The Effect of Postoperative Face-Down Positioning and of Long- versus Short-Acting Gas in Macular Hole Surgery: Results of a Registry-Based Study.

PURPOSE: To determine whether sulfur hexafluoride (SF6) gas is noninferior to longer-acting gases in macular hole surgery and whether withholding postoperative face-down positioning (FDP) is noninferior to FDP. DESIGN: Registry-style, prospective, nonrandomized, observational cohort study. PARTICIPANTS: Patients with idiopathic macular holes undergoing primary surgery. METHODS: Surgeons were invited to submit clinical details of all macular hole cases receiving surgery. Baseline demographic and clinical information were collected, as well as details of surgical intervention and postoperative posturing advice. Primary follow-up data were collected 3 months postoperatively. MAIN OUTCOME MEASURES: Macular hole closure at 3 months. A noninferiority approach was used, with a noninferiority margin set at 5% decreased frequency of success. RESULTS: A total of 2456 eyes of 2367 patients were included in the study. Outcomes were available in 94.9% of cases (2330/2456). The rate of macular hole closure was 95.0% (2214/2330). Sulfur hexafluoride gas was found to be noninferior to longer-acting gases (95% confidence interval [CI] for adjusted effect on success, -1.76 to +2.25), and noninferiority was demonstrated regardless of macular hole size. Although withholding FDP was found to be noninferior to FDP for the study population as a whole (95% CI for adjusted effect on success, -4.21 to +0.64), the result was inconclusive in holes >400 µm in diameter (95% CI, -9.31 to +1.04). Lack of internal limiting membrane (ILM) peel, increasing hole size, hole duration ≥9 months, increasing age, and 20-gauge surgery all were associated with lower odds of success. Vitreous attachment to the hole margin was not associated with outcome when corrected for hole size, and combined phacovitrectomy surgery was not observed to affect the odds of success in phakic eyes. CONCLUSIONS: Sulfur hexafluoride gas tamponade was noninferior to longer-acting gases in the surgical management of macular hole. Withholding FDP was noninferior to FDP in holes ≤400 µm in diameter. In holes >400 µm in diameter, noninferiority of withholding FDP could not be concluded. We would advise caution if posturing is withheld in this group on the basis of the results of this study and of others.

Associations between preoperative OCT parameters and visual outcome 3 months postoperatively in patients undergoing vitrectomy for idiopathic epiretinal membrane.

PURPOSE: To evaluate the effect of preoperative optical coherence tomography (OCT) features on postoperative visual acuity and change in acuity after epiretinal membrane (ERM) surgery. METHODS: This was a retrospective consecutive case series of patients with symptomatic idiopathic ERMs who underwent vitrectomy and membrane peel between 2008 and 2013. The main outcomes were postoperative letter score and change in letter score. The association between visual acuity and OCT features was estimated using linear regression, correcting for important baseline covariates. OCT features included central foveal thickness, maximum retinal thickness, retinal cross-sectional area, central photoreceptor thickness, central epiretinal membrane, intraretinal cyst presence and location, retinal contraction, foveal ellipsoid zone and external limiting membrane integrity, and pseudoholes. RESULTS: A total of 79 patients were included in the study. Mean visual acuity was 65.0 letters preoperatively and 68.9 letters postoperatively, with average follow-up of 92 days. Better postoperative visual acuity was associated with the presence of preoperative retinal contraction (6.4 letters P = 0.027) and lower preoperative maximum retinal thickness values (0.34 letters per 10 µm reduction, P = 0.003). Change in visual acuity was associated with preoperative foveal ellipsoid zone attenuation (6.6 letters more improvement when present, P = 0.013). Preoperative pseudoholes were associated with a smaller change in visual acuity (7.4 letters less improvement, P = 0.034). No other OCT features were significant, including intraretinal cyst presence and location. Better preoperative visual acuity was associated with better postoperative acuity, but less change in visual acuity postoperatively. CONCLUSION: Preoperative maximum retinal thickness and retinal contraction were predictive of better postoperative visual acuity, while patients with a preoperative attenuated foveal ellipsoid zone were most likely to improve. Patients with preoperative pseudoholes had slightly worse visual acuity postoperatively. Although better preoperative vision was associated with better postoperative vision, it was associated with less change in visual acuity, emphasizing the importance of careful consideration of the desired surgical goals before advising surgery for ERM.

The Visual Outcomes of Macular Hole Surgery: A Registry-Based Study by the Australian and New Zealand Society of Retinal Specialists.

PURPOSE: To present the visual and safety outcomes of surgery for primary idiopathic macular holes including predictors of visual acuity and the impact of combined phacovitrectomy surgery. DESIGN: Registry-style, prospective, nonrandomized, observational cohort study. PARTICIPANTS: Patients with idiopathic macular holes undergoing primary surgery. METHODS: Surgeons were invited to submit clinical details of all macular hole cases receiving surgery. Baseline demographic and clinical information, and details of surgical intervention were collected. Primary follow-up data were collected at 3 months postoperatively or before revision surgery, and surgeons were also asked to submit data at 12 and 24 months postoperatively. MAIN OUTCOME MEASURES: Visual acuity improvement ≥15 letters and ≥0 letters, change in mean visual acuity, visual acuity ≥70 letters (20/40), retinal detachment, and endophthalmitis. RESULTS: A total of 2455 eyes of 2366 patients were included in the study, and hole closure was achieved in 95.6% of eyes with a single procedure. Mean baseline vision was 48.3 letters. The proportion of successful eyes improving ≥15 letters at 3, 12, and 24 months was 59.1%, 69.4%, and 68.2%, respectively. The mean improvement in acuity at 3, 12, and 24 months was 16.0, 19.2, and 23.6 letters, and 92.4%, 93.4%, and 95.8% improved ≥0 letters at 3, 12, and 24 months, respectively. Eyes receiving SF6 gas had better visual acuities at all time points postoperatively (adjusted effect 3.4, 3.1, and 4.6 letters better at 3, 12, and 24 months vs. longer-acting gas, respectively). Combined phacovitrectomy in phakic eyes was associated with better corrected visual acuity postoperatively (vs. vitrectomy surgery alone), a difference that vanished when eyes went on to have subsequent cataract surgery. The rate of retinal detachment postoperatively was 1.3%, and the odds of detachment were greater in eyes receiving longer-acting gases versus SF6 gas (adjusted odds ratio, 2.2; 95% confidence interval, 1.04-4.77; P = 0.039). There were no reported cases of endophthalmitis. CONCLUSIONS: Macular hole surgery substantially improved acuity in approximately two thirds of patients and was seldom associated with loss of vision. SF6 gas was associated with better visual outcomes, an effect that warrants further study.