cost-effectiveness of ocriplasmin in symptomatic vitreomacular adhesion (VMA) with or without full-thickness macular hole ≤400 µm versus standard of care. Methods: A state-transition model simulated a cohort through disease health states; assignment of utilities to health states reflected the distribution of visual acuity. Efficacy of ocriplasmin was derived from logistic regression models using Ocriplasmin for Treatment for Symptomatic Vitreomacular Adhesion Including Macular Hole trial data. Model inputs were extracted from Phase III trials and published literature. The analysis was conducted from a US Medicare perspective. Results: Lifetime incremental cost-effectiveness ratio was US$4887 per quality-adjusted life year gained in the total population, US$4255 and US$10,167 in VMA subgroups without and with full-thickness macular hole, respectively. Conclusion: Ocriplasmin was cost effective compared with standard of care in symptomatic VMA.

Inverted internal limiting membrane flap technique versus complete internal limiting membrane peeling in large macular hole surgery: a comparative study.

BACKGROUND: To compare the anatomical and functional outcomes of the inverted internal limiting membrane (ILM) flap technique and the complete ILM removal in the treatment of large stage 4 macular hole (MH) > 400 µm and to evaluate reconstructive anatomical changes in foveal microstructure using spectral-domain optical coherence tomography. METHODS: This is a retrospective, consecutive, nonrandomized comparative study of patients affected by idiopathic, myopic or traumatic stage 4 MH (minimum diameter > 400 µm) treated with 25-gauge pars-plana vitrectomy with either complete ILM peeling (n = 23, Group 1) or inverted ILM flap technique (n = 23, Group 2), between August 2016 and August 2018. Main outcomes measured were the MH closure rate assessed by spectral-domain optical coherence tomography and the best-corrected visual acuity (BCVA) at six months. Foveal microstructure reconstructive changes were evaluated using SD-OCT to determine predictive factors of postoperative BCVA. RESULTS: Closure of MH was achieved in 16/23 cases of Group 1 (70%) and in 22/23 cases of the Group 2 (96%). Surgical failure was reported in 6 cases of Group 1 and 1 case of Group 2. The MH closure rate was significantly higher with the inverted ILM flap technique (P-value = 0.02). Average BCVA (LogMAR) changed from 1.04 ± 0.32 to 0.70 ± 0.31 in Group 1 and from 0.98 ± 0.22 to 0.45 ± 0.25 in Group 2 (P-value = 0.005) at 6 months. Improvement in BCVA (> 0.3 LogMAR units) was statistically higher in the Group 2 (P-value = 0.03). Restoration of foveal microstructure was significantly higher in the Group 2 at 6 months (52% vs 9%, P-value < 0.01). In Group 2, the integrity of the external limiting membrane at 3 months postoperatively was the only significant feature correlated with postoperative BCVA at 6 months (r = 0.562; P-Value = 0.01, forward stepwise regression analysis). CONCLUSION: Inverted ILM flap technique is more effective than the classic ILM peeling for the closure of large stage 4 MHs > 400 µm, improving both anatomical and functional outcomes. Early recovery of the external limiting membrane at 3 months is a positive predictive value of postoperative BCVA 6 months after inverted ILM flap technique.

Etiologies, Characteristics, and Management of Pediatric Macular Hole.

PURPOSE: To report on the etiologies and prognosis of macular hole (MH) in children and to explore the indicators of spontaneous hole closure and poor final visual outcome (vision worse than 20/200). DESIGN: Consecutive, retrospective case series. METHODS: A consecutive series of patients aged less than 16 years with a full-thickness macular hole treated from 2013 to 2019 in a singer tertiary center was retrospectively reviewed. Data collected from charts included age, sex, best-corrected visual acuity (BCVA), etiology of MH, size of MH, clinical findings, operations, and anatomic and functional outcomes. Logistic regression models were built to establish the predisposing factors. RESULTS: Forty eyes of 40 patients were included. Patients were predominantly male with a mean age of 8.3 years. Among the etiologies, trauma prevailed in 29 (72.5%) eyes. Twenty-nine patients underwent surgery, and 18 (62.1%) had traumatic MH. All had achieved hole closure. BCVA improved at the final visit. Spontaneous closure was found in 10 (25%) eyes after an average 2 months after trauma. Regression analysis showed that a relatively smaller macular hole (P = .006) was likely to experience spontaneous closure. Presence of macular lesions (P = .001) was identified as risk factor for poor final vision. CONCLUSIONS: Most pediatric MH was caused by blunt trauma. BCVA improved after MH closed, regardless of surgery or spontaneous closure. Smaller MH secondary to trauma was more likely to experience spontaneous closure with an average time of 2 months. Presence of macular lesions was a risk factor for final poor vision.